In brief
In a study of 204 Egyptian baccalaureate nursing students, empathy toward people with mental illness rose significantly after a 15-week psychiatric nursing course (mean score 52. 47 to 62.
What this article is about
Quick Answer
In a study of 204 Egyptian baccalaureate nursing students, empathy toward people with mental illness rose significantly after a 15-week psychiatric nursing course (mean score 52.47 to 62.64, p<0.001), with 100% of students reaching high empathy afterward versus 79.9% before. No sociodemographic factor significantly predicted the size of the change, and the one-group design limits causal conclusions.
Student takeaways
Key Takeaways
- Before the psychiatric nursing and mental health course, 79.9% of the 204 students already scored in the high-empathy range on the Empathy toward the Mentally Ill Scale; after the course, 100% scored high (chi-square = 45.580, p<0.001).
- Mean empathy scores rose from 52.47±5.84 before the course to 62.64±5.77 after it, a mean improvement of 20.53%±14.90 (t=21.743, p<0.001).
- At the individual level, 95.6% of students showed improved empathy scores after the course, 1.0% showed no change, and 3.4% scored lower.
- No statistically significant relationship was found between students' sociodemographic characteristics or prior experience with mental illness (sex, age, residence, prior academic or work exposure, prior personal contact) and the size of their empathy improvement (all p>0.05).
- Descriptively, the largest mean empathy gains were seen among male students, students aged 20 to under 22, urban residents, and students with prior personal contact with people with mental illness, though these differences did not reach statistical significance.
Student summary
Why This Research Matters
Empathy is one of the core communication skills a nurse needs, especially when caring for people with mental illness, who often face stigma even inside the health system. This 2015 study, published in the Journal of Education and Practice, asked a simple but important question: does the psychiatric nursing and mental health course in a baccalaureate nursing program actually change how empathetic students are toward patients with mental illness, or do students just arrive with whatever empathy they already have?
The study was carried out at the Faculty of Nursing, Alexandria University in Egypt, by Dr. Marwa Abd El-Gawad Ahmed Mousa, a lecturer in the Psychiatric Nursing and Mental Health Department. The researcher used a cross-sectional exploratory design with a single group of students measured twice: once immediately before their psychiatric nursing course began, and again right after they finished it. This before-and-after comparison, without a separate comparison group who skipped the course, is often called a one-group pretest-posttest design.
The course itself lasted 15 weeks. Students received 3 hours of theory per week for the full 15 weeks, plus 6 weeks of clinical training at 9 hours per week at El-Maamoura Hospital for Psychiatric Medicine, working in small groups of 10 to 12 students. Teaching methods included lectures, group discussion, role play, and interpersonal process recording, a clinical writing exercise used to help students reflect on their interactions with patients.
Out of 213 eighth-semester students originally enrolled, 204 completed both the before and after questionnaires (nine were excluded for repeating the course or missing too much of it due to absence). Most participants were female (61.8%), with a mean age of about 21 years, and about three-quarters lived in rural areas. Most had no prior academic exposure to psychiatry (82.4%) and had not previously worked in a psychiatric setting (86.8%), though about a third had some personal contact with a person with mental illness, most often someone who was homeless.
To measure empathy, students completed the Empathy toward the Mentally Ill Scale, a 16-item tool adapted from the well-known Emotional Empathic Tendency Scale. Scores range from 16 to 80, with scores above 48 counted as "high" empathy.
The results were striking. Before the course, about 80% of students already scored in the high-empathy range. After the course, every single student (100%) scored high. The average empathy score rose from about 52 out of 80 before the course to about 63 after, an average improvement of roughly 20%, a change the researchers found to be statistically significant. Looking at individual students, 95.6% showed some improvement, 1% showed no change, and 3.4% actually scored lower afterward.
Interestingly, when the researcher checked whether student characteristics like sex, age, rural versus urban residence, or prior experience with mental illness predicted how much a student's empathy improved, none of these differences reached statistical significance. There were some numerical trends, for instance, male students and those with prior personal contact with someone with mental illness showed slightly larger average gains, but these differences could have occurred by chance.
The researcher concluded that going through a structured psychiatric nursing and mental health educational experience, combining theory and supervised clinical practice, can meaningfully improve nursing students' empathy toward people with mental illness. She recommended that nursing programs consider using empathy scales like this one as a feedback tool for both students and instructors, and called for future studies that follow students across multiple semesters and compare different psychiatric nursing courses across different nursing schools.
For nursing students, the practical takeaway is that empathy toward people with mental illness is not simply something you either have or don't have. It appears to be something that structured clinical education, self-reflection exercises, and supervised patient contact can actively shape and strengthen over time.
Source abstract
Study Overview
Empathy is an ability and skill that can be learned and developed through appropriate education and practice. While the importance of nurses' empathy is widely acknowledged, little is known about the impact of passing through the psychiatric nursing and mental health educational experience at the Faculty of Nursing, Alexandria University on students' level of empathy. This study aimed to assess the change in level of empathy toward patients with mental illness among baccalaureate nursing students before and after completing a psychiatric nursing and mental health educational experience. The study followed a cross-sectional exploratory research design. It was conducted on 204 students in the eighth semester of the academic year 2012-2013, who were enrolled in the course of psychiatric nursing and mental health. A Student's Socio-demographic Characteristics and Previous Experience with Mental Illness Questionnaire and Empathy toward the Mentally Ill Scale were used to collect data. The results indicated that all students significantly achieved high levels of empathy after the psychiatric nursing experience. It was concluded that passing through a psychiatric nursing and mental health educational experience can improve baccalaureate nursing students' empathy toward patients with mental illness. Recommendations included the need for further studies compare between students' levels empathy toward people with mental illness before and after completing various psychiatric nursing educational experiences at different faculties of nursing.
Evidence appraisal
Main Findings
- Before the psychiatric nursing and mental health course, 79.9% of the 204 students already scored in the high-empathy range on the Empathy toward the Mentally Ill Scale; after the course, 100% scored high (chi-square = 45.580, p<0.001).
- Mean empathy scores rose from 52.47±5.84 before the course to 62.64±5.77 after it, a mean improvement of 20.53%±14.90 (t=21.743, p<0.001).
- At the individual level, 95.6% of students showed improved empathy scores after the course, 1.0% showed no change, and 3.4% scored lower.
- No statistically significant relationship was found between students' sociodemographic characteristics or prior experience with mental illness (sex, age, residence, prior academic or work exposure, prior personal contact) and the size of their empathy improvement (all p>0.05).
- Descriptively, the largest mean empathy gains were seen among male students, students aged 20 to under 22, urban residents, and students with prior personal contact with people with mental illness, though these differences did not reach statistical significance.
Practice transfer
Clinical Relevance
- A structured psychiatric nursing course combining theoretical teaching with supervised clinical placement may help build students' empathy toward patients with mental illness, a skill directly relevant to therapeutic communication in psychiatric and general nursing practice.
- Clinical teaching elements such as role play, small-group supervision, and interpersonal process recording (guided reflective writing on patient interactions) appear to be practical tools nurse educators can use to foster empathic communication skills.
- Because empathy did not differ significantly by student demographics in this study, programs should not assume that any subgroup of students needs a substantially different approach to empathy education based on sex, age, or background alone.
- Instruments like the Empathy toward the Mentally Ill Scale could be used by nursing faculty as a formative feedback tool, helping both students and instructors identify where empathy needs further development during a course.
- Since the study's design cannot separate the effect of the course itself from general maturation or other concurrent coursework, clinicians and educators should treat this as supportive, not definitive, evidence for course-specific effectiveness, and pair it with ongoing supervised practice rather than relying on a single course alone.
Faculty notes
Educational Relevance
This 2015 study by Mousa, published in the Journal of Education and Practice (Vol. 6, No. 24), examined whether a psychiatric nursing and mental health course changed baccalaureate nursing students' empathy toward patients with mental illness. The study was conducted at the Faculty of Nursing, Alexandria University, Egypt, using a one-group, cross-sectional exploratory pretest-posttest design with no comparison group of students who did not take the course.
Participants were 204 eighth-semester students (of 213 originally enrolled; 9 excluded for course repetition or absenteeism) during academic year 2012-2013. The course spanned 15 weeks: 3 theory hours weekly across all 15 weeks, plus 6 weeks of clinical placement at 9 hours per week at El-Maamoura Hospital for Psychiatric Medicine, in small clinical groups of 10-12, using lectures, discussion, role play, and interpersonal process recording.
Instruments included a researcher-developed sociodemographic and prior-experience questionnaire, and the Empathy toward the Mentally Ill Scale, a 16-item, 5-point Likert instrument (score range 16-80; scores above 48 classed as "high" empathy) adapted from Mehrabian and Epstein's Emotional Empathic Tendency Scale, further modified for mental illness content by Turner (2007, reported alpha = 0.71). The researcher's own pilot reliability testing on 20 students yielded Cronbach's alpha = 0.801, and content validity was reviewed by a five-expert jury; the tool was translated into Arabic for administration.
Before the course, 79.9% of students already scored in the high-empathy range; after the course, 100% did (chi-square = 45.580, p<0.001). Mean empathy scores rose from 52.47±5.84 to 62.64±5.77, a mean change of 20.53%±14.90 (t=21.743, p<0.001). At the individual level, 95.6% of students improved, 1.0% showed no change, and 3.4% declined. No sociodemographic or prior-experience variable (sex, age, residence, prior academic psychiatric study, prior psychiatric work, prior personal contact with mental illness) showed a statistically significant relationship with the magnitude of change (all p>0.05), though descriptive trends favored male students, younger students, urban residents, and those with prior contact or academic exposure.
For classroom discussion, this study is a useful case for teaching critical appraisal of pretest-posttest designs. Ask students to identify threats to internal validity here: without a control group, gains could partly reflect maturation, general exposure to nursing coursework across the semester, testing effects (students becoming familiar with the scale), or social desirability responding on a self-report instrument administered by course faculty. It is also worth noting that the literature is genuinely mixed: the authors cite other studies (Nunes et al. 2011; Ozcan et al. 2010; Ward et al. 2012) reporting empathy decline or no change after psychiatric or clinical exposure, which the discussion section engages directly rather than ignoring.
Practical classroom uses include: comparing this design to a randomized or comparison-group alternative; discussing why an Egyptian single-site study's descriptive (non-significant) demographic trends should not be over-generalized; and using the specific instrument (Empathy toward the Mentally Ill Scale) as an example of scale adaptation and translation in cross-cultural nursing research. Faculty might also use the study to prompt discussion of how clinical teaching structure, small-group supervision, role play, and reflective writing (interpersonal process recording) may function as active ingredients distinct from course content alone.
Critical appraisal
Limitations
- The one-group pretest-posttest design lacked a control or comparison group of students who did not take the course, so improvements cannot be fully separated from maturation, concurrent coursework, or general familiarity with the empathy scale over time.
- Empathy was measured using a self-report Likert scale, which is subject to social desirability bias, particularly since the same faculty overseeing the course administered the pre- and post-course questionnaires.
- The study was conducted at a single institution (Faculty of Nursing, Alexandria University, Egypt), limiting generalizability to other nursing programs, countries, or curricula with different course structures.
Classroom use
Discussion Questions
- Why might a one-group pretest-posttest design overstate the true effect of the psychiatric nursing course on student empathy, and what alternative design could better isolate the course's specific contribution?
- The study found no statistically significant link between sociodemographic characteristics and empathy change, yet some descriptive trends (e.g., male students showing larger gains) were reported. How should nurse educators interpret non-significant trends like these?
- The Empathy toward the Mentally Ill Scale was translated into Arabic for use in this study. What steps would you want to see taken to confirm a translated scale still measures the same construct as the original?
- About 80% of students already scored 'high' on empathy before the course even began. What does this suggest about where empathy toward people with mental illness comes from earlier in a nursing curriculum or in students' lives generally?
- The course combined 15 weeks of theory with 6 weeks of supervised clinical placement using role play and interpersonal process recording. Which of these components do you think most plausibly drives empathy change, and how would you test that assumption?
- 3.4% of students scored lower on empathy after the course. What factors might explain a decline in empathy following clinical exposure to patients with mental illness, based on the studies the authors cite (e.g., Ward et al. 2012)?
- How does self-report measurement of empathy differ from observed or patient-rated measures of empathic behavior, and which do you think is more clinically meaningful for patient care?
- The researcher recommends longitudinal studies tracking empathy across all eight semesters of the nursing program. What would such a study need to include to identify which specific educational experiences most influence empathy development?
- Given that this study occurred in Egypt with mostly rural, young adult nursing students, what cultural or contextual factors might limit how directly its findings apply to Canadian nursing education settings?
- If you were designing a follow-up study to test whether empathy gains from this course persist into clinical practice after graduation, what outcome measures and timeframe would you choose?
Knowledge check
Quiz
1. What research design did this study use to assess change in student empathy?
- Randomized controlled trial
- Cross-sectional exploratory (one-group pretest-posttest) design
- Longitudinal cohort study across all semesters
- Case-control study
Rationale: The abstract and methods state: 'The study followed a cross-sectional exploratory research design,' measuring the same students before and after the course with no separate comparison group.
2. How many students' data were included in the final analysis?
- 150 students
- 204 students
- 213 students
- 250 students
Rationale: The abstract states the study 'was conducted on 204 students' after nine of the original 213 were excluded for repeating the course or absenteeism.
3. What instrument was used to measure students' empathy toward people with mental illness?
- The Jefferson Scale of Empathy
- The Empathy toward the Mentally Ill Scale
- The Attitudes to Mental Illness Questionnaire
- The Toronto Empathy Questionnaire
Rationale: The abstract states: 'A Student's Socio-demographic Characteristics and Previous Experience with Mental Illness Questionnaire and Empathy toward the Mentally Ill Scale were used to collect data.'
4. What percentage of students scored in the 'high empathy' range before the course, versus after it?
- 50% before, 75% after
- 79.9% before, 100% after
- 90% before, 95% after
- 60% before, 80% after
Rationale: The results report: before the experience, 79.9% of students had high empathy; after completing it, 100% achieved high empathy (chi-square = 45.580, p<0.001).
5. How did students' mean empathy scores change from before to after the course?
- They stayed the same at 52.47
- They decreased from 62.64 to 52.47
- They increased from 52.47 to 62.64
- They increased from 30 to 60
Rationale: The results state the mean score increased from 52.47±5.84 before the course to 62.64±5.77 after it, a significant mean change of about 20.53% (t=21.743, p<0.001).
6. What proportion of students showed improved empathy scores after completing the course, versus no change or a decline?
- 95.6% improved, 1.0% no change, 3.4% worsened
- 50% improved, 50% worsened
- 100% improved, 0% worsened
- 80% improved, 20% worsened
Rationale: The results state: 'the majority (95.6%) of students showed improvement in their level of empathy, whereas 1.0% and 3.4% of them did not show change or worsened respectively.'
7. Which sociodemographic or experience variables were found to have a statistically significant relationship with the amount of empathy change?
- Sex and age only
- Prior personal contact with mental illness only
- None of the variables tested reached statistical significance
- Residence and prior psychiatric work only
Rationale: The results state there were 'no statistically significant relationships between all students' socio-demographic characteristics and previous experience...and the mean change percent of the Empathy toward the Mentally Ill (p>0.05).'
8. Where and how long was the clinical training component of the psychiatric nursing course delivered?
- 12 weeks at a general hospital, 5 hours/week
- 6 weeks at El-Maamoura Hospital for Psychiatric Medicine, 9 hours/week, in groups of 10-12 students
- 3 weeks in a simulation lab only
- 15 weeks at a community mental health clinic
Rationale: The full text states clinical training was 'given 9 hours/week for 6 weeks' at 'El-Maamoura Hospital for Psychiatric Medicine,' carried out 'on a small group basis (10-12 students/group).'
9. What is the most significant methodological limitation of this study's design for concluding the course caused the empathy change?
- The sample size was too small to detect any difference
- There was no control or comparison group of students who did not take the course
- Empathy was measured using an objective behavioral test rather than self-report
- The study used qualitative interviews instead of a validated scale
Rationale: The study used a one-group pretest-posttest cross-sectional exploratory design measuring the same 204 students before and after, without any comparison group, limiting causal claims about the course itself.
10. What did the researcher recommend for future research based on this study's findings?
- No further research is needed since the results were conclusive
- Further studies comparing students' empathy levels before and after various psychiatric nursing experiences at different faculties of nursing
- Repeating the exact same study with the same students next year
- Abandoning the Empathy toward the Mentally Ill Scale as unreliable
Rationale: The abstract's recommendations state: 'the need for further studies compare between students' levels empathy toward people with mental illness before and after completing various psychiatric nursing educational experiences at different faculties of nursing.'
Study cards
Flashcards
What was the main aim of this study?
To assess the change in level of empathy toward patients with mental illness among baccalaureate nursing students before and after completing a psychiatric nursing and mental health educational experience.
Where was this study conducted?
At the Faculty of Nursing, Alexandria University, Egypt.
What research design did the study use?
A cross-sectional exploratory, one-group pretest-posttest design (same students measured before and after the course, no separate control group).
How many students participated in the final analysis, and how many were originally enrolled?
204 students were included in the final analysis, out of 213 originally enrolled (9 were excluded for repeating the course or absenteeism).
What instrument measured students' empathy toward people with mental illness?
The Empathy toward the Mentally Ill Scale, a 16-item, 5-point Likert scale adapted from the Emotional Empathic Tendency Scale.
Who originally developed the Emotional Empathic Tendency Scale, on which the study's empathy tool was based?
Mehrabian and Epstein (1972); it was later modified for mental illness content by Turner (2007).
What score range on the Empathy toward the Mentally Ill Scale indicates 'high' empathy?
A score above 48 (out of a possible 16-80 range) is considered high empathy; 16-48 is considered low.
What percentage of students had high empathy before the course began?
79.9% of students had high empathy before the course.
What percentage of students had high empathy after completing the course?
100% of students had high empathy after completing the course.
What was the statistical significance of the change in empathy level (high vs. low) before and after the course?
Chi-square = 45.580, p<0.001, indicating a statistically significant increase in the proportion of students with high empathy.
What were the mean empathy scores before and after the course?
Mean score rose from 52.47±5.84 before the course to 62.64±5.77 after the course.
What was the mean percentage improvement in empathy scores, and was it statistically significant?
A mean change of 20.53%±14.90, statistically significant at t=21.743, p<0.001.
What proportion of students showed improvement, no change, or worsening in empathy after the course?
95.6% improved, 1.0% showed no change, and 3.4% worsened.
Did sociodemographic characteristics (sex, age, residence) significantly predict the amount of empathy change?
No; none of the sociodemographic or prior-experience variables tested showed a statistically significant relationship with the amount of empathy change (all p>0.05).
How long did the psychiatric nursing and mental health course last, and how was time split between theory and clinical training?
15 weeks total: 3 theory hours/week for 15 weeks, plus 6 weeks of clinical training at 9 hours/week.
Where did students complete their clinical training for this course?
At El-Maamoura Hospital for Psychiatric Medicine, in small groups of 10-12 students.
What clinical teaching methods were used to help build students' empathy skills?
Role play, interpersonal process recording (a reflective clinical writing exercise), and other clinical assignments, alongside lectures, discussion, and group interaction for theory.
What proportion of students had prior personal contact with someone with mental illness before the course, and who were these people most often?
35.3% of students had prior personal contact; most often a homeless patient (56.9%), followed by a relative (30.6%), friend/colleague (25.0%), or neighbor (16.7%).
What is the key conclusion the researcher drew from this study?
That passing through a psychiatric nursing and mental health educational experience (theoretical and clinical) can improve baccalaureate nursing students' empathy toward patients with mental illness.
What is a major limitation of interpreting this study's results as proof the course caused the empathy increase?
There was no control group of students who did not take the course, so the improvement could partly reflect maturation, other coursework, or repeated exposure to the same self-report scale rather than the course alone.
Search-ready answers
Frequently asked questions
Does taking a psychiatric nursing course actually increase nursing students' empathy toward people with mental illness?
According to this 2015 Egyptian study of 204 baccalaureate nursing students, yes: empathy scores rose significantly from before to after a 15-week psychiatric nursing and mental health course, with all students reaching 'high' empathy afterward compared to about 80% beforehand. However, because there was no comparison group of students who skipped the course, this cannot be treated as definitive proof the course alone caused the change.
What scale is used to measure nursing students' empathy toward the mentally ill?
This study used the Empathy toward the Mentally Ill Scale, a 16-item, 5-point Likert instrument adapted from Mehrabian and Epstein's Emotional Empathic Tendency Scale and later modified for mental illness content by Turner (2007). Scores range from 16 to 80, with scores above 48 classified as high empathy.
How many nursing students were studied, and where?
204 eighth-semester baccalaureate nursing students at the Faculty of Nursing, Alexandria University, Egypt, during the 2012-2013 academic year.
What was the study design, and does it prove the course caused the empathy increase?
It was a cross-sectional exploratory, one-group pretest-posttest design: the same students were measured before and after the course with no separate comparison group. This design shows a change over time but cannot rule out other explanations, such as general maturation or familiarity with the questionnaire.
Did male or female nursing students show greater improvement in empathy?
Descriptively, male students showed a slightly larger average empathy gain than female students, but this difference was not statistically significant (p>0.05), so it should not be treated as a reliable finding.
Does prior personal contact with someone with mental illness affect how much a nursing student's empathy improves during training?
In this study, students with prior personal contact with someone with mental illness showed a slightly higher average empathy gain, but this difference did not reach statistical significance, so no firm conclusion can be drawn.
How long is the clinical training component of this psychiatric nursing course?
Six weeks, at 9 hours per week, conducted at El-Maamoura Hospital for Psychiatric Medicine in small groups of 10 to 12 students, using methods such as role play and interpersonal process recording.
What percentage of nursing students had low empathy before the course, and did any student's empathy get worse afterward?
About 20.1% of students scored low on empathy before the course, dropping to 0% afterward. However, at the individual level, 3.4% of students actually scored lower after the course than before, even though the overall group average rose.
What are the main limitations of this empathy study for nursing education?
Key limitations include the lack of a control group, reliance on self-reported Likert-scale empathy measures, a single-institution sample in Egypt, and no long-term follow-up to see whether empathy gains persisted after the course ended.
What did the study recommend for future nursing education research on empathy?
The researcher recommended using validated empathy scales as ongoing feedback tools for students and instructors, and called for longitudinal studies tracking empathy across all semesters and comparative studies across different nursing faculties and psychiatric nursing course formats.