Pharmacy students' empathy and its determinants: a systematic review

Eligibility criteria

We used the following inclusion criteria to evaluate each of the articles under consideration to respond to our research questions:

Excluded from the systematic review were studies on animals, review articles, qualitative studies, commentary articles, letters to the editor, conference abstracts, books, guidelines, and theses.

Information sources and search strategy

The initial searches were conducted using three electronic databases: PubMed, Science Direct, and Scopus. From July 14, 2022, to the latest recent search on July 16, 2022, we considered articles on factors or determinants about pharmacy students' empathy from this three-database collection. There were no restrictions on publication ages throughout this period. Each database used the terms “factors” AND “pharmacy students” AND “empathy” as a single search term or in combination using Medical Subjects Heading (MeSH) terms with the Boolean operators. We also searched for additional reference materials by consulting the cross-references listed in the included publications via Google Scholar on August 16, 2022.

Study selection and data extraction

The retrieved studies from databases were screened for their title and abstracts by three authors (HP, SAK, and AWW) to ensure they fit the eligibility criteria. We used a common data extraction spreadsheet (Microsoft Excel) to chart the necessary data. To eliminate duplication, Mendeley Reference Manager was used to obtain every article. Next, full texts of selected studies were reviewed by three authors (HP, SAK, YSP) to determine their relevance. Discrepancies whether the title, abstract, and entire manuscript meet the inclusion and exclusion criteria were resolved through discussions between authors until concordance was obtained. A PRISMA diagram was used to record the screening and selection process (Figure 1).

Figure 1. PRISMA diagram of this review.

A data extraction was conducted by the two independent reviewers (HP and SAK) to obtain the key study information. Included studies should provide a primary focus on identifying the determinants which related to pharmacy student empathy. While other supporting variables include characteristics of included studies (the year of publication, country, study design, participants, and type of participants) and measurements adjusted for eligibility criteria.

We created a spreadsheet with details about the publication year, country, study design, participants, participant types, measurements, and factors related to empathy. Two authors (HP and SAK) read the entire paper and highlight the key points discussed inside it, with adjustments for the relevant variables. Furthermore, this pertinent information was reviewed in the results section. The two reviewers' disagreement (HP and SAK) were settled through discussion with another member of the research team (HP, SAK, AWW, YSP) and HP as the person in charge of this discussion process.

One point of disagreement is the assumption that the “country” is related to the country in which the study was conducted rather than the country of the affiliated university. Another example is figuring out the essential factors that related pharmacy students' empathy as indicated in the included studies.

Quality assessment

We utilized Joanna Briggs Institute Critical Appraisal Checklists (JBI) according to the methodological design of the studies: cross-sectional studies, cohort studies, case-control, randomized control trials, and quasi-experimental studies. This is performed to observe the quality of published articles. The JBI critical appraisal method was used to determine the extent to which the included studies attempted to reduce risk of biases related to the appropriateness of the study objectives participant selection, data collection, data analysis, randomization, treatment allocation, blinding, and interpretation of results. There were 8 questions for a cross-sectional study design, 11 questions for a cohort study, 10 questions for a case-control study, 9 questions for a quasi-experimental study, and 13 questions for a randomized controlled trial.

Appraisal of studies was undertaken by two independent authors (HP and SAK) and assessments were compared. The discrepancies were discussed with other research team members (AWW and YSP). Examples of discrepancies include checking to see if the inclusion criteria were explained clearly and checking to see which confounding variables were mentioned in the article.

Each checklist criterion was rated as yes”, “no”, “unclear”, or “not applicable”. When the studies reached up to 49% of the “yes” score, the risk of bias was classified as high; moderate when they reached 50 to 69% of the “yes” score; and low when they reached more than 70% of the “yes” score (Joanna Briggs Institute Critical Appraisal Checklists).

Characteristics of included studies

The included studies were published between 2011 and 2022 and were conducted in seven countries: eight in the United States^2,23–29 and one each from Korea,³⁰ China,³¹ United Kingdom,³² Indonesia,³³ Singapore,³⁴ and Iran.³⁵ Eleven of the included studies used cross-sectional designs, two studies used randomized control trial designs,^24,34 and one of the studies used one group pretest-posttest intervention design.²⁸

Twelve (86%) studies included pharmacy students as participants and two (14%) studies informed pharmacy students and other health professional students or pharmacists.^28,33 Pharmacy students as participants ranged from first year through to fourth year students. Three of the included studies reported first-year level of pharmacy students as participants.^2,26,29 Three studies reported second-year pharmacy students as participants.^23,24,34 Two studies informed first through to fourth year students as participants.^31,32 We found one paper focussed each on the third year,²⁵ the fourth year,³³ the second through to third year,³⁰ the first through to third year,²⁷ and two others that did not specify the education level of students were included in the study.^28,35 The number of participants included in each of the studies ranged from 40 to 1013 pharmacy students.

Outcome measures

All studies evaluated participant improvements in empathy using self-report measures. Self-report measurements typically consisted of a single question or a self-report survey. There were several different self-report survey formats used in included studies. The most frequently used instrument was the Jefferson Scale of Empathy for Health Professions Students (JSE-HPS).^{2,24,28–32,34,35} The JSE-HPS instrument contained 20 items with response options based on a 7-point Likert scale and measuring Perspective Taking, Compassionate Care, and Standing in the Patient's Shoes. Another instrument widely used in included studies was the Kiersma-Chen Empathy Scale (KCES).^26,28,33 The KCES, a 15-item survey with a 7-point Likert-type scale, measured two aspects of empathy: the capacity to comprehend others' perspectives (cognitive domain) and the capacity to empathize with their thoughts and experiences (affective domain). Table 1 provides specifics about the empathy measurement tools used in included studies.

Determinants related to the pharmacy students’ empathy

Gender or sex

Among the included studies in this review, eight studies evaluated the association between gender and the level of empathy^{2,27,29–32,34,35} and one study evaluated the association between sex and the level of empathy.²⁶ Most of them concluded that the overall empathy score in female students was significantly higher than that in males,^{2,26,29,32,34,35} with two included studies discovering no discernible differences between them.^30,31

In 2022, Fashami et al. conducted a cross-sectional study to measure the empathy score among 504 pharmacy students in five Iranian pharmacy schools.³⁵ According to this study, female students scored much higher on empathy than males did overall. Additionally, in the JSE-HPS, females had considerably greater empathy scores in the compassionate care and perspective-taking domains. At the Midwestern University Chicago College of Pharmacy in 2011, Fjortoft et al. performed a survey of 187 first-year pharmacy students.² According to this study, female pharmacy students scored much better on average for empathy than their male colleagues did. Jeon and Cho’s findings contrasted this by stating in their research that there were no noteworthy gender differences.³⁰

Educational intervention

Seven included studies reported that educational intervention can become one of the factors or determinants related to the empathy of pharmacy students.^{23–25,28,29,31,34} Pharmacy students can develop their empathy using a variety of educational interventions, including but not limited to a learning module, role-reversal exercises, patient simulations, workshops, dramatic performances, and games involving patients’ medication.³⁶ Lor et al. conducted a randomized study in which participants in the intervention group underwent a three-day simulation of a specific activity and received daily debriefings from faculty members.²⁴ The three exercises involved were: simulating losing one's dominant hand (participants had to wrap their dominant hand in gauze and were not permitted to use it); simulating losing one's sight (participants had to wear sleep masks); and simulating losing one's ability to speak (participants were only allowed communicate using a whiteboard and marker). Seven days after the intervention, participants who were randomly assigned to a single, three-day empathy intervention experienced a significant rise in empathy scores.

Simko et al. used the apparatuses contained in a Chronic Pain Simulation Empathy Training Kit (CPSETKit) to simulate chronic pain from several disease states.²⁸ The purpose of this study was to assess how using a Chronic Pain Simulation Empathy Training Kit affected the empathy of pharmacy, nursing, and health sciences students (CPSETKit). The use of the CPSETKit increased the empathy for chronic pain patients in health care students. Additionally, Reed et al. investigated whether first-year pharmacy students' empathy levels enhanced after taking a longitudinal professionalism course at two pharmacy schools. The outcomes demonstrate that continuous professionalism training at two pharmaceutical schools raised the level of pharmacy students' empathy.²⁹

Year of study and type of school

Of the 14 included studies, there were four studies^30–32,35 discussed the year of study that related to the empathy of students, and two studies^30,35 explained that the type of school related to the students’ empathy.

Li et al. reported that in comparison to any prior years, the fourth-year students' mean empathy score was significantly higher than in other years but did not differ much.³¹ The second-year students also scored the worst on empathy. The fourth-year class had higher empathy scores than the first-year class, but there was no statistically significant difference in empathy scores by age, which may be because the seniors have finished all of their professional coursework and clinical practice. Due to the fact that pharmacy students in China spend their first three years away from the clinical setting, they seldom come into contact with clinical role models until their last year of training. Students work with patients during their fourth-year clinical clerkships while receiving training in ethics, practice management, and the management and treatment of fearful patients. As a result, they may come at this stage to deeply and vividly understand the significance of the relationship between pharmacists and patients.

On the other hand, Jeon & Cho reported that even though there were no differences across the students’ years of study in their research, the type of university attended determined significant differences in the total empathy score.³⁰ Depending on whether the students came from co-educational or women's universities, significant variations were found for all variables. Students in women's universities exhibited higher levels of empathy overall, compassionate care, and perspective-taking than those at co-educational universities. Since 2011, the four-year BSc pharmacy degree in Korea has been replaced by a two+four hour Doctor of Pharmacy (PharmD) program. The first graduates of the new program will receive their diplomas in 2015. Students could take the Pharmacy Education Eligibility Test (PEET) if they have completed the minimum number of pre-pharmacy courses (two years).

Experience

A total of four studies of included studies evaluated the association between experience and the level of empathy.^27,29,32,33 According to Williams et al., there were no appreciable differences in the cognitive empathy of student groups with direct patient care or chronic illness caregiving experiences.²⁷

Similar to Hall et al., part-time employment experience affect students' empathy scores, even though mean scores were higher for part-time employees compared to non-employees.³² Additionally, students who said they worked with patients had a slightly higher mean empathy score than students who had not worked with patients. These findings are significant because they imply that students who have more patient exposure are not adversely affected by patient contact.

Reed et al. explained that through subgroup analysis of student employment status, i.e., whether they worked or did not work throughout the school year, the latter were similarly more likely to analyze an increase in empathy with time, providing additional support for the moderating influence of health care experience.²⁹ Furthermore, Reed et al. confirmed that there might be chances to tailor training to students' prior experience or levels of fundamental empathy. Teaching that aims to foster empathy might focus on individuals who are most in need given the growing number of abilities that pharmacy schools are expected to cultivate in student pharmacists (although time and resources are limited).

A cross-sectional study on HIV-stigma was undertaken by Sianturi et al. in 2022, using pharmacists and pharmacy students as participants. The findings indicate that pharmacists were more knowledgeable about HIV therapy and shown greater empathy than pharmacy students. These discrepancies in knowledge and empathy may be brought on by the fact that many pharmacy students lack any prior patient-care experience.

Other

Other determinants that discussed in the included studies were career preference,^30,31 intercultural sensitivity,²⁶ stigma,³³ altruism, grit, self-awareness,²⁹ marital status, and family income.³⁵

In the context of pharmacy, empathy may also differ based on career preference. Two studies discussed career preference, and both reported that in terms of students' preferred future careers, there were no significant differences in empathy.^30,31 Future research should clarify whether pharmacists' empathy levels vary depending on their professional field, even though no significant mean differences were found between pharmacy students' preferred future careers in this current study.

A cross-sectional study on HIV-stigma among healthcare professionals was undertaken by Sianturi et al. in 2022, using both pharmacists and pharmacy students as participants.³³ This stigma has been characterized as the irrational belief, unfavorable behavior, and negative attitude toward patients due to their HIV status. The findings indicate that compared to students, pharmacists demonstrated greater empathy and knowledge about HIV treatment. Many pharmacy students lack patient care experience, which could account for the disparities in knowledge and empathy. Lower levels of empathy and inadequate HIV knowledge were substantially associated to stigma.

Altruism, grit, and self-awareness were additional factors that were perceived to be related to empathy scores. According to Reed et al. there is a weak to moderate correlation between empathy and altruism. Along with grit, empathy was tangentially associated with neither self-awareness nor locus of control.²⁹ Ekong et al. showed that the Pearson correlation demonstrated a strong association between higher attitudes toward empathy and a higher propensity for intercultural sensitivity. This relationship was like that with intercultural sensitivity.²⁶ On the other hand, to Fashami et al. found no statistically significant variations were found between empathy scores and its dimensions with regard to marital status and family wealth, in their 2021 study.³⁵