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Review Articles

Learning Empathy Through Simulation

A Systematic Literature Review

Bearman, Margaret PhD; Palermo, Claire PhD; Allen, Louise M. B NutrDiet (hons); Williams, Brett PhD

Author Information
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: October 2015 - Volume 10 - Issue 5 - p 308-319
doi: 10.1097/SIH.0000000000000113
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Simulation-based education, where students engage in an experience to learn, is frequently used to develop empathy and empathetic behaviors in medical,1 nursing,2 and allied health3 students. Simulation techniques in health professional education includes a variety of different approaches such as simulated or standardized patient (SP) methodology, mannequin-based methodologies, role-play, games, and virtual reality.4 This approach is not universally accepted. Wear and Varley5 caution that simulated empathy lacks authenticity as students learn to act “empathetic” for purposes of performance rather than establishing a genuine connection with real people, a notion described as learning to play the “simulation game.”6

The value of empathy to health care practice is not controversial. Hojat7 distinguishes empathy, with its predominantly cognitive and altruistic orientation, from sympathy, which is denoted as a predominantly emotional and self-serving orientation. This distinction, which has its critics,7 is maintained in the associated definition of empathy in health care as a cognitive response of understanding “the experiences, concerns, and perspectives”7 of the patient, including the capacity to communicate this understanding. This emphasis on the behavioral manifestations of empathy is notable as the latter is easier to objectively measure. Some measures of empathy do emphasize the internal experience of empathy,8 and others again require the perspective of a patient.9

This intuitive notion that practitioners’ empathetic behaviors improve the delivery of care is increasingly supported by evidence, such as the better outcome of diabetic patients associated with more empathetic doctors10,11 and the reduction of seclusion and restraint of psychiatric patients associated with more empathetic nurses.12 However, the value of health professional education in teaching empathy is not so clear. On the one hand, the 2013 systematic review conducted by Batt-Rawden et al13 of 18 educational interventions to teach empathy to medical students from 2003 to 2012 concluded that the interventions were mostly effective in promoting empathy despite methodological flaws. This review identified the success of some approaches to teaching empathy, which might be considered simulation, such as “experiential learning” and “drama.” Other studies14,15 also indicate the value of empathy education for practitioners. On the other hand, a recent systematic review found that empathy seems to decline during medical education and residency.16 Similar findings can be found in other disciplines.17 Neumann et al16 believe that this may be a consequence of entering into the clinical environment, which increases feelings of vulnerability; they also note the role of idealistic belief in the role of doctor and some students’ generally heightened levels of distress (eg, burnout, depression).

This article builds on previous reviews by specifically focusing on simulation as the learning strategy. It aimed to determine if simulation-based education of preservice health care professionals, in comparison with an alternative or no intervention, is associated with improved empathetic behaviors. The secondary aim was to explore the key learning and teaching approaches, if any, that are associated with the improved outcomes.


Literature Search and Study Selection

Eleven databases or clearing houses (MEDLINE, EMBASE, CINAHL, PsychINFO, ERIC, Web of Science, Scopus, Informit, Campbell Collaboration, BEME, and Cochrane) were searched for all records from any date up to May 2, 2014. Search terms were grouped into 3 conceptual categories as follows: (i) health professional students, (ii) simulation, and (iii) empathy. Search terms regarding health professional education students included variants of 18 professions combined with variants of education, learner, student, and teaching. Search terms regarding simulation included variants on clinical skill, interactive computer, fish bowl, haptic, manikin/mannequin, role-play, simulated/standardized patient, virtual environment, and simulation. Search terms regarding empathy included compassion, communication skills, doctor-patient relations, emotions, patient-centred communication, and student-patient communication. A specialist librarian oversaw the development and implementation of the search strategies. The initial yield of studies for review contained studies that fulfilled all 3 search concepts, that is, articles that contained search terms for health professional students AND simulation AND empathy. The following limitations were applied: English language, peer reviewed, and availability of the full-text article.

Duplicates and studies that were unrelated to the review question were excluded on title. Ten articles were selected from the yield to pilot the inclusion/exclusion criteria. All authors rated all 10 articles and finalized criteria through consensus. The final criteria for inclusion of a publication were as follows: first, the population of the study was preservice (prelicensure) health professional students; second, the simulations could be any modality including role-play, simulated patients, virtual, or mannequin based; third, that there was some comparison to assess improvement in empathetic behaviors; and finally, that there be some kind of qualitative or quantitative assessment of empathy. In the last case, we included studies that contained subscales or even single items, if the intention was to assess empathy. Veterinary students, cases where there was no enactment of a situation (eg, part-task trainers, paper cases), commentaries or similar, studies that investigated communication without specific mention of empathy, or experiences that were not educational were excluded. Systematic reviews that matched the inclusion criteria were acceptable. All remaining abstracts were then independently examined by 2 of the authors against the inclusion/exclusion criteria for progression to full-text articles.

All remaining studies were read in full text by 2 of the authors and independently examined against the inclusion/exclusion criteria. Agreement was reached through discussion and negotiation.

Data Extraction

Data were extracted from all eligible articles, including the location of study, student sample, study design, simulation modality, comparator, outcomes, and results. Data were extracted by 2 of the authors, and agreement was reached by negotiation. Two of the authors (M.B. and either C.P. or L.M.A.) finalized terms, gaps, and discordances between reviewers. Where effect sizes were not reported, Cohen d was calculated from available data.

Quality Assessment

The included studies presented either entirely or predominantly quantitative data and so were assessed for quality against the Medical Education Research Study Quality Instrument (MERSQI).18 The MERSQI was designed specifically for quantitative observational, quasi-experimental, and experimental studies in medical education and has been tested with respect to item and rater reliability, principal components, and criterion validity.18 Two researchers (M.B. and C.P.) independently assessed the quality of all articles (range, 5–18/18). Differences in interpretation were resolved through consensus.


A narrative, descriptive approach was taken across the studies, drawing from the principles of realist review19 by focusing on “demiregularities” to elucidate potential mechanisms whereby health professional students learn empathy from simulation-based education. Because of limitations of pre-post studies,20 randomized comparative studies were considered most closely, and effect sizes were displayed on a forest plot. Effect sizes were not pooled in a meta-analysis because this is not recommended when there is a diversity of comparators21 or outcomes.22


Literature Search and Study Inclusion

From the initial search of 11 databases, a total of 14,748 articles were retrieved, dated up to May 2, 2014. After duplicates and title review, 836 abstracts were admitted to the next phase. After the review based on the inclusion/exclusion criteria, 765 were excluded. Full publications for the remaining 71 articles were retrieved, and 44 were excluded after review. An overview of the study inclusion process is shown in Figure 1.

Study inclusion process.

Data Extraction and Quality Assessment

Table 1 summarizes the 27 included studies. Fourteen studies were published from 2000 onward, 8 from 2012 onward. Professional groups were as follows: medicine (18), nursing (4), pharmacy (2), social work (1), dental hygiene (1), and nutrition/dietetics (1). There were 14 pre-post designs, 9 randomized controlled trials (RCTs) or randomized trials, of which 1 contained a 3-way comparison and 5 had quasi-experimental designs. This includes 1 study that reported both an RCT and pre-post design. Three studies reported supplementary qualitative methods.

Profile of Included Studies

Of the 9 RCT studies, 4 (44%) reported significant improvements in learners’ empathy or empathetic behaviors between those who learned via simulation and those who were given an n = 2 or no n = 2 alternative (quality assessment range, 11–15.5). Of the 9 RCTs, 3 (33%) reported no significant change between those who learned via simulation and those who were given an n = 1 or no n = 2 alternative (quality assessment range, 9.5–12.5). Of the 9 RCTs, 3 (33%) reported significant differences between different approaches to simulation-based education (quality assessment range, 12.5–15.5). Of the 14 pre-post designs, 12 (86%) reported a significant improvement in learners’ measures of empathy (quality assessment range, 7.5–12.15). One pre-post study (7%) reported a decrease in empathy (quality assessment score, 10.5), and 1 (7%) did not conduct statistical analysis (quality assessment score, 8). Of the quasi-experimental designs, 4 (80%) of the 5 reported significant improvement in learners’ empathy levels between those who learned via simulation and those who were given an n = 1 or no n = 3 alternative (quality assessment range, 8.5–12.5). Of 5 quasi-experimental studies, 1 (20%) reported no change between those who learned via simulation and those who were given no alternative (quality assessment score, 8.5) (Table 1).

One article reported a pre-post and an RCT study of the same intervention in different years. Cahan et al21 describe that the pre-post indicated significant learning for a cohort experiencing an intervention when comparative trials showed that there were no significant differences in empathy between simulation group and those who did not have an alternative.

The outcome measures were diverse, and many were subdomains of other scales. Of the 27 studies, 17 (63%) used self-report measures; 81–3,22,26,29,40,41 used well-studied attitudinal scales such as the Jefferson Scale of Empathy36; 325,28,30 used the literature-based but not rigorously studied scale, the “Maxwell and Sullivan” questionnaire; and 634,39,42–45 used self-designed questionnaires. Of the 27 studies, 10 (37%) used raters’ assessment of behaviors with simulated patients, using previously developed scales or Objective Structured Clinical Examination (OSCE) scores. Raters included simulated patients, trained laypeople, examiners, researchers, and, in one instance, patients. Many studies had a focus on measuring changes in empathetic behaviors through self-ratings or observational ratings; others considered more closely the learner’s affect through attitudinal questionnaires. Some studies focused on attitudes to specific patient experiences (obesity, aged care, mental illness). One RCT demonstrated improved empathy after intervention using one different scale, the Arizona Clinical Interview Rating Scale (ACIRS) but not another, the Roter Interactional Analysis System (RIAS).46


When the simulation designs of the studies were considered as a whole, with a particular focus on mechanisms that might promote learning, 2 themes were noted as follows:

  1. Being a health professional
  2. These designs required the learner to simulate a health professional. These were generally designed for students to develop skills in communication. The most common designs were interacting with an SP or as part of a peer role-play.
  3. Being a patient
  4. These designs required the learner to simulate the patient. The most common designs were role-play, auditory hallucination simulations, and games about negotiating being elderly.

When the studies are categorized according to these themes, of 27 simulation designs, 10 (37%) required the learner to only simulate the patient, 7 (26%) required the learner to only simulate the health professional, and 10 (37%) (most commonly role-play) required learners to act as both or either patient and health professional. Other groupings, such as type of measure, type of comparator, length of intervention, or content of simulation, did not present as coherent themes.

As noted earlier, one study showed different results between a pre-post study and an RCT. Norman20 suggests that experimental designs are best for investigating efficacy. He underlines the limitations of pre-post 1-group design, which cannot distinguish improvements that are due to the intervention from “natural” student progression.20 To reduce this risk of bias and because there were sufficient experimental designs within the included articles, the synthesis process focused on studies where the participants were randomized.

Arms of RCT interventions were categorized according to the 2 themes—being a patient and being a health professional. Refer to Table 2 for details. As mentioned, there were 3 RCTs3,21,23 that did not show significant differences in student empathy development between simulation intervention and a control. In all of these, the intervention required the learners to only “be a health professional” and never a patient. All 4 RCTs that contained interventions where the learner assumed the role of the patient all or some of the time within the simulation22,24,27,28 showed significant improvements relative to a control. These are represented in the forest plot in Figure 2. The study of Sanson-Fisher et al,23 that compared SP and real patient encounters, is separated in the forest plot, as the comparator is very different. RCTs that compare different aspects of simulation are not included in this figure.

Details of Randomized Controlled Trials
Forest plot of RCTs that compare simulation to no or some alternative, with empathy as an outcome. Effect sizes with 95% confidence interval are shown in 3 themes, represented by diamonds, squares, and a triangle. Effect size of RCTs where the comparison is between a “being the patient” (including role-plays) simulation and some or no alternative. Effect size of RCTs where the comparison is between a “being health professional” only (excluding role plays) and some or no alternative (excluding real patients). Effect size of RCT where the comparison is between a “being a health professional” simulation and real patients. Across these themes, the study author and date are in bold when the comparator is “no alternative”; other studies have nonsimulation comparators.

There was a range of educational design features surrounding the simulated experience. There were 4 (15%) of 27 comparative studies that compared different types and features of simulation in promoting empathy; 3 of these were randomized (Table 2). Two of these indicated that role-play encounters improved learner’s empathy more than SP encounters27 or using a mannequin.43 One study indicated that SP encounters improved learner’s empathy more than virtual patients,31 and another study had mixed results regarding the efficacy of feedback from SPs compared with feedback from faculty.46


The findings of this review suggest that simulation may be an appropriate educational methodology for developing empathy and/or empathetic behaviors in preservice health professional students. This finding was not universal, and it seems dependent on the type and educational features of the simulations as well as the definition of empathy and associated measures. The variety and complexity of the reported educational designs are exciting from a teaching perspective but make definite conclusions challenging from a research perspective. The challenges with measures are brought into focus by 1 study,29 which indicated a decline in empathy after the intervention. The authors attributed this to a decline in the “personal distress” subscale of the Interpersonal Reactivity Index, which measures “one’s own feelings of discomfort in the face of emotionally challenging interpersonal situations.”29 This inconsistency highlights broader debates about whether empathy should be measured and taught as an internal process or as observable communications.32

Collectively, the randomized controlled studies suggest that the simulation approach that seems most beneficial is one that asks the learners to literally stand in patients’ shoes.

These results are also supported by an RCT, which specifically examined the issue of “playing the patient.” In this study, Bosse et al27 compared communication skills development in learners role-playing (that is, acting as both learner and health professional) with those working with a simulated patient (that is, acting as a health professional) and with a control (no simulation experience). Final-year medical students (n = 103) were assigned to 3 groups receiving education and training in counseling caregivers of sick children. Two groups received counseling and communication training using either role-plays or simulated patient encounters, whereas the control group received the only standard coursework learning material. After the interventions, 6 OSCE stations were undertaken, each with 1 SP. Final OSCE scores were rated using the Calgary-Cambridge Referenced Observation Guide (CCROG); analysis indicated that the role-play group significantly improved compared with the SP group with respect to “understanding the patient’s perspective” (t = 5.11, and P < 0.001, d = 1.12), and notably, this was the only domain where this significant difference was found. This study was rated 15.5/18 on the MERSQI.

The theoretical constructs of empathy support this idea. Assuming the role of the patient introduces the understanding and shared feelings of the patient’s perspective, but then, the learner must remove themselves from the simulation and through debriefing or feedback processes and must translate this experience into the empathetic behaviors we expect from health care practitioners. Simulation education might combat the decline of empathy noted in later years of study,16 as it permits students to manage both a less idealistic view of health care practice and an appropriate level of identification with patients.

Role-play may be particularly valuable. Role-play permits rotating roles of patient and health care provider and therefore provides both the experience of the patient and the experience of working with patients. This role reversal may be an important mechanism in developing empathy and deserves further exploration. Role-play is sometimes seen as a less desirable but a cheaper alternative for SP encounters, but perhaps, it could become first choice for learning empathy and empathetic behaviors. There is also a caveat to using role-play methodology. Without creating an appropriately safe learning environment,33 acting as a surrogate for a patient might also provoke other emotions such as vulnerability or anxiety.35 The role of debriefing may be particularly important in assisting students to translate their experiences as role-play patients to general communication skills.

It is also worth noting that of the 17 studies where the learners were “being a health professional,” only 1 focussed solely on empathy development. Empathy development was interwoven with learning other skills such as interviewing,31 motivational interviewing,24,41 effective patient/client communication skills,3,21,27,29 interpersonal skills,3 and psychomotor skills.43 In many instances, these associated skills developed alongside empathy; sometimes, these skills were used as markers or indicator of empathy. For example, Deladisma et al31 reported the development of nonverbal communication skills and learning to ask clear questions as a measure for increased empathy.

This review builds on and adds to the work of other related systematic reviews, particularly those of Stepien and Baernstein37 and Batt-Rawden et al.13 It contains 23 additional studies not reported within these previous reviews, which explore empathy in medical education, and specifically draws the link between empathy and simulation. This review highlights the value of taking the role of patient, either through role-play or as part of specific “patient experience” simulation design, which was not noted in previous studies, although it is congruent with their findings.

The limitations to the findings of this review are derived from the included studies and from the review process itself. With respect to the included studies, although some had high-quality experimental designs, these were in the minority. Reporting standards were variable; effect sizes were rarely reported, and sometimes, even a lack of means and SDs made calculating these statistics challenging. There were inconsistencies with the outcome measures, as noted earlier in the discussion. There was notably a lack of experimental data examining groups over periods, which might give information about how empathy decays after interventions. The nature of the comparator was not well considered. As has been noted previously,38 studies that aim to compare a new medium to some or no alternatives have limitations because of the difficulty in forming valid comparison groups; this type of the design formed sizeable majority of the included studies. More consideration could be given as to when and why simulation is the optimal way to teach empathy, building on the body of work reported in this review.

Future work might include further experimental studies to replicate the results of the study of Bosse et al,27 which compared the effects of empathy on SP encounters relative to role-play encounters and would be particularly useful, as well as in-depth qualitative comparative investigations of the learner experience “being a patient.” It would be interesting to see if this type of empathy education might be effective for practicing health professionals. The role of feedback is worthy of further exploration. In addition, with the exception of 1 study comparing student behavior with simulated to real patients, all other behavioral ratings were not assessed with real patient encounters, with most tested in simulation. Practitioners have had improvements in empathy assessed by real patients,14,15 and we suggest this type of assessment could be extended to preservice health practitioners.

The review process itself also had limitations. The synthesis was based on a simple categorization of studies. The review strategy was less likely to include qualitative studies, as few of these are framed as comparative studies. There was no systematic hand-searching for additional articles. Balanced against this is the comprehensive search strategy that incorporated 11 databases, independent review for inclusion of each full text by 2 authors, use of an identical data extraction table for all studies, independent duplicate quality assessment, and a synthesis approach that provides an insight into possible learning mechanisms.

In conclusion, the findings of this review suggest that simulation may be a useful educational methodology for developing empathetic behaviors in preservice health professional students. The most interesting inference is the notion that simulations that ask the learner to act in the role of patient may be more effective in developing empathy. This may have significant implications for educational design of simulations in preservice health professional curricula. Further research is needed to confirm this result and also to investigate other features of simulation, which promote or inhibit learning empathy.


The authors thank Anne Young, expert librarian, for her guidance and assistance in searching the literature, and the anonymous reviewers of this article.


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Simulation; Empathy; Role-play; Communication skills; Simulated patients

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