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Empathy in Dentistry: How Attitudes andInteraction With Older Adults Make aDifferenceDeborah Waldropa, Thomas Nochajskia, Elaine L. Davisb, JudeFabianoc & Louis Goldbergb

a School of Social Work, University at Buffalo, Buffalo, New York,USAb School of Dental Medicine, University at Buffalo, Buffalo, NewYork, USAc Ivoclar Vivodent, Amherst, New York, USAAccepted author version posted online: 13 Dec 2014.Publishedonline: 13 Dec 2014.

To cite this article: Deborah Waldrop, Thomas Nochajski, Elaine L. Davis, Jude Fabiano & LouisGoldberg (2014): Empathy in Dentistry: How Attitudes and Interaction With Older Adults Make aDifference, Gerontology & Geriatrics Education, DOI: 10.1080/02701960.2014.993065

To link to this article: http://dx.doi.org/10.1080/02701960.2014.993065

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Gerontology & Geriatrics Education, 00:1–22, 2015Copyright © Taylor & Francis Group, LLCISSN: 0270-1960 print/1545-3847 onlineDOI: 10.1080/02701960.2014.993065

Empathy in Dentistry: How Attitudesand Interaction With Older Adults Make

a Difference

DEBORAH WALDROP and THOMAS NOCHAJSKISchool of Social Work, University at Buffalo, Buffalo, New York, USA

ELAINE L. DAVISSchool of Dental Medicine, University at Buffalo, Buffalo, New York, USA

JUDE FABIANOIvoclar Vivodent, Amherst, New York, USA

LOUIS GOLDBERGSchool of Dental Medicine, University at Buffalo, Buffalo, New York, USA

The development of empathy and positive attitudes are essential ele-ments of professional education. This study explored the nature ofempathy and its association with attitudes about, and exposure toolder patients in a sample of dental students. Students completedan adapted version of the Jefferson Scale of Physician Empathy(JSPE), the Aging Semantic Differential (ASD) and answered ques-tions about their exposure to older people. Factor analysis was usedto identify four factors: (1) Empathy is Valuable, (2) Empathy isDemonstrated, (3) Empathy is not Influential, and (4) Empathyis Difficult to Accomplish. Higher empathy scores were related tothe ASD subscale attitude of acceptability of aging and to greaterexposure to older adults outside of clinical practice. There were nodemographic predictors of higher empathy scores.

KEYWORDS dental education, geriatric dentistry, empathy,attitudes, older adults

Address correspondence to Deborah Waldrop, LMSW, PhD, School of Social Work,University at Buffalo, 685 Baldy Hall, Buffalo, NY 14260, USA. E-mail: dwaldrop@buffalo.edu

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2 D. Waldrop et al.

INTRODUCTION

Oral health is a key element of geriatric care. The American Society forGeriatric Dentistry, the Education Research Group of the InternationalAssociation for Dental Research, and the American Association for DentalResearch have been committed to improving oral health in older adultsthrough education and skill development (American Society for GeriatricDentistry, 2010; Dolan, Atchison, & Huynh, 2005). The development of aworkforce of dentists with knowledge about and skills for working witholder adults would be enhanced by interdisciplinary and interprofessionaleducation (Best, 2010).

For purposes of this article, the term older adults refers to individu-als age 65 or older. Older adults experience greater numbers of coexistentchronic conditions and higher levels of health care utilization, including den-tistry, than people younger than age 65 (Chalmers & Ettinger, 2008; Ettinger,2007; Ferguson, Steinberg, & Schwien, 2010). In most general dental prac-tices, older adults account for the largest number of visits and procedures(Ferguson et al., 2010). Many authors have asserted that geriatric dentistryrequires special knowledge and clinical skills to treat dental conditions thatoccur in older adults, recognize the important connection between oral andsystemic health to maintain optimal oral health and quality of life (Chapple,2009; Frisbee, Chambers, Frisbee, Goodwill, & Crout, 2010; Sheets, Paquette,& Wu, 2009). Good care is enhanced by a humanistic approach, a warm rela-tionship and sensitivity toward the patient’s systemic health and psychosocialconcerns (Scully & Ettinger, 2007). The core values that define profession-alism in dentistry have been identified as competence, fairness, integrity,responsibility, respect, and service mindedness (American Dental EducationAssociation [ADEA], 2013). Service mindedness is defined as compassionatecare for the benefit of individual patients and the public at large. Servicemindedness encompasses the obligation to benefit others, compassion, andempathy. Empathic care requires the ability to understand and appreci-ate another person’s perspectives without losing sight of one’s professionalresponsibilities (ADEA, 2013).

Empathy is particularly germane to quality care for older people and hasbeen linked to positive clinical outcomes (Hojat et al., 2011). However, thespecific features or defining characteristics of empathy may vary across pro-fessional disciplines within health care. Although the impact of empathy hasbeen linked to positive outcomes, the defining characteristics of empathy indentists are largely unknown (Satterfield & Hughes, 2007; Sutherland, 1993).Preparing student dentists with knowledge of, positive attitudes about, andempathy for the growing population of older dental patients is an impor-tant element of education for an aging-prepared health care workforce. Thetwofold purpose of this study was to describe the nature of empathy in

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Nature of Empathy 3

dental students and to investigate how attitudes about and exposure to olderadults influence students’ empathy for older patients.

LITERATURE REVIEW

Health-Related Quality of Life in Older Adults

There is evidence that current older patients are better educated, more polit-ically aware, and have more remaining teeth than in previous generationsof older patients (Federal Interagency Forum on Aging-Related Statistics,2012). However, the older population is not homogenous. Older peoplewho have lower incomes have poorer oral health and more limited accessto services (Tsakos, 2011). Frail and functionally dependent older adults alsoexperience barriers to receiving oral health care (Ettinger, 2010). Systemicdiseases that have an impact on oral health are more common in later lifeand should be an important factor in dental care for all older adults (Scully &Ettinger, 2007; Sheets et al., 2009). There are over 100 systemic diseases thathave oral manifestations, including cardiovascular disease, stroke, respiratoryinfections, pancreatic cancer, diabetes, and nutritional problems (Haumschild& Haumschild, 2009). This interaction of oral and systemic diseases can havea cascade effect on well-being in later life.

It is important for dental professionals to understand the special needsof older people and their ability to undergo and respond to care, estab-lish communication with primary care physicians and be able to manageemergencies (Vieira & Caramelli, 2009). Communication and understandingbetween health care providers and their patients has received increasingattention in dentistry and dental education (Sherman & Cramer, 2005).Dentists’ caring attributes, such as gentleness and friendliness, have beenfound to be valued by patients as much as their professional competence(Gerbert, Bleecker, & Saub, 1994; Nash, 2010; Small, 2005).

The relatively poor oral health status of older people who have coex-isting chronic conditions underscores the urgency for dentists to be able tocare for these underserved subgroups (Baumeister et al., 2007). Yet geriatricdentistry in the United States is still widely conceived of as simply involvingdentures for patients in nursing homes (Ettinger, 2010). The lack of Medicareand other insurance coverage for older adults’ dental services limits accessto care and contributes to complicating comorbid physical and psychoso-cial conditions in people who are frail, functionally dependent, cognitivelyimpaired, or terminally ill (Griffin, Barker, Griffin, Cleveland, & Kohn, 2009;Kiyak & Reichmuth, 2005; Scully & Ettinger, 2007). Moreover, provider reim-bursement for dental services is directly related to one’s state of residenceand is often poor or nonexistent (Ettinger, 2010; Ferguson et al., 2010).Financial barriers to good oral health care can have a negative impact onhealth-related quality of life.

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4 D. Waldrop et al.

Empathy

Understanding another person’s discomfort is essential to providing qual-ity care (Winland, 2006). Empathy is necessary for effective communicationbetween patients and providers to achieve optimal clinical outcomes.Empathy has been defined as a “predominantly cognitive attribute thatinvolves an understanding of patients’ experiences, concerns and perspec-tives combined with a capacity to communicate this understanding and anintention to help” (Hojat, 2007, 2009; Hojat et al., 2009, p. 1183). Hojat et al.(2002) developed a measure of empathy that provides the opportunity toexplore educational and clinical correlates as well as whether the level ortype of empathy differs across the stages of medical education. Higher empa-thy scores have been positively associated with clinical competence and bet-ter patient outcomes in physicians (Hojat et al., 2011). The Jefferson Scale ofPhysician Empathy (JSPE; Health Professionals [HP] version) was developedto assess the development of empathy in other health care professionals(Hojat, 2007). The questions on the JSPE and JSPE-HP are the same withminor wording changes to make the JSPE-HP more generic (Hojat, 2007).

The nature of empathy has been studied extensively in medical stu-dents but less so in dental students (Hojat et al., 2001). Sherman and Cramer(2005), using the JSPE-HP, found that the psychometric properties of empathyin a sample of dental students were comparable to those found in medicalstudents (Sherman & Cramer, 2005). Four factors emerged: (1) perspec-tive taking, (2) compassionate care, (3) standing in the patients’ shoes, and(4) efforts to ignore emotions in patient care. The questions associated witheach factor can be found in Sherman & Cramer, 2005. This article presentsthe results of an analysis of the nature of empathy in dental students and itsassociation with attitudes about and exposure to older adults.

METHOD

Project Overview and Study Design

The overall project is a large-scale longitudinal interdisciplinary effort thataimed to provide dental students with aging-enhanced education that willprepare them for effective practice with growing numbers of older people.Initially, we explored dental students’ knowledge about aging and found thatthough information is readily consumed by dental students, positive attitudesare not as easily taught (Fabiano, Waldrop, Nochajski, Davis & Goldberg,2005; Waldrop, Fabiano, Nochajski, Zittel-Palamara, Davis & Goldberg, 2006).Subsequently, we explored the association between attitudes about andexposure to older adults and learned that attitudes are significantly influ-enced by the amount of exposure to older people (Nochajski, Waldrop,Davis, Fabiano & Goldberg, 2011). However, attitudes and knowledge mayonly partially contribute to the development of a caring professional.

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Nature of Empathy 5

The study aimed to answer three research questions: (1) What are thecharacteristics of empathy in dental students? (2) Do levels of empathy varyby gender and age? and (3) What is the association between students’ atti-tudes about, exposure to, and empathy for older patients. We hypothesizedthat empathy would vary by gender and be positively associated with age.We also hypothesized that students’ attitudes about and exposure to olderadults positively influence their empathy for their older patients. The resultspresented in this article are cross-sectional.

Setting

The University at Buffalo, School of Dental Medicine (SDM) admits approx-imately 90 new dental students into its 4-year program each year. The SDMClinic is a major source of outpatient care for people who are disabled orhave medically complex conditions. Of the approximately 46,600 visits peryear, 72% are made by people age 50 years e or older (62% of the clinicpopulation). Dental students begin to see patients in the campus-based clinicduring the 2nd year, and their exposure intensifies in the 3rd and 4th year.

Sample Recruitment

The sampling strategy was purposeful; each student in all 4 years of dentalschool was invited to participate. Participation was voluntary. The study wasdescribed during required classes for students in each year of the program,and class time was given for completion of the instrument. For the academicyear of this study, there were a total of 344 students who had started theprogram: N = 81 in the 4th year, 71 completed the survey (87.7%); N = 87 inthe 3rd year of the program, 61 completed the survey (70.1%); N = 88 in the2nd year of the program, 81 completed the survey (92.1%); and N = 86 inthe 1st year of the program and 100% completed the survey. A total of 299(86.9%) completed the survey. The study was approved by the Universityat Buffalo Social and Behavioral Sciences Institutional Review Board. Studyparticipation was completely voluntary. A written informed consent was nutused. Completion of the survey document was assumed to imply consent.

Sample Demographics

The sample included 292 students. The Mean age was M = 26.3 (SD =4.2 years) with an age range from 19 to 42 and 55.5% were younger thanage 26. The sample included n = 169 men (56.5%). Nine percent said theirparents were age 65 or older, 63.5% indicated that their grandparents wereage 65 or older, and 30.8% said they had other relatives who were in thisage group.

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6 D. Waldrop et al.

Instrumentation

The survey instrument had four sections: (1) Questions About You (demo-graphics), (2) The Aging Semantic Differential (attitudes), (3) The JeffersonScale of Physician Empathy (empathy), and (4) Frequency of Interactionswith Older Adults.

QUESTIONS ABOUT YOU

Students were asked for their age, year in dental school, gender, and maritalstatus.

AGING SEMANTIC DIFFERENTIAL

The Aging Semantic Differential (ASD) involves 32 pairs of items (Rosencranz& McNevin, 1969). Items consist of bipolar adjective pairs that are oppo-site in meaning, and participants respond on a scale of 1 to 7 betweenthe adjectives. The summary scale score ranges from 32 to 224, with lowerscores reflecting more positive attitudes. There are four subscales: PersonalAutonomy-Dependence, Instrumental-Ineffective, Personal Acceptability-Unacceptability, and Integrity. Positive scores reflect attitudes that olderadults are independent, effective, acceptable, and have integrity. Subsequentconfirmatory factor analysis has been conducted by Intriere, von Eye, andKelly (1995). The instrument has been used with a number of differentgroups and, when submitted to factor analysis, demonstrates different fac-tor structures with different groups (e.g., medical students, undergraduatestudents). The ASD has been shown to demonstrate high internal reliability(Cronbach’s alpha .89) (Intrieri et al., 1995; Varkey, Chutka, & Lesnick, 2006).

THE JEFFERSON SCALE OF PHYSICIAN EMPATHY

The Jefferson Scale of Physician Empathy (JSPE) is a 20-item instrument thatuses a 7-point Likert-type scale and was developed to measure health careproviders’ level of empathy for their patients (Hojat et al., 2001). Scoresranged from 20 to 140, with higher scores reflecting a more empathic behav-ioral orientation. The JSPE has been shown to demonstrate a high level ofinternal reliability (Cronbach’s alpha = .90). For our purposes, the JSPE wasamended to use dental instead of medical and dentist instead of doctor.

INTERACTIONS WITH OLDER ADULTS

This section involved five multiple choice questions about students’ fre-quency, context, and type of interactions with older adults, outside of the

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Nature of Empathy 7

dental clinic as well as their interactions with older adults in the clinical set-ting. The “frequency” questions asked students to estimate how often outsideof the clinic they interact with people who are older than age 65 (more thanonce a day, daily, a few times a week, a few times a month, rarely, never).The “context” question asked students to indicate with whom they interactwho is older than age 65 (parents, grandparents, other relatives, neighbors,friends, others) by choosing all that apply. The “type” question asked stu-dents to check all types of interactions they have with older adults outside ofthe clinic (assist with chores, transportation, live with, caregiving, assist withpersonal care, attend religious services, at holidays only, and other).

Analysis

Survey results were entered into SPSS (version 22) for data managementand analysis, which took place in stages. First, descriptive statistics werecompiled. Next, to answer the first research question, maximum likelihoodextraction was used to assess the factor structure of empathy in studentdentists. Maximum likelihood extraction was also used to answer the sec-ond research question and to explore the association between empathy anddemographic characteristics. A series of multiple regression analyses wereused to answer the third research question and to explore the relationshipbetween empathy and students’ attitudes toward older adults and the con-text and type of older adults with whom the students had contact outsidethe clinic.

Bivariate analyses were used to compare the relationship between classand scores for the total empathy scale. ANOVA with Bonferroni adjustmentswas used to compare the responses of each class on the factors. Age wasrecoded into two categories, younger than 26 and 26 or older. Bivariateanalyses for the age categories and gender were conducted using indepen-dent sample t tests. Correlations shown in Table 3 were standard Pearsoncorrelations, as the measures were all continuous in nature.

Multiple regression analyses were conducted using the JSPE total scoreand the four factors as dependent measures in separate analyses to determineif the influence of outside contacts with older people was more stronglyassociated with empathy than it was for attitudes. . In all multiple regres-sion analyses, listwise deletion was used, resulting in a sample of 292 ofthe original 299 individuals in the sample. The losses in the sample wereevenly distributed across the four classes. Entry was simultaneous, as wewere interested in looking at unique contributions to the prediction of thedependent measure. Collinearity was assessed using tolerance and varianceinflation factors (VIF). There were no collinearity issues in any of the analy-ses as all tolerance (<.2) and VIF (>5) indicators were not within the cautionareas.

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8 D. Waldrop et al.

RESULTS

The Factor Structure of Empathy in Dental Students

Initially, all 20 JSPE items were used, and four factors were identified usingthe scree plot and Eigen values of greater than one as a means for factoridentification. However, four items did not load above .40 and were droppedfrom further analysis. A four-factor structure of empathy in dental studentsemerged which accounted for 63.7% of the total variance. The factors were(1) Empathy Is Valuable, (2) Empathy Is Demonstrated, (3) Empathy Is notInfluential, and (4) Empathy Is Difficult to Accomplish. Table 1 presents thefactor loadings.

● Empathy Is Valuable (Factor 1) had an initial Eigen value of 5.98, and fiveitems accounted for 37% of the overall variance in the scale. Empathy isconsidered a therapeutic element of the helping relationship.

● Empathy Is Demonstrated (Factor 2) had an initial Eigen value of 1.93, andthree items accounted for approximately 12% of additional variance in theoverall scale. Empathy encompasses behavioral elements to show caringfor a patient.

● Empathy Is not Influential (Factor 3) had an initial Eigen value of 1.27,and six items accounted for approximately 8% of the variance in the over-all scale. Understanding of or attentiveness to patients’ concerns has nobearing on treatment outcomes.

● Empathy Is Difficult to Accomplish (Factor 4) had an Eigen value of 1.02,and two items accounted for an additional 6% of the overall scale variance.Understanding a patient’s experience is challenging.

There were no differences between classes in gender or age. Therewere no significant differences in empathy scores by age. Females weresignificantly higher on the overall empathy scale, F(1, 296) = 4.72, p =.030, η2 = .0158. Additionally, when considering the factors, females weresignificantly higher than males on Empathy Is Demonstrated (Factor 2), F(1,294) = 5.57, p = .019, η2 = .0186; and significantly lower on Empathy Is notInfluential (Factor 3), F(1, 296) = 7.09, p = .008, η2 = .0234; and EmpathyIs Difficult to Accomplish (Factor 4) F(1, 294) = 6.80, p = .010, η2 = .0226(see Table 2).

THE RELATIONSHIP BETWEEN ATTITUDES, EXPOSURE AND EMPATHY FOR

OLDER ADULT PATIENTS

Results for the correlations shown in Table 3 suggest that empathy (JSPEtotal score) was related to the attitudes (ASD subscale). There also weresignificant associations between empathy and the number of different typesof older people (e.g., older relatives, neighbors) the student had contact

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Nature of Empathy 9

TABLE 1 The Factor Structure of Empathy in Dental Students Maximum Likelihood Extraction

Factor

1 2 3 4

emp6 My patients feel better when I understandtheir feelings

.784 .265 −.118 −.152

emp5 I believe empathy is an importanttherapeutic factor in medical or surgicaltreatment

.751 .190 −.198 −.035

emp8 An important component of the relationshipwith my patients is my understanding of theiremotional status, as well as that of their families

.669 .325 −.238 −.152

emp4 Empathy is a therapeutic skill without whichsuccess in treatment is limited

.634 .177 −.178 −.033

emp3 My patients value my understanding of theirfeelings, which is therapeutic in its own right

.608 .237 −.163 −.161

emp13 I try to understand what is going on in mypatients’ minds by paying attention to theirnon-verbal cues and body language

.344 .881 −.056 −.118

emp12 I consider understanding my patients’ bodylanguage as important as verbal communicationin caregiver-patient relationships.

.408 .778 −.146 −.084

emp14 I try to imagine myself in my patients’shoes when providing care to them.

.390 .565 −.041 −.214

emp9 I do not allow myself to be influenced bystrong personal bonds between my patients andtheir families

−.080 .027 .670 .104

emp10 Attentiveness to my patients’ personalexperiences does not influence treatmentoutcome

−.206 −.152 .569 .009

emp1 My understanding of how my patients andtheir families feel does not influence medical orsurgical treatment.

−.038 −.066 .514 .102

emp7 Patient’s illness can be cured only by medicalor surgical treatment; therefore, emotional ties tomy patients do not have a significant influenceon medical or surgical outcomes

−.333 −.268 .424 .259

emp2 I believe emotion has no place in treatmentof medical illness

−.266 −.109 .418 .153

emp15 I try not pay attention to my patients’emotions in history taking or in asking abouttheir physical health.

−.151 .065 .415 .278

emp18 Because people are different, it is difficultfor me to see things from my patients’perspectives.

−.196 −.047 .210 .729

emp16 It is difficult for me to view things from mypatients’ perspectives

−.025 −.276 .189 .595

JSPE = Jefferson Scale of Physician Empathy.Extraction method: maximum likelihood, rotation method: Varimax with Kaiser Normalization, Factor 1:Empathy is valued, Factor 2: Empathy is demonstrated, Factor 3: Empathy is not influential, Factor 4:Empathy is difficult to accomplish.Rotation converged in six iterations.JSPE items are listed by number (e.g., emp 1 and grouped by factor).JSPE factor items are bolded and outlined.

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TAB

LE2

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102.

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Res

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10

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TAB

LE3

Corr

elat

ion

Mat

rix

for

Attitu

des

Tow

ard

and

Inte

ract

ions

With

Old

erA

dults

and

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12

34

56

78

910

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men

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.672

∗∗∗

13

Acc

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ty.5

79∗∗

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93∗∗

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ity.6

24∗∗

∗.5

97∗∗

∗.6

66∗∗

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5#

Conte

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.071

.178

∗∗.0

89.0

331

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Typ

es.1

66∗∗

.215

∗∗∗

.108

.086

.455

∗∗∗

17

Freq

uen

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Inte

ract

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.160

∗∗.1

92∗∗

.109

.073

.250

∗∗∗

.344

∗∗∗

1

8#

Old

erPat

ients

Tre

ated

.079

.087

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.010

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1

9To

talJS

PE

.182

∗∗.2

32∗∗

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44∗∗

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43∗

.265

∗∗∗

.279

∗∗∗

.093

−.03

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.191

∗∗.1

85∗∗

.233

∗∗∗

.173

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97∗∗

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79−.

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∗∗∗

111

Fact

or

2JS

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.117

∗.1

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34∗∗

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81.1

40∗

.120

∗.0

35−.

064

.758

∗∗∗

.660

∗∗∗

112

Fact

or

3JS

PE

−.17

2∗∗−.

209∗∗

∗−.

198∗∗

−.10

2−.

219∗∗

∗−.

257∗∗

∗−.

068

.007

−.74

9∗∗∗

−.45

5∗∗∗

−.33

5∗∗∗

113

Fact

or

4JS

PE

−.08

7−.

149∗

−.11

6∗−.

079

−.16

8∗∗−.

177∗∗

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11

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12 D. Waldrop et al.

with and the number of contexts of interaction (e.g., caregiving, attendingreligious services) in which the contact occurred outside of the clinic, butnot with frequency of such interactions or the number of older adults treatedin the clinic.

Results for the multiple regressions for JSPE total scale scores are pre-sented in Table 4. The overall equation was significant, F(11, 258) = 5.746,p < .0001, R2 = .197, and demonstrates that the acceptability of older adults(ASD subscale) was positively associated with empathy scores (see Table 4).Greater numbers of different types of older adults with whom the student hadcontact and higher numbers of different contexts for these interactions werepositively associated with the empathy. However, neither contact withinthe clinic nor the actual frequency of contact with older adults outside ofthe clinic was positively associated with empathy. Results for Empathy IsValuable (Factor 1) were significant, F(11, 258) = 3.176, p < .005, R2 = .119,adjusted R2 = .082, and are presented in Table 5. The Acceptability sub-scale of the ASD showed a positive marginal trend, suggesting that studentswho had positive Acceptability scores also had high scores on Empathy IsValuable (Factor 1). The only significant association was for the number ofcontexts of interactions that the student had with older adults. The relation-ship suggests that the more contexts the student was exposed to with olderadults, the higher the score on Factor 1, Empathy Is Valuable.

The results for Empathy Is Demonstrated (Factor 2) were significant,F(11, 258) = 3.651, p < .0001, R2 = .148, adjusted R2 = .112, and are pre-sented in Table 6. Empathy was positively associated with the Acceptabilitysubscale of the ASD. There was a positive association for gender, and femaleshad higher levels of acceptability. There was also a marginal effect for thenumber of different types of older adults the student had contact with outsidethe SDM clinic (Table 6).

The results for Empathy Is not Valued (Factor 3) were significant, F(11,258) = 4.075, p < .0001, R2 = .148, adjusted R2 = .112. The only otherfactor that was significant was the number of different types of older adultscontacted outside the SDM clinic, indicating that the more types of olderadults they had contact with, the less likely they were to view the use ofempathy as negative (Table 7).

The results for Empathy Is Difficult to Accomplish (Factor 4) weresignificant, F(11, 256) = 2.553, p = .004, R2 = .099, adjusted R2 = .60.However, the only significant factor was sex, with females showing lowerscores than males. The number of different types of older adults con-tacted outside the clinic was marginal, reflecting that as this increased theperception of empathy being difficult decreased. No other factors weresignificant.

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TAB

LE4

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13

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TAB

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TAB

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15

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TAB

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The

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tera

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ns

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ceIn

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1.80

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−.11

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nom

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−.26

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132

−.12

5In

tegr

ity.1

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102

.083

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Num

cont

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0.0

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48.0

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309

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8−.

109

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um

type

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−2.8

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wis

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antic

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stru

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ults

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ted.

16

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Nature of Empathy 17

DISCUSSION

We explored the nature of empathy and its association with attitudesabout and exposure to older patients in a sample of 292 dental studentsat the University at [BLINDED FOR REVIEW] School of Dental Medicine.Maximum likelihood extraction of the JSPE yielded four factors: (1) EmpathyIs Valuable, (2) Empathy Is Demonstrated, (3) Empathy Is not Influential, and(4) Empathy Is Difficult to Accomplish. Higher overall empathy scores werepositively related to the attitude of acceptability and to exposure to olderpeople outside of the clinic setting.

Exposure to older adults in the clinic was not related to higher empa-thy scores. However, higher frequency of contact with different types ofolder adults and greater numbers of different contexts were related to higherempathy scores. The Acceptability subscale of the ASD was positively relatedto higher empathy scores.

Females were significantly higher on the overall empathy scale andon Empathy is Demonstrated (Factor 2) scores and significantly lower onEmpathy is not influential (Factor 3), and Empathy is Difficult to Accomplish(Factor 4). The findings that females demonstrated higher empathy is consis-tent with previous literature (Beauchamp & McKelvie, 2006; Gabard, Lowe,Deusinger, Stelzner, & Crandall, 2013; Nash, 2010).

These study findings build on previous studies and contribute to thegrowing literature about empathy development in professional education inhealth care. Sherman and Cramer (2005) identified four factors that includeda number of crossover loadings by using a principal components analy-sis: perspective taking, compassionate care, standing in the patient’s shoes,and efforts to ignore emotions. Our findings suggest that there may besome parity in the nature of empathy in dental students. The elements ofCompassionate Care (S-C) and Empathy Is Valuable suggest the belief thatempathy is therapeutic. The elements of Perspective Taking (S-C). Standingin a Patient’s Shoes (S-C) and Empathy Is Demonstrated suggest that thereis a behavioral element of empathy. Finally, the elements of Empathy Isnot Influential, Efforts to Ignore Emotions (S-C), and Empathy Is Difficultto Accomplish perhaps suggest that empathy may be detrimental to patientoutcomes in dentistry.

Sherman and Cramer (2005) did not investigate the association of iden-tified components with other characteristics. We determined the number ofunderlying dimensions of the Empathy scale for dental students and usedmaximum likelihood, focusing more on the underlying dimensions. Theresults from Sherman and Cramer for the factor analysis were different thanours. Sherman and Cramer found gender differences, as we do, with femalesscoring higher than males. Sherman and Cramer also indicated that the scoresdropped as a function of class. We see some of that, with an important

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18 D. Waldrop et al.

rebound in the 4th year. However, the results are not significant—but theydo present an interesting discussion point.

In a previous study of attitudes, we found that the 4th-year dental stu-dents showed the most gain in positive attitudes. We attributed this gain toexposure to older adults in the clinic and to mentorship. Although the expec-tations were that attitudes would be influenced by clinical exposure and to beassociated with higher empathy scores, this did not occur. Increased clinicalcontact did not directly influence attitudes or empathy. The 4th-year studentsshow levels of empathy that are similar to those in the 1st-year students, withthe 2nd- and 3rd-year students showing lower levels. Given the previousfindings with dental students (Sherman & Cramer, 2005) that demonstrate asimilar pattern for empathy scores, with decreases from year 1 to year 2, andyear 2 to year 3, then an increase in year 4, contributing factors may includethat the increase in empathy for the 4th-year students may be a result of clin-ical mentorship and role modeling. Changes in empathy may also be relatedto experience whereas students see greater numbers of patients they beginto experience the value of empathy. During the 2nd and 3rd years of dentalschool, students have less patient contact, and more emphasis on technicalaspects of treatment.

It is also important to note that the Acceptability subscale from the ASDwas the only one to show any association with empathy. The implicationis that acceptance of older adult behavior is key to positive empathy devel-opment. Thus, facilitating the development of acceptance in dental studentsmay lead to greater empathy for older dental patients.

Another important finding relates to the relationship of empathy andthe different contexts that the students had exposure to older individuals.Greater exposure was associated with more positive empathy scores. Oneconsideration for dental education is the potential influence of increasedexposure to older adults in a variety of contexts. This may help build moreacceptance and influence empathy towards older patients.

Limitations

The study had several limitations that are important to address. First, the datawas cross-sectional. Longitudinal data would provide a deeper perspectiveon the nature of empathy in dental students and whether it changes with pro-fessional development. Second, the data is a convenience sample, collectedfrom only one university clinic setting. Comparative data from more than onedental school would validate the structure of empathy and its relationship toattitudes and exposure. Third, our questions on exposure to types of olderadults and different social contexts were categorical. Open-ended questionsabout students’ interactions with older adults would allow us to discover therichness of their experience with older adults (e.g., how they interact, the

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Nature of Empathy 19

nature of their relationship with older people). Future research is neededto confirm whether clinical training impacts empathy negatively and, if so,whether interventions can be designed to mitigate this impact (Chen, Lew,Hershman, & Orlander, 2007).

Implications for Education

Research has indicated that dentists have misinformation about older peopleand can be reluctant to treat frail and functionally dependent older adultsthus raising the question of whether inadequate education about older peo-ple deters dentists from caring for older patients (Antoun, Adsett, Goldsmith,& Thomson, 2008; Holm-Pedersen, Vigild, Nitschke, & Berkey, 2005). Clearly,technical expertise is important for the provision of effective oral health care.However, dentists are also important members of the interdisciplinary health-care team who can contribute to enhanced well-being in their older adultpatients by understanding the interrelationship between systemic and oralhealth concerns and quality of life (Best, 2010).

CONCLUSIONS

The nature of empathy has been studied extensively in medical studentsbut less so in dental students. The factor structure presented here differsfrom that found among medical students and suggests that the nature ofempathy may vary by profession. In a study of physicians, the empathyitems aligned with factors described as “perspective taking,” “compassion-ate care,” and “standing in the patient’s shoes” (Hojat et al., 2002). Thefindings reported here suggest that among this sample of dental studentsthe factor “empathy is not influential” may suggest that empathic behavioris perceived to hinder accomplishment of competent care, and “empathyis difficult to achieve” may suggest perceptions that demonstrating empa-thy is challenging. Understanding the components of empathy by disciplineis fundamentally important to improving education of an aging-preparedworkforce. Moreover, levels of empathy have been found to erode overthe course of medical school (Colliver, Conlee, Verhulst, & Dorsey, 2010).Understanding whether empathy changes over the course of dental schooland, if so, how and when are important considerations in the continuingdevelopment of dental education. The incorporation of intensifying clinicalexposure over time in dental school may also be related to the developmentof a greater understanding of patients’ experience with coexistent health andpsychosocial problems.

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