Developing the Empathy Process in Clinical Practice among Nursing Students: A Grounded Theory Study

Abstract

Empathy is a fundamental professional competency in nursing that underpins holistic,person-centered care, therapeutic nurse–patient relationships, quality nursing practice, and positive patient health outcomes. It comprises cognitive, affective, and behavioral dimensions that must be integrated into professional nursing practice. Although nursing education recognizes empathy as an essential competency alongside clinical competence, most nursing curricula continue to emphasize technical and procedural skills more than emotional development and emotional regulation. Consequently, nursing students frequently encounter challenges in expressing empathy while maintaining professional standards, particularly in complex and emotionally demanding clinical situations. Previous studies have predominantly employed cross-sectional surveys or intervention-based designs to measure empathy levels or evaluate educational programs. Although these studies have confirmed the positive effects of empathy on nursing care and patient outcomes,they provide limited understanding of the developmental process through which nursing students transform emotional awareness and understanding of patients into authentic empathic caring behaviors. In particular, little is known about how empathy develops during clinical practice,where students gain their most meaningful learning experiences. Therefore, this study aimed to develop a substantive theoretical explanation of the process through which nursing students develop empathy during clinical practice using a grounded theory approach.

This qualitative study adopted the grounded theory methodology proposed by Corbin and Strauss. Participants consisted of eleven nursing students (three males and eight females),aged 20–23 years, including four third-year and seven fourth-year students. All participants had completed at least one semester of clinical practice and had experience caring for more than ten patients in various clinical settings, including medical, surgical, oncology, maternity,emergency, and psychiatric units. Participants were recruited through purposive sampling followed by snowball sampling, and data collection continued until theoretical saturation was achieved.Data were collected through semi-structured in-depth interviews, field observations, field notes,and memo writing. Each interview lasted approximately 30–60 minutes, was audio-recorded with participants' consent, and transcribed verbatim. Data collection and analysis were conducted concurrently using the constant comparative method. Analysis followed the coding procedures of Strauss and Corbin, including open coding, axial coding, and selective coding, to construct a substantive theory explaining the process of empathy development. Trustworthiness was established according to Lincoln and Guba's criteria, including credibility, transferability, dependability, and confirmability, through member checking, expert consultation, reflective memoing, and continuous comparative analysis.

The findings revealed that empathy is a dynamic developmental process that gradually evolves through authentic patient care experiences, involving continuous transformations in nursing students' cognitive, affective, and behavioral responses. The resulting theoretical model consisted of five interrelated components.First,causal conditions included patient characteristics and clinical contexts, particularly caring for patients experiencing severe illness or psychosocial problems,which stimulated students' emotional awareness and initial emotional responses. Second, the core phenomenon was identified as a psychological transition from sympathy to empathy. Through sustained patient interactions, reflective thinking, and connecting personal experiences with patients’ lived experiences. Third, interaction strategies included self-emotional regulation and consultation with clinical nurse educators to maintain a balance between empathic engagement and professionalism. Fourth, intervening conditions included clinical experience, diversity of patient conditions, continuity of patient care, and familiarity with patients, all of which influenced the extent to which empathy developed. Finally, consequences included more effective communication with patients, greater commitment to providing holistic and patient-centered care, enhanced professional responsibility.

The findings of this study demonstrated that the transformation from sympathy to empathy represents the core developmental process through which nursing students cultivate professional empathy during clinical practice. This transformation is facilitated by authentic clinical experiences, reflective learning, emotional self-regulation, and supportive supervision from clinical nurse educators, ultimately integrating empathy into students' professional identity and translating empathic understanding into high-quality nursing care. These findings suggest that nursing education programs should intentionally design diverse and longitudinal clinical learning experiences that enable students to establish meaningful and sustained relationships with patients. In addition, clinical nurse educators should foster psychologically safe learning environments, provide ongoing constructive feedback, emotional support, and guided reflection to strengthen students' emotional regulation and facilitate the development of professional empathy.Integrating these educational strategies into nursing curricula may contribute to preparing compassionate, emotionally competent, and professionally responsible nurses capable of delivering high-quality, patient-centered care.

Keywords: Clinical nursing practice, Nursing education, Empathy, Grounded theory, Nursing students

Author Contributions:
SK: Conceptualization, Method and design, Data analysis, Revising and editing the manuscript,Corresponding with the editor-in-chief
KR: Conceptualization, Method and design, Data collection and analysis, Writing, revising, and editing the manuscript