Adv in Health Sci Educ (2015) 20:669–682 DOI 10.1007/s10459-014-9554-0

Nursing students’ experiences of the empathy of their teachers: a qualitative study Kristina Mikkonen • Helvi Kynga¨s • Maria Ka¨a¨ria¨inen

Received: 5 March 2014 / Accepted: 22 September 2014 / Published online: 30 September 2014  Springer Science+Business Media Dordrecht 2014

Abstract The purpose of this study was to describe nursing students’ experiences of empathy of nursing teachers with the emphasis on how experiencing empathy from their teachers influences students, their learning and professional development. This research was a qualitative descriptive study conducted through face-to-face interviews with nursing students. Content analysis was used to analyze the data. The results indicate that the teachers’ empathy towards students and their learning either produces a constructive learning experience and a caring learning environment or obstructs their learning and has negative consequences for a student’s quality of life. Empathy from teachers towards the students when becoming a nurse facilitates professional education and offers potential strength-based learning; on the other hand, it can hinder the learning of correct principles of nursing care and challenges students stay true to their personal principles. The results indicate that empathy has a positive impact on students’ professional development in nursing and their learning environment. Teachers should be strongly encouraged to place a greater emphasis on the principle of empathy and caring in nursing, which would involve having good communication with students. Keywords

Empathy
Education
Nursing student
Teacher
Professional relationships

Research approval was obtained in April 2012 from the research director of Kemi-Tornio University of Applied Sciences, Finland. The contact person is Mrs. Sinikka Kahkola, email: [email protected]. K. Mikkonen (&)
M. Ka¨a¨ria¨inen Faculty of Medicine, Institute of Health Sciences, University of Oulu, Oulu, Finland e-mail: [email protected] M. Ka¨a¨ria¨inen e-mail: [email protected] H. Kynga¨s Faculty of Medicine, Institute of Health Sciences, Oulu University Hospital, University of Oulu, Oulu, Finland e-mail: [email protected]

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What is already known about this topic • Empathy is closely linked with a caring process in nursing • Caring is a fundamental aesthetic element of nursing epistemology • An empathetic caring environment fosters nurses’ respect, acceptance and advocacy for their patients • Empathetic teachers’ behavior increases learning motivation

What this paper adds • • • •

Empathy positively and directly influences nursing students’ professional development Empathetic teachers’ behavior bolsters students’ willpower to continue their studies Lack of empathy has negative consequences for students’ quality of life Unempathetic teachers’ behavior towards students negatively influences patient care

Introduction Empathy has been frequently researched in nursing science, and is seen as a crucial component of diverse kinds of helping relationships (Reynolds and Scott 1999). However, the influence of nursing teachers’ empathy towards their students and the students’ professional development has only been indirectly addressed in a few scientific studies. Thus, the purpose of this study was to describe nursing students’ experiences of empathy from their teachers, with the emphasis on how it influences the students, their learning and professional development. Empathy has been shown to be one of the essential communication traits, and it is seen as an important requirement in clinical practice to provide high quality patient care (Neumann et al. 2009). There is a strong emphasis put on the need for improving empathy and communication skills in nursing, based on research findings, which revealed a lack of empathy in nursing practice and education (Ancel 2006; Brunero et al. 2010). Empathy has been shown to help nursing students to achieve a higher quality of patient-centered education and practice (Reynolds and Scott 2000). However, in several studies, nursing education has been strongly criticized for producing nurses who have good technical skills, but lack communication skills, a caring philosophy, critical thinking and creativity (McGregor 2005; Smith 2007). The analysis of the reviewed literature indicates that the concept of empathy in nursing and teaching is seen as an intellectual process, which involves at least two people, who have the ability to understand and the capacity to communicate that understanding back to the receiver in a caring and nonjudgmental way, with the emphasis on building cognitive professional communication and critical thinking (Ancel 2006; Finn 2009; Gillespie and McFetridge 2006; Halpern 2009; Kunyk and Olson 2001; Kelly 2007; Mercer and Reynolds 2002; Reynolds and Scott 2000; Rogers 1975; Morse et al. 2006; Williams and Stockley 2010). The literature also shows that empathy is closely linked with a caring process (Kunyk and Olson 2001), which is a fundamental aesthetic element of nursing epistemology (McEwen and Wills 2007). For example, core principles of the Human Caring theory (Watson 2008) include establishing a caring environment without authoritarian values and creating interpersonal caring relationships between nurses and patients (Wade and Kasper

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2006). A caring process fosters respect, acceptance, honor of human dignity, ethical decision-making, role modeling in educational contexts, advocacy for nurses’ own patients and other key aspects of holistic nursing care (Watson and Foster 2003, Watson 2008). The theory of Human Caring (Watson 2008) also presents 10 Carative human to human factors, two of which are particularly relevant to the focal concern of this paper (the influence of teachers’ empathy on nursing students and their professional development). The first, Development of a helping-trusting, human caring relationship, indicates that teachers should have non-judgmental attitudes, hold unconditional regard, show respect for others’ lived experience, and communicate both respectfully and constructively (Watson 2008; Wiklund Gustin and Wagner 2013). Good working relationships with teachers and communication skills in caring and empathy have been shown to increase a learner’s motivation, positive learning progress and critical thinking, as well as prepare students to see and treat their patients in ethically caring ways and bring students closer to achieving expertise in nursing (Beckman and Lee 2009; Sawatzky et al. 2009). A professional level of communication with an emphasis on empathy has been shown to result in better clinical outcomes in students, lead to less clinical errors, more satisfaction, less burn-outs, fewer complaints, improved moral values and increased levels of empathy towards the patients (Cederbaum and Klusaritz 2009; Mercer and Reynolds 2002). It also resulted in better collaborative relationships, increased motivation, and helped students to understand excellence in nursing in humanistic ways (Cederbaum and Klusaritz 2009; Mercer and Reynolds 2002). The second Carative factor in the theory of Human Caring (Watson and Foster 2003; Watson 2008) particularly relevant to this study is Promotion of interpersonal teaching– learning, which indicates that teachers should be aware of students’ experiences and needs, and accept differences. In a study of Jordanian nursing students in their clinical learning, Lopez (2003) compared the role of a caring teacher to that of a caring mother, and identified three stages in the teaching–learning process: dependence, independence and identification. In early stages of clinical practice her findings show that empathetic and bonding experiences with their teachers helped the students to progress to the second stage of independence, while successful transition from dependency to independency resulted in students’ mastery and growth of competence (Lopez 2003). Suikkala and Leino-Kilpi (2005) discovered that students, who had seen their mentors as positive role models and gained a humanistically orientated learning perspective, placed an emphasis on patientcentered care. Thus, caring and empathetic behaviors in nursing and nursing education are known to enhance students’ learning experiences. However, there is little knowledge of how teachers’ empathy directly influences students’ learning and their professional development as nurses. Therefore, in the study presented here we interviewed nursing students and applied inductive qualitative analysis to address two related research questions: • How does the empathy of nursing teachers’ influence students and their learning? • How does experiencing empathy from teachers prepare students to become a nurse?

Methods A qualitative research method was chosen since an examination of empathy as an element of communication competence in teachers of nursing is a broad, poorly understood and seldom researched area (Elo and Kynga¨s 2008).

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Data collection The data were collected using face-to-face interviews during spring 2012. The students were recruited by email and open invitation (from the researchers) to participate in interviews from second and third year nursing students from a University of Applied Sciences in Northern Finland. The selected participants were all nursing students enrolled in degree programs taught in English. Among non-English speaking European countries, Finland provides most English-Language-Taught Degree Programs in Health Sciences. Each program requires English proficiency. Students who met the inclusion criteria and accepted an invitation to take part in an interview were interviewed. The inclusion criteria were: ability to speak English, participation in an English-Language-Taught Degree Program in Nursing, and completion of the first year of their studies. Twelve students were interviewed (n = 12): seven females and five males. Students came from widely different cultural backgrounds including South and North America, African countries, China, Russia and Finland. The average age was 26; the youngest student was 17 and the oldest 40. The sampling and coding process was stopped when additional data demonstrated frequent replication in the interview comments of the participants (Bowen 2008). The saturation of collected data was reached after no new categories and further themes were found (DiCicco-Bloom and Crabtree 2006). The systematic review of Guest et al. (2006) on qualitative interviews points to a general agreement between authors doing qualitative research that saturation of data is reached with a relatively low number of participants, which became evident during the data collection process of this study, too. Face-to-face interviews gave more space for the researcher to gather rich research data and to ask the student being interviewed about relevant issues. All interviews were conducted in English, using university settings familiar to the students and took approximately 40 min. The interview was pretested on one of the volunteer students and this test interview was used in the final data analysis, since it met the inclusion criteria. The interview questions were classified according to the research questions and covered the following topics: the influence of empathy on the students and their learning, and the influence of empathy on becoming a nurse. The interview used predetermined, open-ended questions, giving space for emerging questions during the dialogue (DiCicco-Bloom and Crabtree 2006). At the beginning of the interview, the students were also asked about their understanding of the concept of empathy. This question was seen as important in avoiding study biases. Most of the students were multiculturally grounded and there was a risk of there being overly significant differences in their general understanding of the concept of empathy. The participants under the study have agreed on the definition of empathy. The participants defined empathy as an understanding of the other person’s situation, feelings, emotions and background; as being able to see the other person’s perspective, perceiving the other’s position and being able to express that understanding on the level of the other human. Ethical considerations The research was conducted according to the code of research ethics, keeping to the principles of beneficence and respect for human dignity and justice. After approval for the research was obtained from the administrator of the University of Applied Sciences in Northern Finland, a contact person was emailed. Students invited to the interview were given full freedom of participation or non-participation in the interviews. They were given

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a guarantee that their answers would have no negative consequences on their studies or grades. The students gave informed consent, after which they were assured guaranteed confidentiality and the full freedom to terminate their participation in the research at any point. Students were also informed that audio tapes and notes made during the interview were kept in a locked cabinet, only accessible to the researcher. It was explained that the anonymous data would be stored for a certain time on a computer disk, at the end of which, the data would be permanently erased and not used further for the purpose of research. (Polit and Beck 2008). The researcher undertaking the study is a qualified health science teacher with no professional connections with the university, its staff or students under the study. Data analysis The collected data were transcribed into a Word document and data analysis was carried out on the basis of the research questions (Jacelon and O’Dell 2005; Graneheim and Lundman 2003). Qualitative content analysis was based on an inductive approach. The goal of the qualitative content analysis was to identify main categories and patterns among the sub-categories. (Elo and Kynga¨s 2008). The qualitative content analysis involved active reading, verifying, correcting, modifying and organizing the data. The data analysis was conducted manually without the use of computer software. Using editing analysis can be seen as most appropriate for this type of research data. (Table 1). The unit of analysis was an entire phrase taken from the interviews. The condensed meaning units were organized into a certain scheme of subcategories when creating the corresponding coding. (Graneheim and Lundman 2003). The data were coded and organized after several interpretative steps, to ensure no meanings were lost or buried (Jacelon and O’Dell 2005). A name was given to each sub-category corresponding to the meaning of its coding. The coding and sub-categories were constantly checked, rechecked and compared with the collected data in order to verify the meaning and common themes in the different interview statements (Bowen 2008). The formation of sub-categories and categories was not shaped according to the numeric frequency of the found units, but rather on the described meanings and the connections between the meanings found within the interviews (Elo and Kynga¨s 2008). Finally, the categories were compared with the data collected from interviews in order to confirm the understood meaning of the data (Bowen 2008).

Table 1 Example of coding interview statements Interview statement

Condensed meaning unit

Coding or code

…if I don’t find empathy from the teacher…, I get stressed, I don’t know how and what to do, and how to come up from this situation. It feels like you don’t get help from anyone, you feel like you are not motivated anymore…

I don’t know how and what to do; how to come up from this situation; It feels like you don’t get help from anyone;

No knowing how and what to do Feeling of helplessness (through lack of guidance)

You feel like you are not motivated anymore;

Feeling lack or loss of motivation for learning

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Results Influence of teachers’ empathy on students and their learning The students’ responses strongly indicate that empathy from their teachers promotes a constructive learning experience and a caring learning environment, while a lack of empathy obstructs their learning and has negative consequences for their quality of life. (Table 2). The constructive learning experience category included the subcategories motivation in learning, improved learning outcomes, encouragement to learn and positive learning experience. Students said that when they received empathy from their teachers they were motivated to learn more, to continue their studies, to study harder, to achieve better learning outcomes, and to become best in class. It motivates me, so when the teacher comes down to my level and understands me, why not come up and do the best what I can, so that we both achieve (Interviewee seven, female). Improved learning outcomes included students stating that empathy helped them to learn and graduate faster, helped them achieve better learning outcomes, gave them a passion for studies, and had a positive impact on learning. Encouragement to learn was identified from continuing their studies, studying more and having the willpower to continue. A positive learning experience was described by students when having a well set example, good experience of learning practical nursing skills, experiencing empathy and handling the challenges well. It’s important, because it motivates the student to do better, and it also helps the student to commit to their studies and actually try to learn things, and encourages the students, when they see that the teachers are really trying to help them understand, it helps them get to their studies. (Interviewee one, female) The category of a caring learning environment included a reduction of stress, better communication, and the building of a positive student–teacher relationship. Reduction of stress included less stress in learning, in studies and in personal life. Students also saw better communication as a perceived effect of empathy in that it resulted in positive twoway interaction and gave them the freedom to ask, express worries and seek clarification of given tasks. In the latter category students felt that they could find acceptance and trust, that they have freedom of choice, the teacher has credibility, there is positive interaction, and they experience self-confidence and a reduction in fear. I think it affects the relationship, it’s easier to express your questions, worries. It also, for example personally myself, I react strongly to teachers or staff members, who seemed to be distant or a little bit, not necessary rude, but cold, and that annoys me (Interviewee eleven, female). Obstructed learning was classified into the sub-categories of a lack of motivation in learning and learning apprehension. Lack of motivation in learning included unreachable standards set by the teacher, lack of guidance in learning and unfairness in course evaluation. Learning apprehension was expressed by a feeling of being stupid for asking questions, a feeling of not knowing anything, in a lack of feedback, no improvement of learning outcomes, staying behind in the subject, apprehension to learn more in the subject, loss of interest in learning and giving up on studies completely.

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Table 2 Influence of Teachers’ Empathy on Students and their Learning Category

Sub-category

Code

Constructive learning experience

Motivation in learning

Motivation to Motivation to Motivation to Motivation to outcomes Motivation to

Improved learning outcomes

Faster learning and graduation Better achievements in learning Better learning outcomes Passion for studies Positive impact on learning

Encouragement to learn

Encouragement to continue Encouragement to study more Encouragement to have the willpower to continue

Positive learning experience

Well set example of teachers Good experience in learning practical nursing skills Empathy in nursing Handling the challenges well

Reduction of stress

Less stressful learning Less stressful studies Less stressful personal life

Better communication

Gives freedom to ask Explains task clearly Gives freedom to express worries Offers easier ways to interact and to ask questions

Building of a positive student–teacher relationship

Feeling accepted by teacher Seeing teacher’s credibility Trust in what the teacher says Freedom of choice in learning and achieving Promotes self-confidence Reduction of fear to interact with teacher

Lack of motivation in learning

Feeling lack or loss of motivation for learning Unreachable standards set by teacher Lack of guidance in learning Unfairness in course evaluation

Learning apprehension

Feeling of being stupid for asking questions Feeling of not knowing anything Lack of feedback No improvement in learning outcomes Staying behind in the subject Apprehension to learn the subject Loss of interest in learning Giving up on studies

Caring learning environment

Obstructed learning

learn more continue with studies study harder achieve better learning become the best

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Table 2 continued Category

Sub-category

Code

Negative consequences for student’s quality of life

Mental distress

Feeling of helplessness (through lack of guidance) Feeling of opposition from teachers (distant behavior) No knowing how and what to do Discouragement through blame- related comments Fear of asking or talking to teachers Feeling of demoralization Additional stress in learning and/or in personal life Low self-esteem in learning Frustration in professional development Discomfort in personal learning Feeling low about one’s own learning achievements Anger towards teachers Disrespect towards teachers

Miscommunication

Bad communication skills Misunderstanding Lack of understanding Not being able to express yourself Distance between the student and the teacher

The negative consequences for a student’s quality of life were classified into the subcategories of mental distress and miscommunication. Mental distress included confusion, discouragement, fear, demoralization, disrespect, feelings of low self-esteem, humiliation and helplessness. Maybe sometimes you are so late, sometimes they have to understand when I try to explain why I am so late, and the teacher will just shout at you. And say this time you shouldn’t be in class or something. I feel so bad, I can’t even explain why. The teacher should ask first why, maybe you have some problem and they don’t give that chance to explain and you feel so discouraged (Interviewee six, male). One of them was when we did one exam, and I was very disappointed with my grade and I felt that I did at least a little bit better. When I went to teacher, she almost walked away, I did not get any explanation why or to know what I should have done differently. But even that wasn’t that important, but the way I was treated (Interviewee 11, female). Influence of teachers’ empathy on students becoming a nurse The influence of empathy from teachers on becoming a nurse were divided into the categories facilitating professional education, strength-based learning, hindering learning of the correct principles of nursing care and staying true to personal principles (Table 3). Facilitating professional education included the sub-categories of growing to become an empathetic nurse, learning to provide enhanced patient care, building constructive professional growth and understanding the philosophy of caring in nursing. Students

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emphasized that empathy from teachers helped them grow to become an empathetic nurse when they could experience empathy from their teachers. An experience of empathy further enhanced the care of patients in educating the students to understand the patient’s situation and to provide comfort, by conveying the positive experience of empathy to the patient. It helped the students learn to understand the position of their patients and to show care towards them, and in turn helped the patients reduce their worries. Constructive professional growth involved transferring learned experiences into practice, learning the ethical qualities of a nurse, receiving a helping tool in empathetic caring in the field of nursing, finding stability in theoretical and practical principles of care, having a positive experience in a new career, and demonstrating better performance in nursing. Understanding the philosophy of caring in nursing was displayed in becoming familiar with the caring environment and in a right understanding of care and in the perceived effect of a positive caring environment in nursing. Strength-based learning was organized into the sub-categories of role modeling by teachers and receiving affirmative encouragement to become a professional nurse. Also at that time we are like clay, we have to grow up and stand, we also are affected how teachers behave with us, and we have to be that way. It is like the same when the child is growing up in the family, so we learn from the teachers (Interviewee four, female). The category hindering learning of the correct principles of nursing care included subcategories of negative impact on patient care, and lack of empathy in delivering that care to patients. The negative impact category included consequences on patient care, where students saw negative results in clinical nursing care, acknowledging their lack of knowledge and skills in offering empathy towards their patients. Some students felt that a lack of empathy from the teacher would not hinder them in expressing empathy towards their patients. The category of staying true to personal principles was divided into sub-categories of a contradictory behavior of a negative example and dealing with conflicting pressure. Students said that a lack of empathy in their teachers also encouraged them to work at a higher standard than their teachers. However, they felt there might be negative consequences on their professional development as a result of losing motivation and not being able to become a successful nurse. Dealing with conflicting pressure included risking becoming mechanical in their nursing and even experiencing negative feelings about their personal beliefs regarding empathy.

Discussion In order to describe nursing students’ experiences of their teachers’ empathy, it was essential to review the students’ perceptions about empathy in teaching, their expectations of it and its influence on their learning. The students’ reports that teachers’ empathy fosters constructive learning experiences are consistent with previous findings that constructive and empathetic communication in nursing education and clinical practice enhances learning motivation and progress (Beckman and Lee 2009; Sawatzky et al. 2009). Further experiences shared by the students were that experiencing empathy from their teachers helped them to find the willpower to continue and encouraged them to learn. These findings regarding the influences of a caring learning environment are consistent with two core principles of Watson’s (2008) theory of Human Caring: building a positive

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Table 3 Influence of teachers’ empathy on students becoming a nurse Category

Sub-category

Code

Facilitating professional education

Growing to become an empathetic nurse

Becoming an empathetic nurse Experiencing an encouraging process in becoming an empathetic nurse Learning to become a more empathetic person and a nurse

Enhanced care of patient

Teaching to understand the patient’s situation and provide comfort Carrying a positive experience of empathy to the patient Learning to understand the position of the patient Showing care towards the client Learning to show empathy towards the patient Helping the patient reduce their worries

Constructive professional growth

Transferring learned experiences into practice Learning the ethical quality of the nurse Receiving a helping tool in empathetic caring in the field of nursing Finding stability in theoretical and practical principles of care Having a positive experience in a new career Receiving positive influence for a future career Having better performance in nursing

Understanding the philosophy of caring in nursing

Familiarity with the caring environment Right understanding of care in nursing Perceived effect of positive caring environment

Role modeling

Receiving a model of empathy Learning by example Taking role modeling into clinical practice Practicing by provided example Setting an example of empathy

Affirmative encouragement

Provides assurance for self-confidence Offers help to achieve Gives motivation to become a nurse Provides coping tools in stressful clinical situations Helps productivity in the future

Negative impact on the care of patients

Negative results in the care of patients Dissatisfaction of care by patient Difficulties in showing correct type of care towards the patient Difficulties practicing nursing skills correctly Lack of knowledge and ability to show empathy towards the patient Not being able to understand the patient’s needs Reduced quality of professional care Not learning to know the patient’s needs

Lack of empathy

Difficulties in being empathetic with the patient Not having enough skills and knowledge to provide empathy at the right time

Contradictory behavior of negative example

Encouraging an improvement in one’s nursing above what is experienced Does not obstruct the desire to become an excellent nurse Does not limit level of empathy

Dealing with conflicting pressure

Makes life difficult at the time Breaking down of personal beliefs Challenges to remain caring and empathetic according personal beliefs

Strength- based learning

Hindering learning of the correct principles of nursing care

Staying true to personal principles

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interpersonal caring relationship by creating freedom and minimizing authoritarian values in teachers. The importance of a caring learning environment and empathetic perspective is corroborated by a previous analysis of students’ reported perceptions of caring in online education, as reflected in quotations such as: ‘‘If faculty doesn’t care, why should I?’’, ‘‘Caring encourages me to do the best I can’’, and ‘‘I go the extra distance for the people I feel care about me’’ (Leners and Sitzman 2006 p. 317). Studies by Mann (2014) and Sitzman (2010) on online education further confirm the benefits of a caring learning environment for successful learning. Additional findings concern students’ experiences of teachers’ unempathetic behaviors and effects of a lack of empathy, which they said had negative consequences for their quality of life, including deeper feelings of mental distress. Induction of negative feelings such as discouragement, helplessness, opposition and demoralization strongly conflict with core principles of the Human Caring theory (Watson 2008), which emphasizes the importance of honoring human dignity and respect. Thus, multicultural (and other) education establishments should consider such results by strongly emphasizing the need for educational staff to be empathetic when working with nursing students. The results also indicate that teachers’ empathy facilitates professional education, which is consistent with core principles of holistic nursing care in both the theory of Human Caring (Watson 2008) and nursing philosophy (McEwen and Wills 2007). The holistic view of nursing includes providing care for patients by holding moral values and a vision of excellence in the nursing profession (Austgard 2008). Thus, the importance of empathy and understanding the philosophy of caring in nursing for enhancing patient care should be promoted and reinforced by the professional behavior of teachers involved in nursing education. These results regarding role modeling by teachers are consistent with findings of a longitudinal study by Ward et al. (2012), and An exploratory study of student nurses’ empathy (Ouzouni and Nakakis 2012). The latter suggested that nursing education should provide positive role models for students, and stressed the importance of fostering empathy towards students in the early years of their nursing education. Similarly, Perry (2009) has shown that exemplary nurses are also excellent role models for nursing students, and can contribute to novice professionals’ education in practice settings. In the cited study Perry fruitfully applied a framework incorporating social learning theory (Bandura 1997) and the theory of Human Caring (Watson 2008). Thus, role modeling of empathetic behavior by teachers, and application of social learning theory, could provide additional tools for nurse educators to strengthen a holistic approach for nurturing the development of future professionals. According to the interviewed students, the consequences of teachers lacking empathy for their development as professional nurses included doubts that they could become the nurses they wanted to be without a suitable role model during their education. They reported that it had negative impacts on their quality of patient care, satisfaction, knowledge, skills and empathy towards patients. These findings have alarming implications for nursing care, and strongly corroborate the need for improvements in empathy and role modeling in nursing education. Trustworthiness of the study In a qualitative study it is important to evaluate the trustworthiness of the data obtained. Trustworthiness refers to the degree of confidence that a researcher has in the acquired data (Polit and Beck 2008). From the framework of trustworthiness (Elo et al. 2013) for

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qualitative research the criteria of credibility, dependability and confirmability were used in the quality assessment of this research. Credibility was maintained by using the research data without manipulating it in any way and thus biasing the results. Dependability of the research was enhanced by using the same time frame, questions and conditions for interviewing all 12 students. Confirmability was improved by keeping objectivity when asking questions during the interview, having a non-directive counseling approach when listening to students’ personal experiences, keeping names anonymous when reading and analyzing the data for coding, reading through the transcripts several times and categorizing data into identified themes, consulting with the cowriters about the results and asking for confirmation in the interpretation of the data. Study limitations There may be some limitation related to the cultural diversity and understanding of empathetic behavior among the international group of participants. However, Fields et al. (2011) recently showed that there was no scientifically significant relationship between empathy score and the various ethnicities of students with different religious backgrounds. Further, the majority of students came from the same University of Applied Sciences, which can influence the results because empathy in nursing is understood in a more limited way when receiving the same kind of courses with the same type of teachers. The interview questions were pretested on one participant, but the study could have been strengthened by using several pretest interviews before the data collection. Further, the empirical evidence could be strengthened by designing a questionnaire based on the interview data and examining the results using a quantitative method. The students’ opinions of their teachers can help those teachers understand what expectations students have and how to help them achieve their goals.

Conclusion The results indicate that empathy has a positive and direct influence on students’ professional development in nursing and their learning environment. A negative experience related to teachers’ empathy can obstruct the students’ learning, impair their quality of life, and hinder their professional development. The findings imply that teachers should be strongly encouraged to place a greater emphasis on the principle of empathy and caring in nursing, which involves behaving empathetically and creating caring learning environment for students. It has been shown that skills in empathy may be taught in nursing education thus improving patient care (Curnico et al. 2012; Ozcan et al. 2012). Such skills could be taught as part of the educational development of nursing teachers. The results show that there is a need for teachers to be able to express empathy towards their students. It suggests further instruction or educational systems for teachers could be developed in order to increase their empathic skills, and to show the importance of empathy on the further development of students in their learning and professionalism. Several courses on teaching empathy have been developed following the research by Vanlaere et al. (2010) and Ozcan et al. (2011), which could be further considered for nursing education. Further research including assessments of practicing nurses’ retrospective views of their professional development from study years to becoming a nurse, focusing on their

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development of empathy and its influence on patient care, could provide valuable additional knowledge for nursing science.

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