| Home | E-Submission | Sitemap | Contact us |  
Korean J Med Educ > Volume 30(3); 2018 > Article
Kim: Factors influencing nursing students’ empathy



This study attempted to examine nursing students’ self-esteem, interpersonal relationships, and self-efficacy, to identify factors affecting empathy.


A predictive correlational design was used. The participants in this study were nursing students from fours university of Korea. The questionnaires were administered to a convenience sample of 147 nursing students in the Republic of Korea.


Mean item scores for self-esteem, interpersonal relationship, self-efficacy, and empathy were 3.83, 3.63, 3.30, and 3.44, respectively (possible range, 1–5). Empathy was correlated with self-esteem, interpersonal relationships, and self-efficacy. The multiple regression analysis revealed that 45.9% of the variance in empathy is attributable to gender, major satisfaction, self-esteem, self-efficacy, and interpersonal relationships. The most important factor interpersonal relationship explained.


Improving nursing students’ major satisfaction, self-esteem, self-efficacy, and interpersonal relationships are strategies that may foster empathy.


Empathy is the ability to understand another person’s emotions and circumstances, thereby fostering communication [1]. It is essential for understanding and promoting others’ health and plays a vital role in forming treatment relationships and thus determining nursing quality [2]. An empathic approach to patient care can lead to more positive outcomes such as enhancing patient satisfaction, compliance with treatment regimens, factual history-taking, accurate diagnoses, effective resource utilization and the minimization of patient litigation [3]. Empathy in clinical environments results in greater patient satisfaction [4] and better compliance [4]. Increased empathic behaviors can enable greater diagnostic accuracy and minimize clinical errors and lapses in professional behavior [5].
Despite the compelling evidence for the importance of empathy in patient care, the literature suggests current undergraduates in the healthcare field not only display less empathy than did previous generations [6] but they also fail to acknowledge the importance of empathy [7]. Empathy is closely related to interpersonal relationships, communication skills, self-esteem, and self-efficacy [8] and those with high empathy tend to form positive relationships [9]. Furthermore, several factors that influence nursing students’ empathy have been confirmed, such as motivation for choosing nursing as a major or satisfaction with their nursing major [10]. However, studies of factors contributing to nursing students’ empathy are limited.
Williams et al. [11] emphasized that patients want empathic and emotionally capable nurses. They suggest educators are responsible for promoting students’ empathy through education. According to Vanlaere et al. [12] empathy involves cognitive responses learned and developed through basic nursing instruction and clinical practice. Globally, nurse educators have recognized empathy as the basis of therapeutic communication and have incorporated it into nursing curricula [12]. Both the study of factors influencing nursing students’ empathy and the development and application of educational programs to promote empathy are very important, as they focus on the future of the nursing profession. Thus, the present study investigated nursing students’ empathy levels and related factors to provide fundamental data for educational programs aimed at promoting empathy. This study investigated: (1) nursing students’ empathy levels; (2) the relationship between empathy, selfesteem, self-efficacy, and interpersonal relationships and their general characteristics; (3) correlations between nursing students’ empathy, self-esteem, selfefficacy, and interpersonal relationships; and (4) the influence of self-esteem, self-efficacy, and interpersonal relationships on empathy.


1. Study design

This descriptive survey investigated nursing students’ empathy, self-esteem, self-efficacy, and interpersonal relationships, and the factors that influence nursing students’ empathy.

2. Participants

The participants in this study were nursing students from four universities located in Daejeon. The final subjects were selected using G*Power ver. (Heinrich-Heine-University Düsseldorf, Germany). When a multiple regression analysis for the ten predictive variables was conducted, the minimum sample size calculated for a medium effect size of 0.15, with a significance level of 5% and a test power of 90%, was 147 subjects. A total of 160 people were recruited, but 13 subjects provided insincere answers; thus, 147 participants’ responses were analyzed.

3. Measures

1) Empathy

The Interpersonal Reactivity Index, which was developed by Davis [13] and adapted for use in Korea by Jeon [14] was used to measure empathy. It comprises two factors (cognitive and emotional empathy) with 28 total questions. Each item is scored on a 5-point Likert scale, with higher scores indicating higher levels of empathy. The reliability (Cronbach’s α) of Korean scale of Jeon [14] was 0.83, and it was 0.74 in this study.

2) Self-esteem

The Rosenberg Self-Esteem Scale [15] which was translated into Korean and adapted by Yang [16] was used to measure self-esteem. It comprises ten items (five positive and five negative), each scored on a 5-point Likert scale, with higher scores indicating higher levels of self-esteem. Possible scores range from 10 to 50. The reliability (Cronbach’s α) of the adapted scale was 0.85, and it was 0.83 in this study.

3) Interpersonal relationships

Relationship Change Scale of Schlein and Guerney [17], modified by Lee and Moon [18] to fit the Korean context, was used to measure the quality of everyday interpersonal relationships. This scale comprises 25 items, each scored on a 5-point Likert scale, with higher scores indicating better interpersonal relationships. The reliability of the adapted scale was 0.88, and it was 0.94 in this study.

4) Self-efficacy

The Self-efficacy Scale, which was developed by Sherer et al. [19] and adapted by Hong [20] was used to measure self-efficacy. It measures an individual’s confidence level for specific performance in specific circumstances. This scale comprises 17 items, each scored on a 5-point Likert scale, with higher scores indicating higher self-efficacy. Cronbach’s α for the scale was 0.86 when measured initially and 0.93 in this study.

4. Data collection and ethical considerations

This study was conducted with the approval of the Daejeon University Research Ethics Committee (approval no., 1040647). Prior consent to use the tools was obtained via email. Data were collected between February 1 and March 25, 2016. The researcher visited the university nursing departments between February 1 and March 25, 2016. And the researcher explained the study purpose and program process. Investigations began after university permissions were obtained. Participants were first informed that their anonymity would be maintained, that the data would be processed for study purposes only, and that they could decline to participate at any point during the study.

5. Statistical analysis

IBM SPSS ver. 21.0 (IBM Corp., Armonk, USA) was used for data storage and tabulation, and for generating descriptive statistics. Means were used to describe the descriptive data, and an independent samples t-test and analysis of variance were used to determine if any differences existed between gender, grade, age groups, and religion. A Shapiro-Wilk normality test was conducted to check the normal distribution. The correlation between empathy, major satisfaction, self-esteem, interpersonal relationships, and self-efficacy were analyzed using Pearson’s correlation coefficients, and a hierarchical multiple regression was used to investigate the effects of empathy factor.


1. Participant demographics

Participants’ mean age was 22.23±2.05 years. The majority of the participants were women and 3rd and 4th year students (124 and 84 students, 84.4% and 57.1%, respectively). Regarding “major satisfaction,” 74 participants (50.3%) were “almost satisfied,” 39 (26.5%) were “moderately satisfied,” 28 (19.0%) were “very satisfied,” and six (4.1%) were “almost dissatisfied” (Table 1).

2. Descriptive statistics of study variables

Mean empathy score was 3.44±0.34 (maximum=5); self-esteem ranged from 2.67 to 5, with a mean value of 3.83±0.62. The mean interpersonal relationships score was 3.63±0.53, and the mean self-efficacy score was 3.30±0.58 (Table 2).

3. Differences in study variables according to participants’ characteristics

Results of the normality test show that the scores for empathy, self-esteem, interpersonal relationships, and self-efficacy of each group were normally distributed. For empathy, self-esteem and self-efficacy there were no significant difference depending on age, gender, grade, or religion. For self-esteem, there was a significant difference depending on age (F=5.182, p=0.007), but there was no significant difference depending on other variables (Table 3).

4. Correlations between subjects’ empathy, self-esteem, interpersonal relationships, and self-efficacy

Empathy was positively correlated with self-esteem (r=0.453, p<0.001), interpersonal relationships (r=0.529, p<0.001), and self-efficacy (r=0.270, p=0.001). Selfesteem was positively correlated with interpersonal relationships (r=0.670, p<0.001) and self-efficacy (r=0.582, p<0.001), and interpersonal relationships was positively correlated with self-efficacy (r=0.435, p<0.001). Thus, a positive correlation was observed among all variables in this study. Major satisfaction was positively correlated with self-esteem (r=0.281, p<0.001), interpersonal relationships (r=0.167, p=0.043), and selfefficacy (r=0.309, p<0.001) (Table 4).

5. Factors influencing participants’ empathy

A hierarchical multiple regression was conducted to investigate the factors that influence empathy. The basic assumptions of the regression analysis for independent variables—normality, linearity, equal dispersed phase, and multicollinearity of residuals—were tested. Histogram and regression standardization confirmed that the residuals were close to the 45-degree line in the normal P-P plot analysis, whereas in the dispersion phase diagrams of the residuals were randomly distributed along the mean value 0, within 3, without particular rules, trends, or trend cycles. Regarding auto-correlation of errors, the Durbin-Watson statistics value of 2.050 was close to the reference value 2, indicating no auto-correlation problems. Its tolerance ranged from 0.441 to 0.986, which is above 0.1, and the variation inflation factor ranged from 1.014 to 2.270, remaining below the standard of 10, thus confirming no problems with multicollinearity.
When the general characteristics variables were first included to determine the factors influencing participants’ ability to empathize (Model 1), an explanation power of 0.1% was observed. When the variable of major satisfaction was additionally inserted to Model 1 (Model 2), the explanation power rose to 6.6%. Consequently, when the variables of self-esteem, interpersonal relationships, and self-efficacy were added to Model 2 (Model 3), the explanation power increased to 45.9%. In Model 3, the factors that influenced the ability to empathize were gender (β=0.180, p=0.004), major satisfaction (β=0.135, p=0.039), self-esteem (β=0.385, p<0.001), interpersonal relationships (β=0.387, p<0.001), and self-efficacy (β=0.121, p=0.034) (Table 5).


This study attempted to examine nursing students’ empathy, self-esteem, interpersonal relationships, and self-efficacy, in addition to identifying the factors contributing to their empathy. The mean empathy score of 3.44 is slightly higher than the “moderate” rating. These results are similar to those obtained by Chung [10] in his study of nursing students, which used the same tools, and obtained by Lee et al. [21] in their study that measured nurses’ empathy levels. These findings suggest students’ empathy is inadequate; thus, systematic education strategies to enhance nursing students’ empathy levels are necessary.
In this study, empathy was significantly correlated with self-esteem, interpersonal relationships, and selfefficacy. That is, higher self-esteem and self-efficacy, and better interpersonal relationships, are associated with higher levels of empathy. This is consistent with previous studies that found higher self-esteem [22] and positive interpersonal relationships [9] can improve empathy. This underscores the need for interventions and supportive environments that improve students’ selfesteem and self-efficacy and promote interpersonal relationships. Furthermore, Adler and Fagley [23] reported that educators’ supportive language, encouragement, positive conversations, and manners, among other factors bolster students’ self-esteem. Such supportive education methods can foster nursing students’ selfesteem, interpersonal skills, and empathy.
Self-esteem, interpersonal relationships, self-efficacy, major satisfaction, and gender had significant influences on nursing students’ empathy, contributing 45.9% of the variance. The most influential factor was interpersonal relationships. This is consistent with findings of Lim and Park [9] of an inverse relationship between stressful interpersonal relationships and empathy. Poor interpersonal skills and previous negative experiences can lead to negative reactions to others’ thoughts and emotions. The resulting negative emotions can then inhibit empathic concerns [9]. Moreover, interpersonal relationships are related to communication, empathy, and self-esteem [24]. Communication skills are essential to forming positive interpersonal relationships, and both of them can improve with consistent and systematic education and training [12]. Furthermore, empathy involves understanding myriad patient experiences. This skill can be facilitated through discussions concerning diverse subjects and through extra-curricular activities [25]. According to Vanlaere et al. [12], methods that facilitate understanding others’ experiences, such as role play and scenario-based simulation practice, can help students develop empathy more so than theory. Educators play an important role in fostering empathy. They need to provide students with opportunities to understand others’ emotions and circumstances, as well as opportunities to express empathy [26].
Empathy is an essential skill for forming treatment relationships with patients. It can be improved through systematic training and education. Nurses and nursing students can actively manage challenging clinical situations [26] and form positive interpersonal relationships when empathizing with others. Self-esteem and self-efficacy contribute to the development of empathy [9]. Thus, multilateral and multi-dimensional education programs and applications that can improve self-esteem, self-efficacy, interpersonal relationships, and empathy are necessary.
This study is significant because it identifies major satisfaction and interpersonal relationships as significant factors that affect nursing students’ empathy. However, it has some limitations. The findings must be interpreted with caution, as the sample was selected from a single city, thus limiting its generalizability. Furthermore, the number of male participants was small. Follow-up studies with sufficient male samples are needed, so that gender differences can be verified. Third, since all the variables were measured using self-reports, these findings may not be representative of participants’ responses in real-life situations.




The authors received no financial support for the research, authorship, and publication of this article.
Conflicts of interest
No potential conflict of interest relevant to this article was reported.
Authors’ contribution
All work was done by Jihyun Kim.

Table 1.
Participants’ Demographic Characteristics (N=147)
Variable Value
Age (yr) 22.23±2.05
 ≤21 56 (38.1)
 22 50 (34.0)
 ≥23 41 (27.9)
 Female 124 (84.4)
 Male 23 (15.6)
 1–2 63 (42.9)
 3–4 84 (57.1)
 Protestant 39 (26.5)
 Catholic 23 (15.6)
 Buddhist 13 (8.8)
 None 71 (48.3)
 Others 1 (0.7)
Major satisfaction 3.733±0.77
 Very satisfied 28 (19.0)
 Almost satisfied 74 (50.3)
 Moderate 39 (26.5)
 Almost dissatisfied 6 (4.1)
 Very dissatisfied 0
Living status
 Rented/boarding house 44 (29.9)
 Parents 40 (27.2)
 Dormitory 45 (30.6)
 Friend 14 (9.5)
 Other 4 (2.7)

Data are presented as mean±standard deviation or number (%).

Table 2.
Participants’ Empathy, Self-Esteem, Interpersonal Relationships, and Self-Efficacy Scores (N=147)
Variable Minimum Maximum Mean±standard deviation
Empathy 2.61 4.36 3.44±0.34
Self-esteem 2.67 5.00 3.83±0.62
Interpersonal relationship 1.96 5.00 3.63±0.53
Self-efficacy 1.88 4.94 3.30±0.58
Table 3.
Differences in Study Variables According to Participants’ Characteristics (N=147)
Characteristic No. of participants Empathy Self-esteem Interpersonal relationship Self-efficacy
Age (yr)
 ≤21 56 3.45±0.36 3.82±0.64 3.61±0.48 3.22±0.58
 22a) 50 3.41±0.28 3.65±0.63 3.61±0.55 3.25±0.53
 ≥23b) 41 3.46±0.49 4.06±0.57 3.69±0.57 3.46±0.61
 F-value (p-value) 0.371 (0.691) 5.182 (0.007) 0.327 (0.722) 2.347 (0.099)
 Scheffe’s test a)<b)
 Female 124 3.46±0.34 3.79±0.61 3.63±0.51 3.29±0.59
 Male 23 3.34±0.34 4.02±0.65 3.67±0.64 3.35±0.49
 t-value (p-value) 1.502 (0.135) -1.648 (0.102) -0.370 (0.712) -0.454 (0.651)
 1–2 63 3.46±0.40 3.90±0.66 3.63±0.51 3.28±0.60
 3–4 84 3.42±0.30 3.78±0.59 3.63±0.54 3.31±0.56
 t-value (p-value) 1.502 (0.135) -1.648 (0.102) -0.370 (0.712) -0.454 (0.651)
 Yes 76 3.46±0.37 3.89±0.61 3.69±0.53 3.31±0.56
 No 71 3.41±0.31 3.77±0.63 3.57±0.52 3.28±0.59
 t-value (p-value) 0.876 (0.382) 1.207 (0.229) 1.394 (0.165) 0.326 (0.745)

Data are presented as mean±standard deviation, unless otherwise stated.

a) 22 years old.

b) Over 23 years old.

Table 4.
Correlations between Empathy, Self-Esteem, Interpersonal Relationships, and Self-Efficacy (N=147)
Variable Empathy Self-esteem Interpersonal relationships Major satisfaction
Empathy - 0.158 (0.057)
Self-esteem 0.453 (<0.001)** - 0.281 (0.001)**
Interpersonal relationships 0.529 (<0.001)** 0.670 (<0.001)** - 0.167 (0.043)**
Self-efficacy 0.270 (0.001)* 0.582 (<0.001)** 0.435 (<0.001)** 0.309 (<0.001)***

Data are presented as r (p-value).

* p<0.05,

** p<0.01,

*** p<.001.

Table 5.
Factors Influencing Empathy (N=147)
Dependent variable Independent variable Unstandardized coefficients
Standardized coefficients
t-value R2 (adjusted R2) F-value
β Standard error β
Model 1 Grade 1.089 1.632 0.056 0.667 0.123 (0.001) 1.105
Gender 3.109 2.223 0.116 1.399
Model 2 Grade 0.455 1.589 0.023 0.286 0.292 (0.066) 4.457***
Gender 4.260 2.177 0.160 1.957
Major satisfaction 3.426 1.033 0.271 3.318*
Model 3 Grade 0.162 1.215 0.008 0.133 0.694 (0.459) 21.649***
Gender 4.811 1.659 0.180 2.900**
Major satisfaction 1.710 0.822 0.135 2.080**
Self-esteem 0.643 0.153 0.385 4.196**
Interpersonal relationship 0.280 0.061 0.387 4.561**
Self-efficacy 0.130 0.083 0.121 1.564*

Dummy variables: grade (1–2, 1; 3–4, 0) and gender (women, 1; men, 0).

* p<0.05,

** p<0.01,

*** p<0.001.


1. Del Canale S, Louis DZ, Maio V, et al. The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy. Acad Med 2012; 87(9):1243-1249.
crossref pmid
2. Burhans LM, Alligood MR. Quality nursing care in the words of nurses. J Adv Nurs 2010; 66(8):1689-1697.
crossref pmid
3. Ahrweiler F, Neumann M, Goldblatt H, Hahn EG, Scheffer C. Determinants of physician empathy during medical education: hypothetical conclusions from an exploratory qualitative survey of practicing physicians. BMC Med Educ 2014; 14: 122.
crossref pmid pmc pdf
4. Dal Santo L, Pohl S, Saiani L, Battistelli A. Empathy in the emotional interactions with patients: is it positive for nurses too? J Nurs Educ Pract 2013; 4(2):74-81.
5. Boyle M, Williams B, Brown T, et al. Levels of empathy in undergraduate health science students. Internet J Med Educ 2010; 1(1):1-7.
6. Konrath SH, O’Brien EH, Hsing C. Changes in dispositional empathy in American college students over time: a meta-analysis. Pers Soc Psychol Rev 2011; 15(2):180-198.
crossref pmid
7. Fields SK, Mahan P, Tillman P, Harris J, Maxwell K, Hojat M. Measuring empathy in healthcare profession students using the Jefferson Scale of Physician Empathy: health provider--student version. J Interprof Care 2011; 25(4):287-293.
crossref pmid
8. Bae EK. The effect of empathic ability on school adjustment mediated by self-esteem. J Korean Assoc Psychother 2011; 3(1):85-100.

9. Lim SJ, Park EY. Changes in communication and relationship pattern for undergraduate nursing students after ‘Satir communication education’. J Korean Acad Soc Nurs Educ 2013; 19(2):151-162.
crossref pdf
10. Chung MS. Relations on self-esteem, empathy and interpersonal relationship for reinforcing competence in communication of nursing students. J Korean Acad Soc Nurs Educ 2014; 20(2):332-340.
crossref pdf
11. Williams B, Boyle M, Brightwell R, et al. An assessment of undergraduate paramedic students’ empathy levels. Int J Med Educ 2012; 3: 98-102.
12. Vanlaere L, Timmermann M, Stevens M, Gastmans C. An explorative study of experiences of healthcare providers posing as simulated care receivers in a ‘care-ethical’ lab. Nurs Ethics 2012; 19(1):68-79.
crossref pmid
13. Davis MH. A multidimensional approach to individual differences in empathy. JSAS Cat Sel Doc Psychol 1980; 10: 85.

14. Jeon BS. The relationship between empathy and altruistic behavior. [unpublished master’s thesis]. Daejeon. Korea: Choongnam National University; 2003.

15. Rosenberg M. Conceiving the self. New York, USA: Basic Books; 1979.

16. Yang HJ. The interaction effect between daily hassles and self-esteem on adjustment to college. [unpublished master’s thesis]. Seoul, Korea: Yonsei University; 2002.

17. Schlein S, Guerney BG. Relationship enhancement. San Francisco, USA: Josey-Bass; 1971.

18. Lee HD, Moon SM. The effect of group counseling program for interpersonal relationship training. Gyeongsang Natl Univ Res 1980; 19: 195-203.

19. Sherer M, Maddux JE, Mercandante B, Prentice-Dunn S, Jacobs B, Rogers RW. The self-efficacy scale: construction and validation. Psychol Rep 1982; 51(2):663-671.
20. Hong HY. The relationship of perfectionism, self-efficacy and depression. [unpublished master’s thesis]. Seoul, Korea: Ewha Woman’s University; 1995.

21. Lee EJ, Kim YK, Lee H. A study on the cultural competence of community health practitioners. J Korean Acad Community Health Nurs 2012; 23(2):179-188.
22. Murray SL, Holmes JG, Collins NL. Optimizing assurance: the risk regulation system in relationships. Psychol Bull 2006; 132(5):641-666.
crossref pmid pdf
23. Adler MG, Fagley NS. Appreciation: individual differences in finding value and meaning as a unique predictor of subjective well-being. J Pers 2005; 73(1):79-114.
crossref pmid
24. Jeong HS, Lee KL. Factors affecting nursing students’ interpersonal relationship ability. J Korean Data Anal Soc 2012; 14(5):2635-2647.

25. Chaffin AJ, Adams C. Creating empathy through use of a hearing voices simulation. Clin Simul Nurs 2013; 9(8):e293. e304.
26. Panosky D, Diaz D. Teaching caring and empathy through simulation. Int J Hum Caring 2009; 13(3):44-46.

Editorial Office
The Korean Society of Medical Education
(204 Yenji-Dreamvile) 10 Daehak-ro, 1-gil, Jongno-gu, Seoul 03129, Korea
Tel: +82-2-2286-1180   Fax: +82-2-747-6206
E-mail : kjme_office@daum.net
About |  Browse Articles |  Current Issue |  For Authors and Reviewers
Copyright © 2021 by Korean Society of Medical Education.                 Developed in M2PI