Working nurses’ empathy with patients in public hospitals

Objective: to determine the levels of empathy in professional nurses of a high-complexity hospital, to relate age to empathy (and each one of its dimensions), and to establish if there are differences between these levels according to the type of working schedules. Method: comparative, correlational and cross-sectional design. The sample used (n=271) constituted 40.9% of the total number of nursing professionals. Psychometric properties of the Jefferson Scale of Empathy for Health Professionals were studied. Descriptive statistics were calculated: mean and standard deviation. The association between empathy and age was estimated using regression equations and statistical significance of the regression coefficients, after evaluating the type of curve using variance analysis. Results: the underlying model of three dimensions of empathy was identified. The values of the descriptive statistics observed were relatively low in empathy and its dimensions. Empathy levels were not associated with the age range. No differences in empathy were found between the types of work schedules. Variability was found in the dimensions: “compassionate care” and “Walking on the patient’s shoes”. Conclusion: these results show that the levels of empathy observed may imply a deficient performance in empathetic care for patients.

that the necessary intersubjectivity can be generated so that the nursing professional can perform with high degrees of success (18)(19) . Therefore, the importance of empathy consists in the practical fact of establishing the appropriate interaction with the patient to provide the humanized care that every patient needs and, at the same time, generate human satisfaction in the patient under care. Empathy is considered as a modulator of the factors that positively or negatively influence this attribute (9)(10)(11)(12) . The acquisition of empathy is not a purely innate attribute but is formed through complex processes during a person's natural development (12)(13)(14)(15)(16)(17)(18)(19)(20) . Due to the complexity of this attribute, the empathic training of future nursing professionals should be the object of attention from the first years in the teaching-learning process (20)(21)(22)(23)(24)(25)(26)(27)(28)(29) .
There are several instruments to measure empathy, among which are those that have a cognitive approach, for example: Hogan Empathy Scale (EM); affective, for example: Questionnaire Measure of Emotional Empathy (QMEE); and integrators, for example: Interpersonal Reactivity Index (IRI) (30) . At present, the most used is the integrative vision (31) . However, the measurement of empathy in students and health sciences professionals required an instrument that measured empathy but in a precise context: empathy with the patient. The Jefferson Medical Empathy Scale (32)(33) , the Jefferson Medical Empathy Scale for medical students (Version-S), emerged.
This scale has been adapted for different specialties, with discriminant validity due to the lack of significant association with irrelevant conceptual measures such as self-protection (31)(32) . Authors (34) have recently published a paper that exhaustively describes other characteristics of this scale, which has been used in its different versions to measure students and health professionals. This scale is also characterized by its stability. Studies that have used this scale report that it repeatedly maintains the three dimensions stable: two cognitive, Perspective Taking (PT) and "Walking in Patient Shoes" (WIPS), and one emotional, Compassionate Care (CC). The facts described above justify the use of the JSE in the study of empathy with the patient in professionals and students of health sciences due to the results observed in the psychometric and trustworthiness studies.
Studies of empathy in professional nurses are scarce, but they provide relevant information that must be studied and explained (16)(17)(18)(19) , with greater production in populations of nursing students (9,(13)(14)(15)(16) . In the first case, these studies dealt with empathic performance in adverse work conditions and patients' perception of the attitude of nurses, and, in the second case, they evaluated the levels of empathy in the training process of nursing studies.
However, there are few studies on nursing professionals in Latin America that massively evaluate the empathy of nursing staff with the patient and, at the same time, practice in highly complex hospitals in relatively large cities. It is also unknown how the levels of empathy with the patient are distributed in relation to the different types of work schedules (hour load) even though there are studies that establish some degree of relationship between this type of load and the presence of depressing factors, for example, Burnout (35) . On the other hand, it has been observed that, in general, the published literature refers that age is not correlated with the levels of empathy in nursing students and professionals and concludes, implicitly or explicitly, that this variable does not seem to be important (13)(14)(15)(16) . Consequently, the theoretical and practical meaning of the absence of this correlation has not been discussed about the causes that can produce it and the effect that this could have on patient care, especially of those nursing professionals who show low or insufficient levels of empathy.
This paper aims to determine the levels of empathy (and its dimensions) in nursing professionals from a highly complex hospital, relate age to empathy (and each of its dimensions) and establish whether there are differences between them. To meet this objective, it is necessary to previously submit the empathy data to psychometric studies to confirm the structure of three underlying dimensions in the empathy construct in relation to the data observed in the present study (9,20,26,(33)(34) .

Method Design
Comparative, descriptive and cross-sectional study.

Participants
The sample is composed of 271 professional nurses at a public hospital in Cuenca, Ecuador. This sample corresponds to 40.9% of the total number of nursing professionals working at the mentioned hospital (N=663).
The participation of the people evaluated was voluntary.
The sampling was convenience. The Hospital where the study was conducted (May 2022) is classified as Third Level (High Complexity). It is run by a decentralized public entity that belongs to the Ecuadorian Social Security Institute (IESS) whose non-delegable purpose is the provision of Compulsory General Insurance throughout the national territory (36) .

Procedure
The translation and adaptation of the JSE-HP were carried out through the process of translation and retrotranslation of the original instrument in English (39) .
Subsequently, it was subjected to a pilot study made up of 30 nursing professionals, drawn from the same study population, to verify the understanding of the questions.
Finally, the underlying three-dimensional model was verified by factorial analysis establishing factorial validity.

Data analysis
Before to data analysis, the Kolmogorov-Smirnov statistic was evaluated to test univariate normality and Mardia's multivariate kurtosis coefficient (40) to check if the data presented multivariate normality. Subsequently, the various descriptive statistics were calculated, and a confirmatory factor analysis (CFA) model was established based on the Maximum Likelihood method and using Bootstrap, simulating 5000 samples, as a technique that allows making a better fit in the context of the absence of multivariate normality (41) . To assess the fit of the CFA

Assessment of normality
Before data analysis, compliance with the normality assumption was tested. Observe a significant Kolmogorov-

Confirmatory factor analysis
To provide evidence of the validity of the empathy construct, confirmatory factor analysis is used, observing a bad adjustment of the data to the three-factor model of empathy proposed by Hojat (2002)  .070), with factorial weights that vary from λ= .11 to λ=.82. Based on the above, it was decided to respecify the model, eliminating items with factor loadings lower than 0.50 (42) . Retaining the three original factors, but

Associations
The results of the association of the variable age and empathy (in its dimensions) were not significant.

Descriptive analysis
The results of the estimation of the descriptive statistics are presented in Table 1. The highest CV values are concentrated in the CC and WIPS dimensions, revealing the heterogeneity of the data, unlike the PT dimension and the total empathy score which show homogeneity.

Discussion
Empathy is a complex construct. Its roots are found in the phylogenetic development and the ontogeny of the subject of the human species (43)(44) . The phylogenetic component is still active and its action could be expressed through a "synthesis of development systems where morphological inheritance, motor skills, and socio-ecological factors converge" (36) , but this development is characterized by the fact that the mechanisms that install quantitative and, above all, qualitative changes are extremely slow (44)(45) .
It is then inferred that the development of empathy in a person is fundamentally modulated by the influence of the processes associated with ontogeny (46)(47) .
Empathy has cognitive and affective components or dimensions (48) . These components interact with each other dialectically. The interactions between the dimensions of empathy materialize in neural networks and the properties of these networks are essentially referred to as a flow of information between them. The interactions between networks may be different (different flows), which could also determine different functional organizations of the network and, therefore, may give rise to different traits of empathy (48)(49)(50) .
The exact cause of this difference is unknown, but it could relate to topological networks with unequal characteristics that determine individual differences in the dimensions of empathy (49) . The formation of the specific topology of the networks in each human being will be strongly influenced by external stimulations more than by genotypic potentiality (45) . Some of these stimuli can be as specific as the family environment (51) or as general as society as a whole (50) . Questions arise from the ideas expressed above. One of them is whether empathy can be developed indefinitely during the lifetime of a human being. It has been suggested that the neurogenesis present in adults shows the possibility of generating brain plasticity and some studies show a high structural and synaptic plasticity in adults (52) . However, this plasticity tends to decrease over time (53) . From the above, it is inferred that empathy is not an attribute that develops indefinitely and constantly over time (44,46) , at least, there are no studies that demonstrate, directly or indirectly, that brain plasticity can contribute significantly to the development of empathy in the course of a person's life.
In fact, it is known that the prefrontal cortex of the brain is responsible for executive functions and, therefore, for the control of cognition (54) . This process is reached between Dávila Pontón Y, Díaz-Narváez VP, Montero Andrade B, López Terán JJ, Reyes-Reyes A, Calzadilla-Núñez A.
the ages of 25 and 30 with the complete maturity of the prefrontal cortex (55) . Therefore, the topology described above reaches its definitive structure in the interval of years mentioned. However, this does not mean that a person above this age stops their learning activity associated with the cognitive dimension of empathy.
The issue is that empathy is a system constituted by a the earliest childhood (57)(58) . Child abuse, for example, seriously alters neurological development and delays brain maturation. The consequences can fluctuate from the affectation of attention capacity to the deficit of intellectual development. It negatively influences the processes of neurogenesis, myelination, and neuronal pruning, with consequences on the limbic system and the cerebral cortex. The brain vulnerability hypothesis shows us that "damage may imply a subsequent neurodevelopment that will not be equivalent to the path it could take without the damage produced" (32) and that brain plasticity, in adults, would not be sufficiently effective to repair this damage. If the damage finally occurs, it will affect (to one degree or another) the neurobiological conformation of the components of the limbic system and with this, the ability to generate the necessary interconnections of the network associated with the affective dimension (feeling of compassion) will also be affected. Depending on the degree of affectation, the network that emerges from the affected dimension will not be able to interact adequately with the rest of the networks generated for the other (cognitive) dimensions. Of course, in normal subjects, there are no damages as severe as those described, but there are non-severe "damages" that affect the development of empathy as a whole.
The variability of the levels of empathy observed in the sample of nursing professionals in this study (with almost extreme maximum and minimum values) raises the urgent need to take measures in relation to the empathic behavior of the nurses studied. The causes that originate these results, in light of the theoretical elements exposed, could be explained by the presence of problems that have not yet been solved in the empathic training of nursing students and health sciences in general (59) . It is known that the humanization process in patient care is multifactorial and the empathy of the nursing staff with the patient is an important element of it. But if it is affirmed that humanization must be built from patient care training (60) , empathy with the patient in the nursing profession must also be built longitudinally and from the first year of training with nursing professionals (7,20,(25)(26) .
The possible contribution of this work could be summarized in the following points: a) The scarcity of studies that evaluate these levels in practicing nursing professionals should be a matter of concern for the corresponding researchers; b) The presence of relatively low levels of empathy in practicing nursing professionals is a finding that must be studied and determine the possible causes that produce it; c) The absence of association between age and empathy is a frequent finding in studies of empathy with the patient. This finding, however, has not been associated with ontogenetic processes imbricated in empathy training, among them, the training process during their stage as a nursing student and d) The absence of differences in the levels of empathy between nursing professionals with different workloads is a finding that should be studied and exceeds the objectives of this study.