Developing Empathy in Nurses: An Inservice

Training Program
Gülsüm Ançel

The purpose of this study was to determine whether inservice communication

training enhanced the empathic skills of 263 nurses employed at Hacettepe
University Hospital. Data were collected using a nurse information form,
participants’ satisfaction form, and the Empathic Communication Skill B
(ECS-B) form developed by Dökmen [Dökmen, Ü. (1988). A new measure-
ment model of the empathy and developing empathy by using psychodrama.
Journal of Education Faculty of Ankara University, 21, 155–190]. The ECS-
B was used as both a preintervention and a postintervention measure. The
data were expressed as means, percentages, and standard deviations, and
were analyzed using Pearson’s chi-square test and repeated-measures
analysis of variance. The posttest scores of nurses increased from 155.6
to 180.5, and training played a role in enhancing nurses’ empathic skills
with regard to all variables ( P < .05). However, a more comprehensive and
continuous training should be planned, and its impact on behavior and
patient outcomes should be investigated.
D 2006 Elsevier Inc. All rights reserved.

E MPATHY HAS BEEN emphasized, particu-

larly since the 1990s, as the central helping
component in therapeutic nurse–patient interactions
(Morse, Bottorf, Anderson, O’Brien, & Soldberg,
2006). Empathy is a teachable skill that is crucial in
helping relationships (Reynolds & Scott, 1999).
However, various investigations have found the
empathy level of nurses to be low or moderate
(Kalisch, 1971b; LaMonica & Karshmer, 1978;
Ponte, 1992; Reynolds & Scott, 2000; Watson,
Garfinkel, Gallop, Stevens, & Streiner, 2000;
Wilkinson, Bailey, Aldridge, & Roberts, 1999).
Duff and Hollinshead stated that 71.1% of registered
nurses, 80% of licensed practical nurses, and 74.0%
of nurse aides do not develop empathy with their
patients (Kalisch, 1971a). Wilkinson (1999)
reported that there has been very little development
in nurses’ communication skills in the last 20 years.
Studies on empathy and communication skills have
shown that further efforts are required to increase
nurses’ levels of empathy and communication skills
for effective care.
RELATED LITERATURE ON EMPATHY
Empathy is the ability to perceive the meaning
and feelings of another and to communicate those
feelings to the other person. The concept of empathy
was originally used by Lipps in 1897 (Richendoller
& Weaver, 1994). There are many current defini-
tions of empathy, with the majority being based on
Rogers’ (1975) definition (Dökmen, 1988; Walker
& Alligood, 2001; White, 1997). Rogers describes
empathy as the state of perceiving the internal frame
of reference of another person with accuracy and
with emotional components and meanings that
pertain to it, as if one were the other person, but
without the loss of the bas-ifQ condition (Rogers,
1975). Rogers’ description shows that empathy has
affective, cognitive, and communicative compo-
nents and considers an bempathic cycleQ (as cited in
Wiseman, 1996). Barrett-Lennard (1993) suggested
an empathic cycle based on Rogers’ model. This
cycle involves the following stages: understanding
From the Cebeci School for Health Sciences, Ankara
University, Ankara, Turkey.
Address reprint requests to Gülsüm Ançel, RN, PhD,
Associate Professor, Bilkent II, G-3 Blok, No. 17, 06530
Ankara, Turkey.
E-mail addresses: ancel@medicine.ankara.edu.tr,
gulsum _ ankara@yahoo.com
B 2006 Elsevier Inc. All rights reserved.
0883-9417/1801-0005$30.00/0
doi:10.1016/j.apnu.2006.05.002

Archives of Psychiatric Nursing, Vol. 20, No. 6 (December), 2006: pp 249 - 257 249
250
and recognizing the empathee’s emotions, commu-
nicating this understanding to the empathee, (the
empathee) recognizing that this has been under-
stood, and giving feedback.
Exactly what empathy is remains unclear
(Kunyk & Olson, 2001; Price, 1997; Walker &
Alligood, 2001; White, 1997). To clarify empathy,
it has been analyzed as a concept, its components
have been defined, and different models have been
developed. In Wiseman’s (1996) review of empa-
thy and analysis of the concept, the defining
attributes were summarized as follows: seeing the
world as others see it, being nonjudgmental,
understanding another’s feelings, and communicat-
ing such understanding. In another study, empathy
was characterized by five concepts, namely, human
trait, professional state, caring, communication
process, and special relationship (Kunyk & Olson,
2001). At present, empathy is considered multi-
dimensional, including emotional, cognitive, com-
municative, moral, behavioral, and relational
dimensions (Bash, 1992; Cliffordson, 2002; Olsen,
2001; Ponte, 1992; Richendoller & Weaver, 1994).
The conceptualization of empathy remains
incomplete, and this has led to uncertainties in
teaching and measurement methods and in deter-
mining what is to be measured (Reynolds, Scott, &
Jessiman, 1999; Walker & Alligood, 2001). In the
literature, there are three types of empathy or
communication training models (Gysels, Richard-
son, & Higginson, 2005; Kalisch, 1971b; Kruijver,
Kerkstra, Franke, Bensing, & Wiel, 2000; Parle,
Maguire, & Heaven, 1997; Wilkinson, 1999). The
first training model comprises specific training
programs, such as skills workshops or psycho-
drama. The second comprises traditional classroom
instructions, such as learning the foundation of
theories, practicing basic skills, and role playing.
The third comprises experiential learning techni-
ques that consider students’ relationships with
patients to improve them based on education given
to professionals. Studies have shown education to
be effective in increasing empathy and communi-
cation skills, but determining which program is
more effective needs to be examined in more detail.
The measurement of empathy poses further
problems. However, it is becoming increasingly
clear which tool measures which component of
empathy. For example, the Questionnaire Measure
of Emotional Empathy (Mehrabian & Epstein,
1972) measures affective components, the Empathy
GÜLSÜM ANCS EL
Construct Rating Scale (LaMonica, 1983) measures
behavioral components, and the Interpersonal
Reactivity Index (Davis, 1983), based on a multi-
dimensional concept, measures both affective and
cognitive dimensions.
According to Cliffordson (2002), the majority of
the definitions of empathy are hierarchical struc-
tures, and considering the concept of empathy via a
hierarchical approach facilitates both an under-
standing of the concept and the measurement of its
multiple dimensions. Morse et al. (2006) recom-
mended an alternative communication model in the
hierarchical structure. According to this model, in
the first stage, the nurse has spontaneous and
reflexive responses; however, in the second stage,
the responses are learned and therefore can be
controlled. This model is similar to basic and trained
classifications (Alligood & May, 2000). Olsen
(2001) defined a three-stage hierarchical develop-
mental structure to explain how nurses understand a
patients’ personhood and for advanced empathic
practice recommended in cognitive structural
theory. In this study, empathy and its measurement
were considered via a hierarchical approach.
METHOD
The purpose of this study was to determine
whether inservice communication training
enhanced the empathic skills of nurses, taking the
following questions into account: What is the
nurses’ level of empathy? Can the nurses’ level
of empathy be increased? Does inservice training
have an effect on the level of nurses’ empathy?
Sample and Setting
The study was conducted in the adult department
of Hacettepe University Hospital. Four hundred
fifty nurses are employed in inpatient wards, in the
operating room, and in the outpatient department.
All 263 nurses working in inpatient wards were
included in the study because they have more
intense contact with either patients or significant
others. After approval had been obtained from
relevant committees, the nurses were informed
about the study, and 263 agreed to participate.
Instruments
The data were collected using three instruments:
! The nurse information form included nurses’
characteristics and independent variables. It
DEVELOPING EMPATHY IN NURSES
included questions on age, marital status,
education, work experience and place of
work, previous sources on communication
that they had read, and previous courses on
communication that they had attended.
! The trainees’ satisfaction form, developed by
the investigator, included the trainees’ evalua-
tions of the program duration, content, and
relevance to their needs; the techniques
employed; training materials; and the training
environment. This form was administered
after each group had received training.
! The Scale for Empathic Communication Skill
B (ECS-B) form devised by Dökmen (1988)
was used as both a preintervention and a
postintervention measure.
The ECS-B measures the affective and cognitive
components of empathy and the verbal response
dimension of communication. This scale classifies
the stages of empathy and was developed based on
the standard scale devised by Rest et al. (1974),
using the moral developmental stages described by
Kohlberg. In Dfkmen’s empathy classification,
there are three empathic response stages, namely,
bthey,Q bI,Q and byouQ (Figure 1). The person
responding at the btheyQ stage always makes
evaluations based on society’s judgments (i.e., what
others feel and think) rather than focusing on the
problem. This is the response stage of least quality.
In the bIQ stage, one responds to the criticism of
another, giving advice and evaluating the problem
according to one’s own interpretation, and trans-
ferring one’s own feelings and experiences regard-
ing that subject. The byouQ stage involves putting
oneself into another’s place to understand the
problem, reflecting what is understood by the
Fig 1. Basic empathy steps in staged empathy classification (Dökmen, 1997).
251
other, supporting the individual, and understanding
deep feelings.
The validity and reliability of the ECS-B scale
have been tested. A correlation coefficient of r =
.91 was determined in a reliability study; in a
validity study, no significant difference was found
between groups (t = 6.77, SD = 26, P b .001). The
ECS-B includes 6 scenarios and problem cases and
72 response statements (12 for each problem).
Subjects are asked to mark four empathic
responses for problem cases in each scenario.
Among the options for the response suggested for
each problem, there is one statement for an
birrelevant response.Q The responses of those who
had less than four responses for six scenarios and
those who had irrelevant responses were excluded
from the evaluation based on the fact that they had
not read the scale carefully enough. Twenty-four
responses by the subjects were evaluated according
to scores on a Likert-type scale. Empathic skill
scores in the scale range between 64 and 249.
Planning and Implementation of the Inservice
Training Program
The training was prepared according to the
needs of the trainees. Six psychiatric nurses were
trained by the author as trainers, and the program
was conducted together with the author. Principles
such as focusing on bhere and nowQ and ensuring
confidentiality were incorporated into group rules,
and a contract of training was made with the
trainees. The training was conducted in a manner
similar to that described in Yalom’s interaction
group. A hierarchical emphatic cycle was modeled.
Necessary revisions were made to the subsequent
group’s training in accordance with the results of
the trainees’ satisfaction form and feedback.
252
The training was based on adult teaching models
and principles. The nurses did not wear their
uniforms during the training sessions to allow
them to express their individuality more comfort-
ably. The training was conducted with the active
participation of trainees from the planning stage to
the evaluation stage.
The content of education was organized to obtain
the highest level of empathic response in Dfkmen’s
staged empathic classification (Figure 2). In the
btheyQ stage, social effects and parent ego state were
studied because empathic response is based on
society’s judgments. The bIQ stage involved self-
examination, using the four dimensions of Camp-
bell’s self-knowledge (as cited in Videbeck, 2001).
For psychological self-knowledge in the model,
feelings, motivation, stress sources, self, and per-
sonality were studied. For physical self-knowledge,
body perception, body image, and physical potential
were studied. For the environmental dimension,
social environment and relationships with others
were studied. Again, for the same purpose, the first
three quadrants of a Johari Window were also used
(as cited in Stuart & Sundeen, 1987). In the first
quadrant, the skill of listening to oneself is
significant, and so listening was studied. The second
quadrant requires listening to other people and
learning from them. In this step, listening and
understanding were studied. The third quadrant
indicates the aspects of the individual known only to
Fig 2. Inservice training program.
GÜLSÜM ANCS EL
oneself. In this step, the skill of expressing oneself
was studied. The fourth quadrant includes character-
istics unknown to the individual and to others; this
quadrant was not taught. Exercises were used to
teach the steps of this model. For example, each
member looked in a mirror and shared how one saw
oneself with the group. The members were asked to
complete sentences including bI,Q such as bwhat I
like most about myself,Q bmy characteristics that
should change,Q and bwhat I like/dislike doing.Q
They also had their close friends write sentences
about them so they could learn how others perceive
them. Alternatively, each member wrote one’s name
on a piece of paper and handed it to the next
member, who wrote the first thing that came into
mind about that person. Hence, all members of the
group received feedback from all participants on
how they are perceived and how they reflect
themselves, and they were able to evaluate what
had been written about them. This facilitated the
teaching of the byouQ stage of empathic response.
The teaching of the byouQ stage involved active
listening, asking open-ended appropriate questions,
understanding, putting oneself in another’s place,
empathic response, and verbal and nonverbal
communication practices. To teach the trainees
how to put themselves in another’s place, role
playing and imagination, case studies, and personal
experiences were used. The trainees listened to mu-
sic to develop their ability to focus on recognizing
DEVELOPING EMPATHY IN NURSES 253

feelings, listening, and understanding. For empathic
communication, concepts such as concreteness,
respect, sincerity and reflecting, guiding, and
encouragement to continue responses were studied.
For exercises related to this, The Skilled Helper: A
Model for Systematic Helping and Interpersonal
Relating by Egan (1990) and Helping Skills: A Basic
Training Program by Danish, D’Augelli, and Hauer
(1994) were used. In this step, the trainees studied
how to distinguish empathic responses in sample
cases. They were supported in giving appropriate
responses, they acted out the scenarios prepared by
them, and they watched films on this subject and
discussed them.
The inservice training program lasted 4 hours/
day, totaling 20 hours. The nurses participated in the
training, which lasted for a week, in groups of 20.
The training of all groups was completed in
13 weeks. In addition to the 20 hours of training,
the trainees were given homework and exercises
every day, and the subjects were consolidated.
For example, they were asked to write sentences
that established connections between every emo-
tion, feeling, thought, behavior, and experience.
Necessary technical equipment and audiovisual
devices were utilized for effective learning.
Data Analysis
Because irrelevant responses were received from
73 of 263 nurses in the study, their tests were
invalidated; thus, data from only 190 nurses were
evaluated. SPSS for Windows 12.0 was used for
statistical analyses. The data were presented as
means, standard deviations, and percentages. Pear-
son’s chi-square test and repeated-measures analysis
of variance (ANOVA) were used to assess relation-
ships among demographic variables. P b .05 was
considered significant.
FINDINGS
This study was conducted to determine the effect
of inservice training on increasing nurses’ levels of
empathy. The characteristics of participating nurses
whose ECS-B scales were valid are presented in
Table 1. The majority (67.9%) of participants were
single, 50.0% were 24 years old or younger, 35.8%
were between 25 and 30 years, 14.2% were 31 years
and above, 38.4% had a baccalaureate degree, and

Table 1. The Distribution of Nurses’ ECS-B Scores Before and After Training, by Variables
ECS-B Score Before Training ECS-B Score After Training

Variables No. % x̄ SD x̄ SD

Marital status
Married/divorced 61 32.1 153.1 23.6 175.6 23.1
Single 129 67.9 156.8 22.9 182.8 21.7
Age (years)
V24 95 50.0 155.5 22.3 180.2 21.7
25–30 68 35.8 159.2 24.2 184.5 19.8
z31 27 14.2 147.3 21.2 171.8 28.5
Educational level
Less than bachelor of science 117 61.6 148.5 20.8 174.4 23.6
Bachelor of science 73 38.4 167.1 22.0 190.1 15.9
Previous participation in communication training
Yes 35 18.4 154.5 24.1 177.6 24.8
No 155 81.6 156.0 23.0 181.2 21.9
Reading books on communication
Yes 135 71.0 157.4 22.6 181.5 21.4
No 55 39.0 151.4 24.0 178.3 24.7
Years worked
1–3 83 43.7 157.7 21.7 181.6 22.2
4–6 51 26.8 154.5 24.5 179.4 21.8
7+ 56 29.5 153.6 24.1 180.0 23.4
Working area
Surgery 95 50.0 151.4 21.2 178.1 24.8
Internal medicine 55 39.0 159.8 21.8 183.8 16.3
Others 40 21.0 160.1 27.6 181.9 23.2
Total 190 100 155.6 23.1 180.5 22.4
254 GÜLSÜM ANCS EL

61.6% had a lower level of education. Of the Table 2. Results for Repeated-Measures ANOVA
participants, 81.6% had not previously participated Variables F P

in any training program on communication, but Marital status

71.0% stated that they had read literature on Time 262.0 .001
communication. Half of the nurses were employed Group–time 1.298 .256
Group 2.982 .086
in the surgical department, 39.0% were employed in Age
the internal medicine department, and the remainder Time 236.5 .001
were employed in other departments; 43.7% of the Group–time 0.030 .970
participating nurses had been employed for 0–3 Group 3.568 .030
Education
years, 26.8% had been employed for 4–6 years, and
Time 290.8 .001
29.5% had been employed for more than 7 years. Group–time 0.847 .358
Among the 190 nurses who participated in the Group 38.193 .001
training and had valid scales, the lowest ECS-B Communication training
score before and after training was 110, the highest Time 172.9 .001
score before training was 213, and the highest score Group–time 0.340 .560
Group 0.412 .522
after training was 216. The average ECS-B score Reading sources
was 155.6 on the first test and 180.5 on the last test Time 271.6 .001
(i.e., an increase of 25.1 points was achieved). Group–time 0.825 .365
The pretest and posttest ECS-B scores according Group 1.969 .162
to variables, their means, and their standard devia- Years working
Time 303.0 .001
tions are also shown in Table 1. According to the Group–time 0.262 .770
independent variables, there were no differences in Group 0.419 .659
nurses’ ECS-B scores before the training ( P N .05). Work area
Only the ECS-B scores of those with less than a Time 262.2 .001
Group–time 0.978 .378
bachelor-of-science education were lower than
Group 2.580 .079
those with a bachelor-of-science education, and
NOTE. Time = pretraining–posttraining outcomes.
the scores of nurses 31 years or older were lower
than those nurses 20–25 years old ( P b .05). After
training, the nurses’ ECS-B scores according to the effect of age (v 2 =23.32, P b .05) and education.
variables were higher in all groups (Table 1). Those in the 25- to 30-year age group were educated
To determine whether this increase was statisti- to a higher level than those in the other age groups.
cally significant, repeated measurement of ANOVA The increase in ECS-B score in this age group was
was conducted. According to the results (Table 2), 15.8%, but was 16.6% in the 31-year age group. It
inservice training significantly increased the was 13.3% in those with a bachelor-of-science
nurses’ ECS-B scores ( P b .05). The relationship education, but 17.5% in other groups. This finding
between training and variables revealed that shows that the change resulting from inservice
increases in ECS-B score were similar in terms training was high in those with low ECS-B scores
of marital status ( F = 1.298, P = .256), age ( F = and was low in those with high scores.
0.030, P = .970), education ( F = 0.847, P = .358), The 263 nurses were divided into 13 groups,
previous participation in communication training with a mean of 20 in each group. The differences
( F = 0.340, P = .560), reading educational books between the 13 groups were not examined because
on communication ( F = 0.825, P = .365), work the number in each group was not valid for the
experience ( F = 0.262, P = .770), and place of scale and the groups differed from each other in
work ( F = 0.978, P = .378). The independent terms of group factors.
variables had no effect on the increase in ECS-B The results from the trainees’ satisfaction form
scores; only inservice training was influential. showed that 98.9% of the nurses regarded the
However, a significant difference was found for trainers as adequate, 99.2% found the materials and
the increase in ECS-B scores between nurses who techniques utilized to be adequate, and 97.7% con-
were in different age groups ( F = 3.568, P = .030) sidered the content of the subject and its relevance to
and education groups ( F = 38.193, P = .001). their needs to be adequate. The environment was
Pearson’s chi-square test was used to examine the regarded as unsuitable by 4.3% of the participants,
DEVELOPING EMPATHY IN NURSES
and 93.6% of the nurses suggested that a longer and
continuous training be given.
DISCUSSION
Empathy is a teachable communication skill.
However, problems in communication training
continue to exist both in school and after school
(Ashmore & Banks, 1997; Chant, Jenkinson,
Randel, Russel, & Webb, 2002; Gysels et al.,
2005; Kruijver et al., 2000; Suikkala & Kilpi,
2001). These problems are related to educational
programs, theory–practice gap, and the importance
given to communication in the health care system.
In addition, there continues to be confusion
regarding the concept of empathy and how to
measure it in empathy education, highlighting the
importance of a well-structured training program.
In this study, the effect of education prepared
based on Dfkmen’s staged empathic classification
was measured using a tool also developed by
Dfkmen. Inservice training was influential in this
study in increasing the nurses’ empathy levels, in
agreement with the literature (Chant et al., 2002;
Gysels et al., 2005; Yates, Hart, Clinton, McGrath,
& Garthy, 1998). However, some studies found
limited or no change (as cited in Kruijver et al.,
2000; Razavi & Delvaux, 1997; Watson et al.,
2000). The present study evaluated the effect of
nurses’ characteristics such as age, education, and
work experience; in all variables, a similar increase
in scores was determined. Although the increase in
empathy scores after the training was similar for
the variables, the increase varied among nurses in
different age and education groups. Those with low
ECS-B scores before inservice training had higher
increases in the age and education groups, whereas
those with high scores had lower percentage
increases. This shows that the inservice training
achieved a certain level of empathy in all groups.
Those who had received previous communication
education through books or courses were not found
to have higher levels of empathy. We had no
information about the books they had read or the
courses they had attended; therefore, we were
unable to evaluate how these had affected their
levels of empathy. In some studies, empathy was
not found to be influenced by the nurses’ character-
istics, such as level of education and work
experience (Watson et al., 2000). Ponte (1992)
found that, as age and years of experience
increased, verbal response decreased; as educa-
255
tional level increased, there was a decrease in
listening and perceiving in the empathic model.
She related this finding to the fact that nurses with
more education and experience assume more roles
in planning and show more highly technical skills.
In many studies, empathic skills were found to be
higher in nurses who are young, new in the job,
and more educated (as cited in Watson et al.,
2000). In addition, the characteristics of nurses
need to be examined in more detail because factors
impeding an empathic approach include lack of
time, lack of support from unsympathetic col-
leagues, personality style, unmet personal needs,
unresolved personal problems, weariness, anxiety,
burnout, and perception of empathy as an author-
itarian attitude or as informing patients (Price,
1997; Reynolds & Scott, 1999, 2000; Richendoller
& Weaver, 1994; Tyner, 1985).
In the literature, different findings are reported
about how nurses’ characteristics and education
influence each other. Undoubtedly, not only the
characteristics of the participants but also the
content and length of education, techniques used,
and educators’ backgrounds all play roles in the
effectiveness of an educational program. In related
studies, education was effective when conducted
for a long period with small groups and when using
several methods together with learner-centered and
didactic components (Chant et al., 2002; Gysels et
al., 2005; Razavi & Delvaux, 1997). The present
study, in which 263 nurses were trained, indicated
that the use of several methods, such as learner-
centered and didactic training and role playing,
made education more effective. Undoubtedly,
longer training and smaller groups would have
been even better. An attempt was made to extend
the 20 hours of education by giving the participants
homework. In the literature, communication train-
ing lasts 6–100 hours for 2–10 weeks, and samples
vary from 8 to 218 subjects (Chant et al., 2002;
Gysels et al., 2005; Kruijver et al., 2000; Reynolds
et al., 1999; Wilkinson et al., 1999).
The trainers in this study had been trained
previously and were in the same profession. This
approach is supported in the literature, and the
background of the teacher and the social system in
the working environment have been found to be
factors influencing education (Kruijver et al.,
2000). The effect of the social system in the
working environment and the background of the
teachers were not examined in this study.
256
The training program in this study taught
communication skills from the least quality to the
deepest empathic response in the bI,Q byou,Q and
btheyQ stages via a hierarchical approach. The
structure of education was based on Dfkmen’s
staged empathy classification. Together with the
main topic of this study, the effect of self-examina-
tion (in the teaching of the bIQ stage of empathic
response) on empathy was examined because self-
examination as self-knowledge is an antecedent of
empathy and therapeutic communication (Hartrick,
1999; Leenerts, 2003; Wiseman, 1996).
The scores obtained by the nurses (x̄ = 180.5) in
this study demonstrate that a higher-than-average
level of empathy was achieved. Their ECS-B
scores were quite high compared to the results of
other empathy studies involving nurses in Turkey
using the same scale (i.e., scores of 118–150, as
cited in Çam, 1995).
The present study only measured the increase in
verbal responses and not the reflection of what had
been learned on patient outcomes in practice. Some
studies have reported that nurses are not able to use
increased levels of empathy because of the
biomedical dominance and the hierarchical struc-
ture of the health care system (Bowles, Mackin-
tosh, & Torn, 2001; Chant et al., 2002). For this
reason, follow-up studies are needed to evaluate
the reflection of empathic communication in
practice, and education must combine theory and
practice that are appropriate to work conditions.
In conclusion, this study revealed that inservice
training directed toward integrating basic commu-
nication skills increased the empathic skills of
nurses. Their ECS scores were higher than average,
although they seemed to increase after training.
Therefore, continuous training should be ensured
to increase their empathy further. Whether the
skills gained will be implemented in their inter-
actions with patients and whether there will be a
long-term change in behavior remain to be
determined in future studies. Irrespective of favor-
able results, a more comprehensive and continuous
training and further studies are warranted for
nurses to implement their empathy.
LIMITATIONS
Inadequate staffing meant that some nurses
participated in the study after night-shift work and
were careless and filled out irrelevant responses.
They could not participate in the training given on
GÜLSÜM ANCS EL
that day, which had an adverse effect on the training
process and on the integrity of the group. During the
first stage of this study, the verbal dimension of
empathy was considered. Longer training was not
possible due to lack of personnel, and the behavioral
dimension of empathy and its reflection on patients
could not be assessed.
ACKNOWLEDGMENT
I offer my sincere thanks to nurses who assumed
responsibility for this study (Feryal Akdemir,
Songql KamVYlV, Mehtap KVzVlkaya, Kezban Demi-
rcioğlu, Leyla DaYtan, and Sultan Kav), Besti
Üstqn for her support, Erdem Karabulut for his
contribution to statistical evaluation, and all nurse
participants who enabled me to have an invaluable
experience in this process through their feedback
and active participation.
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