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Title: Paramedic Empathy Levels: Results from Seven Australian Universities

AUTHORS Dr Brett Williams Department of Community Emergency Health and Paramedic Practice , Australia

Dr Malcolm Boyle Department of Community Emergency Health and Paramedic Practice Monash University Victoria, Australia

Associate Professor Richard Brightwell Paramedical Science Faculty of Computing, Health and Science , Australia

Scott Devenish School of Public Health University of Technology Queensland, Australia

Peter Hartley Faculty of Health, Engineering and Science Victoria University Victoria, Australia

Michael McCall School of Medicine University of Tasmania, Australia

Dr Paula McMullen School of Medicine , Australia

Graham Munro School of Biomedical Sciences University New South Wales, Australia

Professor Peter O’Meara Faculty of Health Sciences La Trobe Rural Health School Victoria, Australia

Vanessa Webb

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Department of Community Emergency Health and Paramedic Practice Monash University Victoria, Australia

CORRESPONDENCE Dr Brett Williams Department of Community Emergency Health & Paramedic Practice Monash University – Peninsula Campus PO Box 527, McMahons Road Frankston, Victoria, Australia, 3199 Email: [email protected] Phone: 61 3 9904 4283 Abstract: Purpose Evidence suggests that improved empathy behaviours among healthcare professionals directly impacts on healthcare outcomes. However, the ‘nebulous’ properties of empathic behaviour often means that healthcare profession educators fail to incorporate the explicit teaching and assessment of empathy within the curriculum. This represents a potential mismatch between what is taught by universities and what is actually needed in the healthcare industry. The objective of this study was to assess the extent of empathy in paramedic students across seven Australian universities.

Methods A cross-sectional study using a paper-based questionnaire employing a convenience sample of first, second, and third year undergraduate paramedic students. Student empathy levels were measured using a standardised self-reporting instrument: Jefferson Scale of Physician Empathy – Health Profession Students (JSPE-HPS).

Findings A total of 783 students participated in the study of which 57% were females. The overall JSPE-HPS mean score was 106.74 (SD=14.8). Females had greater mean empathy scores than males 108.69 v 103.58 (p=0.042). First year undergraduate paramedic mean empathy levels were the lowest, 106.29 (SD=15.40) with second years the highest at 107.17 (SD=14.90).

Value The overall findings provide a framework for educators to begin constructing guidelines focusing on the need to incorporate, promote and instil empathy into paramedic students in order to better prepare them for future out-of-hospital healthcare practice.

Keywords: Empathy, Undergraduates, Paramedics

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Paramedic Empathy Levels: Results from Seven Australian Universities

Brett Williams, Malcolm Boyle, Richard Brightwell, Scott Devenish, Peter Hartley, Michael McCall, Paula McMullen, Graham Munro, Peter O'Meara, Vanessa Webb Introduction

Empathetic behaviour is widely regarded as being important in achieving positive outcomes for patients (Hemmerdinger et al. 2007; Yu and Kirk 2009; Fields et al. 2011). Empathetic healthcare attitudes in patient care have been credited with increasing patient compliance, facilitating greater prognostic accuracy, enhancing patient satisfaction, reducing patient stress levels, minimising the rate of medical errors and achieving optimal physiological results (Hojat 2009; Fields et al. 2011; Hojat et al. 2011). Despite the relative scarcity of published literature in relation to paramedic practice (Boyle et al. 2010), empathy has still been shown to be of vital importance in the out-of-hospital environment. Empathy in paramedics facilitates the creation of an ‘internal frame of reference’ that essentially allows paramedics to act in the best interests of the patient in high-stakes emergency situations without sharing their pain (Regehr et al. 2002). Empathetic paramedic attitudes have also been shown to have had a profound impact on the interaction of paramedics and parents during cases of Sudden Infant Death Syndrome [SIDS] in Scandinavia (Nordby and Nohr 2008). A number of these parents emphatically asserted that paramedic attitudes were vital determinants in their ensuing ability to cope with the sudden death of their child. Many parents expressed a prevailing sense of comfort persisting many years after their loss when recalling empathetic attendant paramedic interactions (Nordby and Nohr 2008).

Despite the overwhelming evidence supporting the benefits of empathy in all aspects of patient care, there appears to be no universally agreed upon definition of empathy in a healthcare context. Most literature appears to support the assertion that empathy is a multi-dimensional construct (Dziobek et al. 2008; Derntl et al. 2010; Ziolkowska- Rudowicz and Kladna 2010; Fields et al. 2011; Dyrbye et al. 2012). As far back as 50 years ago Aring sought to conceptualise empathy by attempting to differentiate it from the notion of sympathy (Aring 1958). Although the two terms are often used synonymously in colloquial language, efforts must be made to distinguish the subtle differences that essentially prove these terms are not interchangeable in healthcare. Sympathy is the act of sharing the feelings of another, whereas empathy is an identification of the feelings of another whilst still maintaining a separation of self from the observed individual (Aring 1958). The vital difference between these two terms in healthcare is that empathy allows a reflective commitment to the patients’ situation whilst still ensuring retention of a professional healthcare identity (Aring 1958). More recent literature has built upon this fundamental idea and further elucidated by describing cognitive and emotional empathy. Cognitive empathy is the ability to appreciate the situation of another, whilst emotional empathy is the affective

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Paramedic Empathy Levels connection with an individual resulting in an ensuing emotional response (Regehr et al. 2002; Dziobek et al. 2008; Maurage 2011; Farrant, J et al. 2012).

Despite the abundance of literature that comprehensively details the importance of empathetic behaviours in healthcare there exists evidence that suggests many healthcare students are lacking proficiency in this area. A recent University of Michigan meta-analysis compiling 30 years of studies concluded that undergraduate students of today have lower empathy levels than students from previous generations (Konrath et al. 2011). Not only are some students incapable of demonstrating empathetic behaviours, many fail to even acknowledge the relevance of this vital skill in relation to their own future healthcare careers (Fields et al. 2011). This is concerning because students are in the ideal environment to develop and consolidate empathetic regard whilst in the tertiary academic setting. Hojat identified that empathy in healthcare workers should be developed through professional education, citing that one of the most important roles of medical education is to champion the need for empathetic engagement in patient care (Hojat 2009). Other papers have drawn similar conclusions, suggesting that the empathetic tendencies of healthcare students are best improved through the intervention of appropriate teaching techniques (Dereboy et al. 2005; Nunes et al. 2011). Through the provision of specific empathetic learning strategies students are able to reflect on their own internalised assumptions and biases, thus increasing their self-awareness and resulting in enhanced patient interaction (Svensen and Bergland 2007). Educational empathy models have been shown to directly increase empathetic regard, with greatest success derived through the engagement of students in experiential styles of learning (Brunero et al. 2010). This makes a strong case as to the role tertiary institutes and industry partners can play in not only imparting traditional clinical skill-based knowledge, but also facilitating the interpersonal and philosophical development of healthcare students.

The concept of teaching and assessing empathy as an independent skill in its own right is a contentious issue in undergraduate healthcare education. Previous research undertaken in other healthcare disciplines such as social work (Gerdes, Segal et al. 2010), midwifery (McKenna et al. 2011), occupational therapy (Brown et al. 2010), medicine (Hojat et al. 2004; Hemmerdinger et al. 2007; Ziolkowska-Rudowicz and Kladna 2010; Neumann et al. 2011) and nursing (Yu and Kirk 2008; Yu and Kirk 2009; Brunero et al. 2010; Libbam et al. 2011) have all emphasised the inherent difficulty in conceptualising and measuring empathy in education, with a number of articles specifically highlighting the discrepancies that exist between the various empathy measurement tools. Given empathy is regarded more as an over-arching philosophical stance rather than an isolative procedural skill; it is difficult for educators to incorporate explicit teaching into healthcare curricula. Indeed of the seven universities included in this study not one institute has developed an assessment that links to empathetic teaching objectives. In light of this it is possible to suggest that paramedic students are being underprepared for what will be required of them once qualified, essentially representing a mismatch between what is taught in universities and what is actually needed in the healthcare industry.

Although paramedic training differs from university-to-university, the importance of effective patient-paramedic relationship establishment is a basic requirement. All seven universities included in this study provide paramedic undergraduate education to students in a pre-employment model, with similar attributes and ethics instilled in

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students upon graduation. The objective of this study was to assess the extent of empathy in paramedic students across seven Australian universities.

Method Design A cross-sectional study using a paper-based questionnaire employing a convenience sample of first, second, and third year undergraduate paramedic students. This non- probability sampling method was used given the easy access to student groups and exploratory nature of this study.

Participants Students enrolled in undergraduate paramedic programs from Monash University (MU), Charles Sturt University (CSU), Victoria University (VU), Edith Cowan University (ECU), University of Tasmania (UT), (LTU), and Queensland University of Technology (QUT) provided data for the analysis. There were 1,821 students eligible for inclusion in the study. Inclusion criteria for the study were being enrolled on a full time basis in one of the paramedic courses.

Instrumentation Student empathy levels were measured using a standardised self-reporting instrument: Jefferson Scale of Physician Empathy – Health Profession Students (JSPE-HPS) which uses a 7-point Likert scale (strongly disagree=1, strongly agree=7) Ten items are negatively phrased and are reversed scored for statistical analysis. The scale takes approximately ten minutes to complete and produces scores between 20 and 140. A high score reflects a higher level of empathy. The JSPE-HPS has reported validity and reliability within the empathy measurement literature (Fjortoft et al. 2011). In their study involving 187 pharmacy students Fjortoft et al., (2011) produced a two-factor structure accounting for 39% of the total explained variance and Cronbach alpha coefficient of 0.84 suggesting the JSPE-HPS is suitable for replication studies.

Procedures At the conclusion of a lecture for each of the undergraduate programs, students were invited to participate in the study. Students were provided with an explanatory statement and were informed that participation was voluntary and anonymous. A non- teaching member of staff facilitated the process and participants were administered a questionnaire containing the JSPE-HPS and a brief set of demographic questions. The scale took students approximately ten minutes to complete and consent was implied by its completion and submission.

Data Analysis The SPSS program (Statistical Package for the Social Sciences Version 18.0, SPSS Inc., Chicago, Illinois, U.S.A.) was used for data storage, tabulation, and the generation of descriptive and inferential statistics. Descriptive statistics means and standard deviations (SD) were used to summarise the demographic and some of the JSPE-HPS measurement data. Inferential statistics, t-tests and one-way analysis of variance (ANOVA), including post hoc tests, were used to compare the differences between age groups, gender, year level, and university. The effect sizes (eta) were

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calculated to evaluate the findings results are considered statistically significant if the p value is < 0.05.

Ethics Ethics approval was initially from the Monash University Human Research Ethics Committee and then from each participating human research ethics committee. Results Participant demographics There were 783 students who participated in the study and were enrolled in the respective undergraduate paramedic programs from MU, CSU, VU, ECU, UT, LTU and QUT. This represents a 42.9% response rate. The majority of participants were enrolled in first year n=377 (48.1%), predominately female n=449 (57.3%), were mostly under the age of 25 n=568 (72.6%) and participating in a single paramedic degree n=680 (86.8%). The full demographic distribution is outlined in Table 1

First year undergraduate paramedic students had the lowest mean empathy scores, 106.29 (SD=15.40). Students from ECU had the highest empathy score of 115.12 (SD=14.10), while VU had the lowest score with 105.46 (SD=15.0). For the full range of results see Table 2. The mean score and standard deviations (SD) for the JSPE-HPS were 106.74 (SD=14.85). The internal consistency was measured using Cronbach’s alpha coefficient. The resultant alpha coefficient for the JSPE-HPS was α=0.83 which was well above the commonly used 0.70 benchmark for scale reliability (Hair et al. 1995).

There was a statistically significant difference in empathy between males and females (M=103.81 v 108.69, t 4.66, p<0.0001). The magnitude of the differences in the means (mean difference = 1.04, 95% CI: 1.04 to 6.93) was small (eta = 0.10). There was a statistical difference between universities F=2.42, p=0.025, eta = 0.23. Post-hoc comparisons using Tukey HSD indicated that the mean score for VU (M=105.46, SD=15.0) was significantly different from ECU (M=115.12, SD=16.5). There was no statistical difference between the year levels, and age groups (see Table 3).

Discussion

This study is believed to be one of the first in Australia to look at paramedic student empathy levels at a national level across multiple universities that have paramedic programs. A number of empathy studies have been undertaken on a variety of undergraduate healthcare students (pharmacy and nursing) using the JSPE-HPS with empathy scores ranging from 110.7 to 111.4 (Fields et al. 2011; Fjortoft et al. 2011). However there are few paramedic empathy research papers which can be used to benchmark this study. Nonetheless one 2010 study identified that paramedic students

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had an overall JSPE mean empathy score of 106.32 which assists in validating our finding of a JSPE mean of 106.74 (Boyle et al. 2010).

Our findings demonstrating higher levels of empathy in female students compared to their male counterparts is a gender-related phenomenon that has strong support in the academic community (Hojat et al. 2004; Kliszcz et al. 2006; Chen et al. 2007; Harlak et al. 2008; Boyle et al. 2010; Brown et al. 2011; Fields et al. 2011; Nunes et al. 2011). Despite this support there exist several conflicting theories that seek to explain this often reported phenomenon. Physiological explanations highlight differences in brain structure and neural circulation between gender groups (Baron-Cohen 2004; Han, Fan et al. 2008). Expanding on this it has been shown females tend to recruit emotion and self-related brain regions whilst males employ cognitive and cortical brain regions to process strategies whilst solving emotional quandaries (Derntl et al. 2010). Postulation also exists that men are predisposed to exhibit a decreased empathetic response in order to promote enhanced rational decision making free from emotional encumbrance (Looi 2008). From an anthropological perspective some literature points towards the development of ingrained gender roles within our society (Mestre et al. 2009), whilst others discuss the parental investment evolutionary theory that asserts females innately experience a heightened nurturing attachment to offspring than males (Magalhaes et al. 2011). Any number of these hypotheses whether singular or combined could potentially explain the higher regard for empathetic interaction with patients demonstrated by female paramedic students.

The JSPE-HPS also identified that first year undergraduate paramedic mean empathy levels were the lowest (106.29) compared with second years (107.17), and third year students (106.71). These findings could lead to cautious assumptions that empathy increases through student undergraduate education, which is in contrast to the previous well-documented research, suggesting that as students move to the end of their undergraduate degrees their empathy for patient’s declines (Hojat et al. 2004; Chen et al. 2007; Newton et al. 2008; Nunes et al. 2011). The frequently cited reason for this decline is that as students progress through their education they are exposed to more clinical placement education opportunities, resulting in cynicism development, de-humanisation of situations and ‘burn-out’ (Chen et al. 2007; Boyle et al. 2010; Williams et al. 2012). Whilst there is some exposure to patients and clinical opportunities in first year, these are usually observational only. The majority of paramedic clinical placements begin during second and third year at MU, ECU, QUT, VU, UT, CSU and LTU. Further longitudinal data is required to ascertain whether these data will alter over time.

When examining the results of the JSPE-HPS on a descriptive level several interesting items were noted. Item ‘It is difficult for me to view things from my patients’ perspectives’ resulted in a mean of 5.38 (SD= 1.479), Item ‘Patients’ illnesses can be cured only by medical or surgical treatment; therefore, emotional ties to my patients do not have a significant influence on medical or surgical outcomes’ delivered a mean of 5.80 (SD=1.495) and Item ‘I believe that emotion has no place in the treatment of medical illness’ returned a mean of 5.95 (SD=1.468). This suggests that in general terms paramedic students seem to view their future healthcare role in terms of a strict medical therapeutic context only, with little to no requirement for a personal emotive connection with a patient. Indeed this claim can be further substantiated by a 2010 study of paramedic, midwifery, nursing, physiotherapy, health science and

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occupational therapy students, whence paramedic students were shown to possess the lowest mean empathy scores of all healthcare students surveyed (Boyle et al. 2010). The implications of this assertion should be interpreted carefully however as at this time there is a dearth of literature examining empathy levels in qualified paramedics. In 1996 Grevin reported that both paramedics and paramedic students had significantly low empathy levels, a personality trait she suggested they were inherently predisposed to (Grevin 1996). Grevin further suggested that low empathy may serve as an adaptive mechanism that allows functional paramedic operation in a persistently stressful emergency workplace (Grevin 1996). Extrapolating from this it is possible that our findings of student attitudes in regards to a seeming propensity to reject emotional connection could actually be mirrored in practicing Australian paramedics. Thus in reality lower empathy may be considered an attribute conducive to successful out-of-hospital practice; however this requires further in-depth exploration before any definitive correlations can be drawn.

Building upon this adaptive mechanism hypothesis further literature was examined as to the resultant implications empathetic behaviour has on health professionals themselves. Whilst a body of knowledge has illustrated the various benefits empathetic healthcare has for receiving patients, there appears to be some conflicting information on the ramifications for the treating professionals. Several authors’ assert that higher empathy in practice may actually be associated with better health professional wellbeing (DiLalla et al. 2004; Thomas et al. 2007; Hojat 2009). Despite the relative paucity of paramedic specific literature the few papers that were identified disagreed with this inference. Paramedics often operate in critical high stimulus emergency environments where they must make quick and potentially life-saving decisions for complex patients with limited medical back-up (Wahlin et al. 1995). During their careers almost all paramedics will be exposed to traumatic incidents; including death of a child, mass casualties and domestic violence, sometimes on a daily basis. It has been suggested that paramedics are vulnerable to developing post- traumatic stress disorder (PTSD), with this vulnerability further amplified if paramedics experience an emotional connection with victims of the above traumatic circumstances (Grevin 1996; Regehr et al. 2002; Mishra et al. 2010; Halpern and Maunder 2011; Holland 2011; Donnelly 2012). Rather than serve to contradict the importance of empathy in paramedic practice however, the authors believe these findings further highlight the need to incorporate specific empathy training into paramedic curricula. Given the resultant health conditions associated with a traumatic workplace environment it is imperative that students are taught the appropriate techniques to allow them to empathise with patient circumstances without becoming emotionally entangled.

Limitations This study is potentially limited by the use of convenience sampling. This method, while being easier to recruit participants, may not recruit a representative sample of students i.e. non-response bias. Consequently, those students who did volunteer to participate may themselves bias the results. Caution is required when interpreting the results as the JSPE-HPS is a self-reporting questionnaire. Therefore results of the students’ reported views and perceptions may differ from their actual empathetic attitudes either in private or when confronted with a patient presenting with one of the clinical situations. A further limitation is the uncertainty surrounding students’

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Paramedic Empathy Levels clinical placement exposure and what, if any, influence this might have on how they self-rate on the scale items. Conclusion

The findings from this study suggest that female students report higher levels of empathy than their male colleagues, and that undergraduate paramedic empathy levels are lowest in first year and highest in second year. The overall findings provide a framework for educators to begin constructing guidelines focusing on the need to incorporate, promote and instil empathy into paramedic students in order to better prepare them for future out-of-hospital healthcare practice. Longitudinal research examining these issues is suggested.

Competing Interests No competing interests.

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References

Aring, C. D. (1958). "Sympathy and empathy." J Am Med Assoc 167(4): 448-52. Baron-Cohen, S. (2004). The essential difference: male and female brains and the truth about autism. Portland, Basic Books. Boyle, M., B. Williams, et al. (2010). "Levels of empathy in undergraduate health science students." Int J Med Educ 1(1). Brown, T., M. Boyle, et al. (2011). "Predictors of Empathy in Health Science Students." J Allied Health 40(3): 143-149. Brown, T., B. Williams, et al. (2010). "Levels of empathy in undergraduate occupational therapy students." Occup Ther Int 17(3): 135-41. Brunero, S., S. Lamont, et al. (2010). "A review of empathy education in nursing." Nurs Inq 17(1): 65-74. Chen, D., R. Lew, et al. (2007). "A cross-sectional measurement of medical student empathy." J Gen Intern Med 22(10): 1434-8. Christison, G., M. Haviland, et al. (2002). "The Medical Condition Regard Scale: Measuring Reactions to Diagnosis." Acad Med 77(3): 257-262. Dereboy, C., H. Harlak, et al. (2005). "[Teaching empathy in medical education]." Turk Psikiyatri Derg 16(2): 83-9. Derntl, B., A. Finkelmeyer, et al. (2010). "Multidimensional assessment of empathic abilities: neural correlates and gender differences." Psychoneuroendocrinology 35(1): 67-82. DiLalla, L. F., S. K. Hull, et al. (2004). "Effect of gender, age, and relevant course work on attitudes toward empathy, patient spirituality, and physician wellness." Teach Learn Med 16(2): 165-70. Donnelly, E. (2012). "Work-Related Stress and Posttraumatic Stress in Emergency Medical Services." Prehosp Emerg Care 16(1): 76-85. Dyrbye, L. N., A. M. Eacker, et al. (2012). "Distress and empathy do not drive changes in specialty preference among US medical students." Med Teach 34(2): e116-22. Dziobek, I., K. Rogers, et al. (2008). "Dissociation of cognitive and emotional empathy in adults with Asperger syndrome using the Multifaceted Empathy Test (MET)." J Autism Dev Disord 38(3): 464-73. Farrant, B. M., J, et al. (2012). "Empathy, Perspective Taking and Prosocial Behaviour: The Importance of Parenting Practices." Infant Child Dev 21(2): 175-188. Fields, S. K., P. Mahan, et al. (2011). "Measuring empathy in healthcare profession students using the Jefferson Scale of Physician Empathy: health provider-- student version." J Interprof Care 25(4): 287-93. Fjortoft, N., L. Van Winkle, et al. (2011). "Measuring Empathy in Pharmacy Students." Am J Pharm Educ 75(6): 1-6. Gerdes, K. E., E. A. Segal, et al. (2010). "Conceptualising and Measuring Empathy." Br J Soc Work. 1–18 doi:10.1093/bjsw/bcq048. Grevin, F. (1996). "Posttraumatic stress disorder, ego defense mechanism and empathy among urban paramedics." Psychol Rep 79(2): 13. Hair, J., R. Anderson, et al. (1995). Multivariate data analysis with readings, New Jersey, Prentice Hall. Halpern, J. and R. G. Maunder (2011). Chapter 8: Acute and chronic workplace stress in emergency medical technicians and paramedics. Handbook of Stress in the

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Occupations. J. Langan-Fox and C. L. Cooper. Cheltenham, UK, Edward Elgar Publishing Limited: 135-156. Han, S., Y. Fan, et al. (2008). "Gender difference in empathy for pain: an electrophysiological investigation." Brain Res 1196: 85-93. Harlak, H., A. Gemalmaz, et al. (2008). "Communication skills training: effects on attitudes toward communication skills and empathic tendency." Educ Health 21(2): 62. Hemmerdinger, J. M., S. D. Stoddart, et al. (2007). "A systematic review of tests of empathy in medicine." BMC Med Educ 7: 24. Hojat, M. (2009). "Ten approaches for enhancing empathy in health and human services cultures." J Health Hum Serv Adm 31(4): 412-50. Hojat, M., D. Z. Louis, et al. (2011). "Physicians' empathy and clinical outcomes for diabetic patients." Acad Med 86(3): 359-64. Hojat, M., S. Mangione, et al. (2004). "An empirical study of decline in empathy in medical school." Med Educ 38(9): 934-41. Holland, M. (2011). "The Dangers of Detrimental Coping in Emergency Medical Services." Prehosp Emerg Care 15(3): 331-337. Kliszcz, J., K. Nowicka-Sauer, et al. (2006). "Empathy in health care providers- validation study of the Polish version of the Jefferson Scale of Empathy." Adv Med Sci 51: 219-25. Konrath, S. H., E. H. O'Brien, et al. (2011). "Changes in dispositional empathy in American college students over time: a meta-analysis." Pers Soc Psychol Rev 15(2): 180-98. Libbam R, McMillan, et al. (2011). "Program Evaluation of Nursing School Instruction in Measuring Students' Perceived Competence to Empathetically Communicate With Patients." Nurs Educ Perspect 32(3): 150-154. Looi, J. C. (2008). "Empathy and competence." Med J Aust 188(7): 414-6. Magalhaes, E., A. P. Salgueira, et al. (2011). "Empathy in senior year and first year medical students: a cross-sectional study." BMC Med Educ 11: 52. Maurage, P., D. Grynberg, et al. (2011). "Dissociation Between Affective and Cognitive Empathy in Alcoholism: A Specific Deficit for the Emotional Dimension." Alcohol Clin Exp Res 35(9): 1662-1668. McKenna, L., M. Boyle, et al. (2011). "Levels of empathy in undergraduate midwifery students: An Australian cross-sectional study." Women Birth 24(2): 80-84. Mestre, M. V., P. Samper, et al. (2009). "Are women more empathetic than men? A longitudinal study in adolescence." Span J Psychol 12(1): 76-83. Mishra, S., D. Goebert, et al. (2010). "Trauma exposure and symptoms of post- traumatic stress disorder in emergency medical services personnel in Hawaii." Emerg Med J 27(9): 708-11. Neumann, M., F. Edelhauser, et al. (2011). "Empathy decline and its reasons: a systematic review of studies with medical students and residents." Acad Med 86(8): 996-1009. Newton, B. W., L. Barber, et al. (2008). "Is there hardening of the heart during medical school?" Acad Med 83(3): 244-9. Nordby, H. and O. Nohr (2008). "Communication and empathy in an emergency setting involving persons in crisis." Scand J Trauma Resusc Emerg Med 16: 5. Nunes, P., S. Williams, et al. (2011). "A study of empathy decline in students from five health disciplines during their first year of training." Int J Med Educ 2: 12-17.

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Regehr, C., G. Goldberg, et al. (2002). "Exposure to human tragedy, empathy, and trauma in ambulance paramedics." Am J Orthopsychiatry 72(4): 505-13. Svensen, A. R. and A. Bergland (2007). "Learning through bodily experience: a possibility to enhance healthcare students' ability to empathize?" Adv Physiother 9(1): 40-47. Thomas, M. R., L. N. Dyrbye, et al. (2007). "How do distress and well-being relate to medical student empathy? A multicenter study." J Gen Intern Med 22(2): 177- 83. Wahlin, U., I. Wieslander, et al. (1995). "Loving care in the ambulance service." Intensive Care Nurs 11(6): 306-13. Williams, B., M. Boyle, et al. (in press). "Cross sectional measurement of empathy levels in undergraduate paramedic students." Prehosp Disaster Med. Yu, J. and M. Kirk (2008). "Measurement of empathy in nursing research: systematic review." J Adv Nurs 64(5): 440-54. Yu, J. and M. Kirk (2009). "Evaluation of empathy measurement tools in nursing: systematic review." J Adv Nurs 65(9): 1790-806. Ziolkowska-Rudowicz, E. and A. Kladna (2010). "[Empathy-building of physicians. Part I--A review of applied methods]." Pol Merkur Lekarski 29(172): 277-81.

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Table 1: Demographic distributions

Variable Descriptor N Percentage (%)

University CSU 75 9.6 ECU 26 3.3 MU 126 16.1 QUT 100 12.8 VU 338 43.2 UT 106 13.5 LTU 12 1.5

Gender Male 331 42.3 Female 449 57.3

Age 17-21 years 370 47.2 22-25 years 198 25.4 26-30 years 107 13.5 31-35 years 39 5.0 >36 years 61 7.7

Year level Year 1 377 48.1 Year 2 246 31.4 Year 3 150 19.2

Course type Single degree 680 86.8 (Paramedic) Double degree 102 13.0 (Nursing/Paramedic)

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Table 2: JSPE-HPS distributions

Variable JSPE-HPS (SD) CSU 109.93 (16.58) ECU 115.12 (14.11) MU 106.34 (13.10) QUT 106.96 (15.49) VU 105.46 (15.00) UT 106.64 (13.83) LTU 107.67 (16.41)

Male 103.81 (14.17) Female 108.69 (14.65)

Year 1 106.29 (15.40) Year 2 107.17 (14.90) Year 3 106.89 (13.71) Year 4 110.60 (8.80)

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Table 3: JSPE-HPS and MCRS comparisons

Scale Age Gender Year Level University

JSPE-HPS F=1.38, p=0.087 t = 4.66, p<0.000 F=0.41, p=0.745 F=2.42, p=0.025

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