Nurse Education Today 33 (2013) 334–338

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

Feeling at hospitals: Perspective-taking, empathy and personal distress among

professional nurses and nursing students
Belén López-Pérez a,⁎, Tamara Ambrona a, Jennifer Gregory b, Eric Stocks b, Luis Oceja a
a
Universidad Autónoma de Madrid, Spain
b
University of Texas at Tyler, United States

a r t i c l e i n f o s u m m a r y

Article history: When facing a person in need, professional nurses will tend to adopt an objective perspective compared to
Accepted 15 January 2013 nursing students who, instead, will tend to adopt an imagine-other perspective. Consequently, professional
nurses will show lower vicarious emotional reaction such as empathy and distress. Using samples from
Keywords:
Spain (Studies 1 and 2) and United states (Study 3), we compared perspective taking strategies and the emo-
Empathy
tional responses of nurses and nursing students when perceiving a sick child (Study 1) and a sick adult (Stud-
Distress
Perspective taking
ies 2 and 3). Taken together, the results supported our hypotheses. We discuss the applied value of
Nursing considering the relationship between perspective-taking and its emotional consequences for the nursing
profession.
© 2013 Elsevier Ltd. All rights reserved.

Introduction expressions. However, this emotional responsiveness only happens

Those emotions that we feel when perceiving the suffering of
others (i.e., vicarious emotions) are a main component of the
nurse–patient relationship. For example, William (1989) found that
nursing students experienced distress and avoided the patient when
she or he was described as having a terminal illness because they
felt unable to relieve the patient's suffering. However, when facing a
non-terminal patient, the students showed empathy and care. In the
same vein, Stotland et al. (1978) had found that highly empathic
nursing students became emotionally exhausted when beginning
their career and would later actively avoid attending to terminal pa-
tients. Campbell-Yeo et al. (2007) suggest that nurses may feel help-
less when they are unable to relieve the pain of a patient and that
repeated exposure to this arousal leads to long-term exhaustion and
diminished interest. And after comparing emotional responses of un-
dergraduate students and graduate nursing students, Kunst-Wilson
et al. (1981) found that empathic accuracy increased with the educa-
tion level of the individual, and that nursing students feel higher
levels of distress when they begin working with patients but later
“learn” not to suffer. This increase in the empathic accuracy is
supported by Eide et al. (2011) who showed that professional nurses
showed high empathic accuracy when perceiving patients' emotional
when patients show sadness (Sheldon et al., 2009).
Feeling either empathy or distress can be influenced by the per-
spective taken by the observer. This perspective-taking is a
cognitive-perceptual process that determines how one individual
comes to understand the thoughts, feelings, and/or perceptual
awareness of another individual (Batson et al., 1987; Borrego,
2009). Two typically studied perspective-taking strategies have
been: remaining detached and not emotionally involved (objective
perspective), and imagining what the other is thinking and feeling
(imagine-other perspective) (Batson et al., 1997; Hoffman, 2002).
These two perspectives are associated with relatively distinct emo-
tional consequences. Specifically, an objective perspective tends to
minimize emotional responses to the unfortunate condition of
others whereas an imagine-other perspective tends to produce
vicarious emotions for the other, such us empathy and distress.
The existing research on nursing has focused on emotional re-
sponses considering either nursing students or professional nurses
and without assessing the different perspective-taking strategies in-
volved. In contrast, the present research investigates the differences in
the perspective taking strategies and vicarious emotional responses to
patients comparing professional nurses with nursing students.
Study 1

In Study 1, we compare the perspective-taking strategies and the

⁎ Corresponding author at: Departamento de Psicología Social y Metodología, Facultad
de Psicología, Universidad Autónoma de Madrid, 28049 Madrid, Spain. Tel.: +34
650305187.
E-mail address: belen.lopez@uam.es (B. López-Pérez).
consequences of nurses and nursing students in a Spanish popula-
tion. We predict that professional nurses will tend to adopt an objec-
tive perspective whereas nursing students will tend to adopt an
“imagine-other” perspective. Our hypothesis is based on two

0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nedt.2013.01.010
 B. López-Pérez et al. / Nurse Education Today 33 (2013) 334–338
findings. First, extensive research shows that objective-perspective
leads to feel a lower vicarious emotional reaction (i.e., empathy
and distress) than does imagine-other perspective (Davis, 1996;
Hoffman, 2002; Batson, 2011). Second, Cameron and Payne (2011)
recently showed that when people anticipate that they are going to
face with the suffering of many they tend to collapse their vicarious
emotional reaction (i.e., compassion, pain or distress). Therefore, as
professional nurses are used to daily face with different victims, we
reasoned that they will try to adopt an objective perspective as an
emotion regulation strategy to prevent a very intense vicarious emo-
tional reaction.
Method
Participants
Sixty people, between 18 and 55 years of age (M = 28.76, SD=
10.14), from different universities (nursing students, n = 30) and hospi-
tals (professional nurses, n = 30) agreed to participate (see Table 1).
Procedure
Participants from different areas of Madrid were asked to partici-
pate. They were told that their opinion was needed on a photograph.
After signing the informed consent, which contained the IRB number
approval from the university or hospital, the participants completed a
packet that consisted of an introduction to the study, followed by the
presentation of a picture (see Appendix 1). The participants then com-
pleted two questionnaires. The first included two separate items in
which participants indicated the extent to which they remained objec-
tive (i.e., “I tend to remain objective and not emotionally involved”) and
imagined the other's thoughts and feelings (“I tend to put myself in the
other shoes to understand how he/she is feeling about it”). Each item
had a 7-point Likert Like Scale response format (1= Never, 7 = Totally).
The second questionnaire was a version of the emotional response
questionnaire developed by Batson et al. (1987), adapted into Spanish
by Oceja and Jiménez (2007). The version used 12 emotional terms,
with a 7-point Likert Like Scale response format (from 1 = Not at all
to 7 =Extremely). This questionnaire was used to assess empathy and
distress and showed good internal psychometric properties in the
American (see Batson, 1991) and Spanish contexts (see Oceja and
Jiménez, 2007).
Results and Discussion
Perspective-Taking Strategies
We conducted a mixed-factor analysis of variance in which
perspective-taking measure was entered as within-subject factor,
role (students vs. professionals) as a between-subject factor, and
age as continuous covariate. The analysis did not show a significant
between-subject effect for either role or age, Fs (1, 57) b 0.40.
The within-subjects effect for perspective strategies also was not
significant, F(2, 56) = 2.00, p > .14. However, as expected, this effect
was qualified by the interaction with the role, F(2, 56) = 5.27,
p b .01. As it is shown in Table 2, the students reported a significantly
Table 1
Samples description for Studies 1, 2 & 3.
Nursing students
Study % % % %
Females Freshmen Sophomores Junior students
1 80 20 30 25
2 72 25 35 15
3 85 30 20 15
335
higher tendency to adopt an imagine-other (M = 5.50, SD = .97) than
an objective perspective (M = 3.20, SD = 1.54), t(29) = 2.53, p b .02.
In contrast, the professional nurses reported an equal tendency to
adopt objective (M = 4.77, SD = 1.10) and imagine-other (Ms =
4.30, SD = 1.60) perspectives. Age did not significantly interact
with perspective-taking strategy, F(2, 56) b 1.
Emotional Consequences
Emotional responses of nursing professionals and student nurses
were assessed with a number of emotion adjectives through the emo-
tional response questionnaire. These adjectives were averaged to form
an empathy index (i.e., warmth, softhearted, tenderness, moved, com-
passionate, and sympathetic; Cronbach's α = .70) and a distress index
(upset, grief, sorrow, distressed, worried, and anxious; Cronbach's
α = .88). We conducted the same mixed-factor ANOVA with emotional
reaction (empathy vs. distress) as a within-subject factor. The analysis
did not yield a significant within-subject effect for the emotional
reaction factor, F(1, 57) = 2.94, p >.09. The interaction of this factor
with either age or role was also not significant, Fs(1, 57) b 1.68, p > .20.
However, the analysis did yield a significant between-subject effect
for role, F(1, 57)= 5.79, p b .02. The professional nurses reported
feeling less empathy (Ms = 4.40, SD= .99) than did nursing students
(M = 5.07, SD= .68), t(58)= 3.04, p b .005. The same pattern was true
for distress (Ms = 3.92 vs. 5.20, SDs = 1.54 vs. .85), t(58)= 3.99,
p b .001 (see Table 2).
Relationships Between Perspective-Taking Strategies and Emotional
Reactions
We conducted two regression analyses, each including as criteria
either empathy or distress, and as predictors the measures of objec-
tive and other-imagine perspectives. The two regression equations
were significant [R 2c = .14 and .14, Fs (2, 57) = 4.61 and 4.57,
ps b .01] and revealed that empathy and distress were negatively
associated with adopting an objective perspective (βs = − 0.29 and
− 0.38, respectively, ps b .03). The unreported predictors were not sig-
nificant (see Table 3).
The results suggest that nursing students tend to adopt an
imagine-other perspective to a greater extent than the objective per-
spective, and that they felt higher empathy and distress when observ-
ing a sick child. These results also suggest that the tendency to adopt
the objective-perspective is negatively associated with feeling such
vicarious emotions.
Study 2
A potential flaw in the procedure of Study 1 is that we used a pic-
ture to depict the needy other. Therefore, the study did not standard-
ize how the picture was interpreted. This may have affected the
emotional response. To remedy this potential flaw, in Study 2 we
added a written description of the needy other illness to the picture
in which he was depicted. Additionally, an adult male is used instead
of a child. The reasons for making these procedural changes were to
standardize how the picture was interpreted.
Professional nurses
% % Years of experience
Senior students Females
25 84 M = 10.50 SD = 7.03
25 82 M = 15.30 SD = 9.42
35 90 M = 19.26 SD = 10.15
336 B. López-Pérez et al. / Nurse Education Today 33 (2013) 334–338

Table 2 t(29)= 3.46, p b .01. Whereas the professional nurses reported an

Statistics for Studies 1, 2 & 3. equal tendency to adopt the imagine-other and objective perspectives
Measure Condition (Ms = 4.60 and 4.50, SDs = 1.63 and 1.41, respectively). Therefore, re-
sembling the results of Study 1, the results show that, in comparison
Nursing students Nursing professionals
a
with the nursing students, professional nurses report a higher tendency
Study 1 Objective-perspective 3.20 (1.54) 4.77 (1.10)b
to adopt the objective perspective. The unreported effects were not sig-
Imagine-other perspective 5.50 (.97)a 4.30 (1.60)b
Empathy 5.07 (.68)a 4.40 (.99)b nificant, Fs b 2.96, ps > .05 (see Table 2).
Distress 5.20 (.85)a 3.92 (1.54)b
Study 2 Objective-perspective 3.43 (1.10)a 4.50 (1.41)b Emotional Consequences
Imagine-other perspective 5.60 (1.30)a 4.60 (1.63)b
Empathy 4.49 (1.32)a 3.37 (1.24)b
As in Study 1, the empathy index (Cronbach's α = .88) and a distress
Distress 3.87 (1.25)a 2.69 (1.25)b index (Cronbach's α = .86) were the two measures of the emotional re-
Study 3 Objective-perspective 3.77 (1.41)a 3.93 (1.48)a action. The mixed-factor analysis of variance with emotional reaction
Imagine-other perspective 5.77 (1.13)a 5.50 (1.28)a entered as within-subjects factor, role as a between-subject factor did
Empathy 5.08 (1.16)a 4.79 (1.61)a
yield a significant between-subject effect for role, F(1, 57)= 5.48,
Distress 3.65 (1.44)a 2.93 (1.33)b
p b .03. Once again, the professional nurses reported feeling less
Note: N = 30 per condition. Values range from 1 to 7. Rows with different superscripts
empathy (Ms = 3.37, SD= 1.31) than did nursing students (M = 4.49,
indicate statistically significant differences at p b .05 or less.
SD= 1.29), t(58)= 3.46, p b .001. The same pattern was true for
distress (Ms = 2.69 vs. 3.87, SDs =1.05 vs. 1.24), t(58)= 2.64, p b .01.
The unreported effects were not significant, Fs b 1.30, ps >.25 (see
Table 2).
Method
Relationships Between Perspective-Taking Strategies and Emotional
Participants
Reactions
Sixty participants from Madrid agreed to participate in this study
We conducted two regression analyses to test whether the measures
(30 nursing students and 30 professional nurses). Nursing students
of the perspective-taking strategies predict emotional reactions. The two
were between 18 and 40 years of age (M = 19.77, SD = 4.78). Profes-
regression equations were significant [R2c =.31 and .32, Fs (2, 57)=
sional nurses were between 26 and 58 years of age (M = 41.60, SD =
12.80 and 13.28, psb .0001] and revealed that empathy and distress
10.79), with an average experience in the nursing field of 15 years.
were significantly associated with imagine-other perspective (βs=
Thus, the total sample age was between 18 to 58 years (M = 30.68,
0.53 and 0.52, respectively, psb .0001) and negatively associated with
SD = 13.77).
objective perspective (βs=−0.25 and −0.29, respectively, psb .02)
(see Table 3).
Procedure
The results are consistent with those of Study 1, and both results
Participants were told, “This study is about different types of emo-
support our hypotheses. Specifically, nurses reported adopting an ob-
tional experiences produced by perception of illness. You will be
jective perspective more often than nursing students, whereas nursing
asked to read a non-fictional case about a sick patient and complete
students adopt an imagine-other perspective more often. Indeed, the
a set of questionnaires.” Upon agreeing to participate, the participant
nursing students feel more empathy and distress than do professional
filled out the informed consent form. The procedure lasted approxi-
nurses. The pattern of associations between perspective-taking strate-
mately 15–20 min. Before viewing the picture and reading the case
gies and vicarious emotional reactions was coherent with previous re-
(see Appendix 2), the participants completed perspective-taking
search (Batson, 2011).
measure described in Study 1. Immediately after viewing the picture
and reading the case, the participants completed the emotional re-
sponse questionnaire (also described in Study1). Study 3

Results and Discussion The goal of Study 3 is to assess the generalizability of the results from
Studies 1 and 2. We conducted a conceptual replication with a North
Perspective-Taking Strategies American sample. The relationship between perspective-taking strate-
The mixed-factor ANOVA with perspective-taking strategy as gies and emotional consequences is discussed.
within-subject factor, role as a between-subject factor, and age as
continuous covariate showed a significant interaction between Method
perspective strategy and role, F(2, 56)= 5.27, p b .01. Specifically, the
students reported a higher tendency to adopt the imagine-other (M = Participants
5.60, SD= 1.30) than the objective (M = 3.43, SD= 1.10) perspectives, The sample consisted of 60 participants: 30 professional nurses
from a large hospital in Texas, and 30 nursing students from the Uni-
versity of Texas at Tyler. Professional nurses were randomly selected
from hospital staff and invited to participate in the study. Access was
granted to the employee break room, which was used to conduct the
Table 3 procedure. The sample was mostly comprised of American females
Regression analyses. ages 24 to 66 (M = 41.07, SD = 12.61).
Study Empathy Distress Nursing students were recruited from the College of Nursing at the
University of Texas at Tyler. Students were informed about the survey
β t p β t p
and asked if they wished to volunteer. The sample was mostly com-
Study1 Objective perspective −.29 −2.26 .02 −.37 −2.92 .01
prised of American females ages 21 to 31 (M = 23.23, SD = 2.42).
Imagine-other perspective .16 1.24 .22 −.02 −.17 .86
Study 2 Objective perspective −.25 −2.28 .03 −.29 −2.70 .01
Imagine-other perspective .52 4.76 .001 .51 4.68 .01 Procedure
Study 3 Objective perspective −.25 −2.28 .03 −.34 −2.76 .01 The materials and the procedure in Study 3 were translated ver-
Imagine-other perspective .53 4.76 .01 .22 1.78 .10
sions of those used in Study 2.
 B. López-Pérez et al. / Nurse Education Today 33 (2013) 334–338
Results and Discussion
Perspective-Taking Strategies
The mixed-factor ANOVA with perspective-taking strategy as
within-subject factor, role as a between-subject factor, and age as
continuous covariate did not yield any significant effect, F(2, 56)b 1.44,
ps>.20.
Emotional Consequences
Again, the empathy and distress indexes (Cronbach's α = .86 for
each) were the two measures of the emotional reaction. The
mixed-factor analysis of variance with emotional reaction as
within-subject factor, role as between-subject factor, and age as
continuous covariate did yield a significant between-subject effect
for role, F(1, 57) = 4.01, p = .05. The professional nurses reported
feeling less empathy and distress (Ms = 4.79 and 2.91, SDs = 1.44
and 1.33, respectively) than did nursing students (Ms = 5.08 and
3.65, SDs = 1.16 and 1.61, respectively). The difference for empathy
was not significant, t(58) = .79, but was for distress, t(58) = 2.05,
p b .05. The unreported effects were not significant, Fs b 2.73, ps > .10
(see Table 1).
Relationships Between Perspective-Taking Strategies and Emotional
Reactions
We conducted two regression analyses to test whether the measures
of the perspective-taking strategies predict emotional reactions. The two
regression equations were significant [R2c =.16 and .16, F (2, 57)=5.69
and 5.69, psb .01] and revealed that empathy and distress were predicted
by imagine-other perspective (βs=0.53 and 0.22, respectively, psb .01)
and that empathy was negatively associated with objective perspective
(β=−0.25, pb .02). The unreported predictors were not significant
(see Table 3).
The results in the American sample differ slightly from the
other two studies. There were no significant differences between
professional and students in the reported tendency to adopt an
objective and imagine-other perspective. Regarding the emotional
reaction provoked by observing an adult in need, both groups felt
similar levels of empathy, but students did report significantly
more distress, which is consistent with the results from Studies
1 and 2.
General Discussion
In the present research, perspective-taking strategies and emo-
tional reaction among nursing students and professional students
were compared. Regarding perspective-taking, the results of the
three studies suggest that, in comparison with the other group, pro-
fessional nurses report a higher tendency to adopt an objective per-
spective, whereas nursing students report a higher tendency to
adopt an imagine-other perspective.
Regarding the emotional reaction, the results of the three studies
showed that students reported more empathy and distress than did
professional nurses. Furthermore, taken together, the results suggest
that these two vicarious emotions are negatively associated with
adopting an objective perspective (i.e., trying to remain not emotion-
ally involved) and positively with adopting an imagine-other per-
spective (i.e., trying to understand the other's situation). These
results are consistent with the research by Batson et al. (1997) and
Hoffman (2002) in that adopting different perspective-taking strate-
gies affects emotional consequences in predictable ways.
It is important to acknowledge that the nursing students who
volunteered in these studies were from different grades. An area of
interest for future research is to follow perspective-taking strategies
over time. For example, Kunst-Wilson et al. (1981) found that stu-
dents who are further along in their education (graduate nursing
337
students) report less distress compared to undergraduate nursing
students.
The present research has important implications. Compared to
nursing students, professional nurses tend to adopt an objective per-
spective which, in turn, reduces the intensity of the vicarious emo-
tional responses, such as empathy and distress that they experience.
This is coherent with the results obtained by Cameron and Payne
(2011) which showed that the emotional response is different when
facing mass suffering, because people tend to keep detached not to
suffer the others' pain. This emotional regulation strategy of reducing
distress and empathy involves both benefits and liabilities. Regarding
the benefits, lower distress may improve job performance and patient
care because it is associated with less conflict among colleagues
(Leiter et al., 2010). Regarding the liabilities, lower empathy among
nurses may consequently decrease the prosocial behavior towards
their patients (Batson, 2011; Davis, 1996).
Another limitation of our work is that professional nurses worked
in different nursing areas (Oncology, ICU, Traumatology & Gynecolo-
gy) but mainly in Oncology, which may contribute to lack of distress.
For future studies, it would be necessary to compare the emotional
response depending on the different nursing areas.
Finally, a longitudinal study with nursing students and profession-
al nurses is needed to test if the changes in the emotional outcome
(lower distress and objective perspective) are learned along the ex-
perience or depend on other factors.
Summing up, the perspective adopted by current and future
nurses may have important consequences. More attention should be
then paid to those training programs that assist these professionals
in controlling and managing the perspective to adopt in each situa-
tion. Langewitz et al. (2010) showed that training professional oncol-
ogy nurses in communication skills increased their empathic accuracy
to patients' emotional cues. Introducing instruments to assess the
perspective-taking and its emotional consequences should be an im-
portant piece of these training programs that benefit the situation of
both those who suffer and those who take care.
Acknowledgements
This research is supported by the project PSI2011-28720 from
the Spanish Ministry of Science and Innovation and the grant
AP2008-00065 from the Spanish Ministry of Education.
Appendix 1. Picture used in the Study 1
338 B. López-Pérez et al. / Nurse Education Today 33 (2013) 334–338
Appendix 2. Picture used in the Studies 2 and 3
James is 57 years old. He was diagnosed five months ago with
stomach cancer. Due to his illness, part of his stomach was removed.
After the operation he lost a lot of weight. Recovery has been slow,
and it is taking him a lot of time to start eating again. He had an
extensive infection and severe pain after his operation:
a) His infection was treated with antibiotics. Now, it seems that he is
overcoming his cancer. Doctors say he will live a normal life in a
few months.
b) His infection did not respond to antibiotics. He was unable to
overcome his cancer. Doctors believe that he will die in a few
months.
(Note: Participants in Studies 2 and 3 received either ending a or
b. There was no significant difference found between these cases.)
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