Jefferson Scale of Empathy Health Profession Students’ version (JSPE-HPS)

Abstract

The Jefferson Scale of Empathy Health Profession Students’ version (JSPE-HPS) is a widely utilized psychometric instrument developed to evaluate empathy among students across non-medical healthcare disciplines, including nursing, pharmacy, dentistry, physical therapy, occupational therapy, and emergency medical services (paramedicine). Adapted directly from the original Jefferson Scale of Physician Empathy (JSPE-S version), the HPS version contextualizes items to broadly address the multi-professional clinical learning environment by replacing physician-specific phrasing with “health care provider.” Grounded in an operational definition that conceptualizes clinical empathy predominantly as a cognitive attribute involving the comprehension of a patient’s experiences, concerns, and perspectives combined with the capacity to communicate this understanding, the scale purposely distinguishes cognitive empathy from emotional sympathy or affective contagion.

The instrument comprises 20 items scored on a 7-point Likert-type scale, yielding aggregate scores ranging from 20 to 140. Ten of the items are positively phrased, while the remaining ten are negatively phrased to minimize acquiescence response bias. Factor analytic investigations across diverse international cohorts consistently reveal a multidimensional structure predominantly composed of three distinct latent dimensions: Perspective Taking, Compassionate Care, and Standing in the Patient’s Shoes. Extensive empirical research indicates robust psychometric properties, with internal consistency coefficients (Cronbach’s alpha) typically falling between .78 and .89, acceptable test-retest reliability over multiple clinical rotations, and robust convergent, discriminant, and criterion-related validity. As healthcare pedagogy increasingly embraces humanistic paradigms and interprofessional collaborative practice, the JSPE-HPS serves as a vital diagnostic, evaluative, and research tool for tracking empathic development and assessing the impact of targeted curriculum interventions.

Keywords

Jefferson Scale of Empathy, JSPE-HPS, clinical empathy, health profession students, perspective taking, compassionate care, psychometric validation, medical education, interprofessional education, healthcare communication

Authors

The Jefferson Scale of Empathy (JSE) and its tailored variants—including the Medical Student version (S-Version), the Health Professionals version (HP-Version), and the Health Profession Students’ version (HPS-Version)—were conceived and psychometrically developed by a team of medical education researchers at Thomas Jefferson University in Philadelphia, Pennsylvania, USA.

• Mohammadreza Hojat, Ph.D. — Research Professor of Psychiatry and Human Behavior, Center for Research in Medical Education and Health Care (CRMEHC), Sidney Kimmel Medical College at Thomas Jefferson University. Dr. Hojat is the principal architect of the scale and has published foundational empirical monographs on clinical empathy.
• Salvatore Mangione, M.D. — Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Sidney Kimmel Medical College at Thomas Jefferson University; recognized scholar in physical diagnosis, the medical humanities, and clinical assessment.
• Joseph S. Gonnella, M.D. — Distinguished Professor of Medicine and Dean Emeritus, Center for Research in Medical Education and Health Care, Sidney Kimmel Medical College at Thomas Jefferson University.
• Thomas J. Nasca, M.D., MACP — Professor of Medicine, former Dean of Sidney Kimmel Medical College, and Chief Executive Officer of the Accreditation Council for Graduate Medical Education (ACGME).
• Collaborating Psychometricians: Michael J. Cohen, J. Jon Veloski, James B. Erdmann, and Gregory C. Kane, who contributed substantially to the early iterative construction, item pool generation, and validation trials of the JSE instruments.

Institutional Contact: Center for Research in Medical Education and Health Care, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA. Inquiries regarding official licensing, normative data sets, and institutional scoring services are managed by the Asano-Gonnella Center for Research in Medical Education and Health Care.

Purpose

The primary purpose of the Jefferson Scale of Empathy Health Profession Students’ version (JSPE-HPS) is to assess the orientation of students in various health-related disciplines toward the patient-provider relationship, specifically examining their capacity and inclination to understand patients’ inner cognitive and emotional experiences. In contemporary healthcare education, empathy is widely acknowledged not merely as a bedside mannerism, but as a core clinical competence directly correlated with diagnostic accuracy, patient compliance, decreased medical malpractice claims, enhanced patient satisfaction, and superior clinical outcomes.

Historically, psychometric instruments assessing empathy, such as the Interpersonal Reactivity Index (IRI) developed by Mark Davis or the Balanced Emotional Empathy Scale (BEES) by Albert Mehrabian, were designed for the general population. These generic instruments frequently conflate cognitive perspective-taking with visceral emotional contagion, personal distress, and uncalibrated sympathy. Recognizing that unmoderated emotional contagion in clinical environments can lead to professional burnout, diagnostic distortion, and compassion fatigue, Hojat and colleagues identified an acute need for a psychometrically sound, context-specific instrument tailored precisely to therapeutic healthcare relationships. The JSPE-HPS addresses this need by providing an objective, standardized index that reflects the nuances of professional patient care.

The scale serves diverse applications across educational and clinical training spheres:

• Longitudinal Tracking: Monitoring changes in student empathic orientations across the progression of academic and clinical training, specifically scrutinizing the well-documented phenomenon of “empathy decline” during demanding clinical clerkships.
• Curricular Evaluation: Measuring the efficacy of explicit interventions, including narrative medicine seminars, simulated patient encounters, communication workshops, humanities-based curricula, and mindfulness training programs.
• Interprofessional Comparisons: Providing a universal, discipline-neutral metric capable of comparing students across varied disciplines (e.g., pharmacy, nursing, physician assistant, physical therapy, and paramedicine), thereby supporting interprofessional collaborative education (IPE) research.
• Research Correlates: Investigating the structural relationships between empathy and psychological variables such as burnout, personality facets (e.g., conscientiousness, agreeableness), emotional intelligence, and clinical diagnostic performance.

Psychological Construct

The psychological construct operationalized by the JSPE-HPS is clinical empathy. Rather than viewing empathy as an innate, unchangeable personality trait or an emotional impulse, the authors define clinical empathy as a predominantly cognitive attribute involving an understanding of the patient’s experiences, concerns, and perspectives, combined with the capacity to communicate this understanding and an intention to help. This conceptualization explicitly separates clinical empathy from sympathy, emotional contagion, and vicarious affective arousal.

Extensive factor-analytic and structural equation modeling studies across multiple international health professions cohorts indicate that the JSPE-HPS assesses this construct across three primary, interrelated dimensions:

1. Perspective Taking

Accounting for the largest proportion of common variance, Perspective Taking represents the core cognitive engine of clinical empathy. It reflects the provider’s ability and active cognitive effort to view clinical realities, fears, and symptom burdens from the patient’s internal frame of reference. Items loading on this factor (e.g., Item 9: “Health care providers should try to stand in their patients’ shoes when providing care to them”; Item 17: “Health care providers should try to think like their patients in order to render better care”) gauge the respondent’s appreciation that illness possesses deeply subjective personal meaning distinct from objective biological pathology. High scorers recognize that decoding non-verbal cues and understanding the patient’s psychosocial context directly illuminates clinical decision-making.

2. Compassionate Care

The second major dimension encapsulates the humanistic and affective appraisal of the therapeutic relationship. It focuses on the provider’s conviction that understanding the patient’s and their family’s emotional state is therapeutically meaningful and contributes to tangible clinical improvement. Items such as Item 2 (“Patients feel better when their health care provider understands their feelings”) and Item 10 (“Patients value a health care provider’s understanding of their feelings, which is therapeutic in its own right”) reflect this orientation. Conversely, several negatively phrased items target the rejection of detached, purely biological reductionism (e.g., Item 14: “I believe that emotion has no place in the treatment of medical illness”). Rather than endorsing boundless emotional sharing, this factor gauges the value placed on warmth, sensitivity, and professional compassion within professional boundaries.

3. Standing in the Patient’s Shoes

Frequently emerging as a distinct third factor (or sub-dimension within cognitive processing), this dimension probes the perceived difficulty or cognitive barrier involved in adopting the patient’s vantage point. It is primarily identified by reverse-scored items such as Item 3 (“It is difficult for a health care provider to view things from patients’ perspectives”) and Item 6 (“Because people are different, it is difficult to see things from patients’ perspectives”). Endorsement of these items suggests a belief that interpersonal diversity presents an insurmountable barrier to mutual understanding. In contrast, disagreement signals cognitive flexibility, self-efficacy in bridging cultural and experiential divides, and an understanding of universal human vulnerability.

Theoretical Framework

The theoretical architecture underpinning the JSPE-HPS is rooted in humanistic psychology, modern social-cognitive neuroscience, and cognitive developmental theory. Central to this theoretical foundation is the classical work of Carl Rogers, who defined empathy as the therapist’s ability to accurately perceive the internal frame of reference of another with emotional resonance and clarity, “as if” one were the other person, without ever losing the boundary of the “as if” condition. Rogers asserted that empathic understanding is one of the necessary and sufficient conditions for therapeutic personality change.

Hojat expanded Rogers’ foundational tenets into medical and allied healthcare pedagogy by establishing an unambiguous theoretical demarcation between empathy and sympathy:

• Empathy (Cognitive): Involves intellectual appreciation, understanding, perspective alignment, and targeted verbal/non-verbal communication. It preserves professional objectivity, prevents emotional exhaustion, preserves diagnostic judgment, and can be systematically learned, taught, and enhanced through instructional interventions.
• Sympathy (Affective): Involves shared emotional pain, visceral distress, feeling *with* rather than *understanding* the patient, and emotional entanglement. Excessive sympathy can deplete cognitive bandwidth, induce burnout, and cloud clinical objectivity.

Neurobiologically, this framework aligns with contemporary models in cognitive neuroscience, which differentiate between two separate neural networks: the bottom-up affective-perceptual system (rooted in the anterior insula, anterior cingulate cortex, and the mirror neuron system, responsible for emotional resonance) and the top-down cognitive perspective-taking system (anchored in the medial prefrontal cortex, temporal-parietal junction, and superior temporal sulcus, supporting Theory of Mind). The JSPE-HPS intentionally measures orientations that rely on this latter executive, reflective mentalizing network.

Furthermore, the scale operates within the theoretical paradigm of Relationship-Centered Care and George Engel’s Biopsychosocial Model. This model posits that disease cannot be meaningfully decoupled from the psychological and social milieu of the afflicted individual. The JSPE-HPS measures the extent to which emerging healthcare professionals adhere to this model versus a strictly reductionist, biomedical perspective that views patients merely as biological machines requiring mechanical repair.

Validity

Extensive psychometric investigations across diverse healthcare disciplines, cultures, and languages provide robust evidence for the validity of the JSPE-HPS:

1. Construct and Structural Validity

Construct validity has been confirmed through repeated exploratory and confirmatory factor analyses. Studies assessing pharmacy students (Fjortoft et al., 2011), nursing students (Ward et al., 2012), paramedic students (Williams et al., 2013), and cross-disciplinary cohorts of allied health trainees consistently demonstrate that the 20 items cluster into the theorized three-factor solution (Perspective Taking, Compassionate Care, and Standing in the Patient’s Shoes). Confirmatory factor analyses show acceptable goodness-of-fit indices across languages (RMSEA ≤ .05; CFI ≥ .90; TLI ≥ .90; SRMR ≤ .06), affirming structural stability across different health professional student populations.

2. Convergent and Discriminant Validity

In convergent validity trials, scores on the JSPE-HPS correlate positively with established psychometric scales measuring conceptually related constructs:

• A statistically significant positive correlation with the Perspective Taking subscale of Davis’s Interpersonal Reactivity Index (IRI) (typically $r = .40$ to $.55$, $p < .001$).
• Moderate positive correlations with the Empathic Concern subscale of the IRI ($r = .35$ to $.48$).
• Statistically significant positive associations with measures of emotional intelligence, such as the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) and the Schutte Self-Report Emotional Intelligence Test ($r &\approx; .38$ to $.45$).
• Positive correlations with personality dimensions of Agreeableness and Openness to Experience on the NEO-PI-R.

Discriminant validity is supported by weak or near-zero correlations with the IRI’s Personal Distress subscale ($r = -.08$ to $.12$, non-significant), demonstrating that the instrument successfully differentiates cognitive clinical empathy from self-oriented emotional vulnerability or neurotic distress. Additionally, JSPE-HPS scores show negligible correlations with generic measures of generalized anxiety, rigid dogmatism, and sociodemographic variables unrelated to empathy.

3. Criterion and Predictive Validity

Criterion-related validity is evidenced by positive correlations between student JSPE-HPS scores and subsequent ratings of clinical competence during Objective Structured Clinical Examinations (OSCEs), particularly in categories evaluating interpersonal communication, rapport building, and patient satisfaction. Furthermore, studies examining gender differences provide empirical support for the scale’s validity: female health profession students consistently demonstrate higher mean empathy scores than male counterparts across virtually all published studies, aligning with broader findings in psychological and evolutionary literature.

Reliability

The JSPE-HPS demonstrates high internal consistency and temporal stability across a broad spectrum of educational environments:

1. Internal Consistency

Across numerous empirical validation investigations, the overall scale has consistently achieved Cronbach’s alpha coefficients indicative of solid reliability without excessive item redundancy:

• Pharmacy Students: Fjortoft, Van Winkle, and Hojat (2011) reported a Cronbach’s alpha of $.83$ in a sample of U.S. pharmacy students.
• Paramedic Students: Williams, Brown, Boyle, and Dousek (2013) demonstrated an alpha of $.84$ among Australian undergraduate emergency care trainees.
• Nursing Students: Psychometric analyses conducted in undergraduate and graduate nursing cohorts in the United States, Europe, and Asia regularly yield alpha values ranging from $.78$ to $.89$.
• Physical & Occupational Therapy Students: Studies across allied physical rehabilitation programs consistently report internal consistency coefficients spanning $.80$ to $.86$.

Split-half reliability coefficients, calculated via the Spearman-Brown prophecy formula, typically range from $.77$ to $.85$. Corrected item-total correlations across the 20 items generally exceed the conventional $.30$ psychometric threshold, ranging from $.32$ to $.65$, confirming that every item contributes meaningfully to the common underlying latent construct.

2. Test-Retest Reliability

Temporal stability assessments have produced satisfactory test-retest reliability coefficients over various test-retest intervals. Among stable cohorts evaluated over periods ranging from three weeks to six months without targeted empathy training, intra-class correlation coefficients (ICCs) and Pearson correlation coefficients have ranged between $r = .65$ and $r = .79$. These coefficients indicate that while clinical empathy is an enduring orientation, it retains sufficient sensitivity to register systematic fluctuations following formal pedagogical interventions or intensive clinical exposure.

Factor Analysis

The latent structural foundation of the JSPE-HPS has been thoroughly examined via both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) across different health science domains.

Exploratory Factor Analysis Findings

Initial principal components and principal axis factoring using orthogonal (Varimax) and oblique (Promax) rotations consistently extract three dominant eigenvalues exceeding unity (Kaiser-Guttman criterion), corroborated by scree plot examinations. Together, these three latent factors typically account for 38% to 52% of the total cumulative variance in student response sets:

• Factor 1: Perspective Taking. This primary factor explains the largest proportion of common variance (generally 25%–35%). Items 2, 4, 5, 9, 10, 13, 15, 16, 17, and 20 load substantially on this dimension, with primary factor loadings typically ranging between $.45$ and $.78$.
• Factor 2: Compassionate Care. Explaining roughly 7%–12% of the variance, this dimension is characterized by items rejecting clinical detachment and emotional indifference, such as Items 1, 7, 8, 11, 12, 14, and 18. Factor loadings range from $.40$ to $.72$.
• Factor 3: Standing in the Patient’s Shoes. Accounting for approximately 5%–8% of the variance, this factor is primarily defined by Item 3 and Item 6, with factor loadings frequently exceeding $.60$. Item 19 (regarding interest in the arts and humanities) often displays secondary or weak isolated loadings, occasionally forming a minor fourth residual factor or loading modestly onto Perspective Taking.

Confirmatory Factor Analysis & Goodness-of-Fit

When evaluated against alternative structural models (such as unidimensional or orthogonal two-factor models), CFA demonstrates that a correlated three-factor first-order model—or a higher-order model where the three factors load onto a general “Clinical Empathy” construct—provides the superior fit to empirical data. Standard model fit parameters routinely yield:

• Comparative Fit Index (CFI) ≥ .91 to .95
• Tucker-Lewis Index (TLI) ≥ .90 to .94
• Root Mean Square Error of Approximation (RMSEA) ≤ .045 to .058 (with 90% confidence intervals below .065)
• Standardized Root Mean Square Residual (SRMR) ≤ .048 to .060

Invariance testing further validates metric and scalar invariance across genders and diverse academic tiers, confirming that differences in observed scores reflect genuine psychological variations rather than measurement artifacts.

Instrument / Measurement Tool

• Instrument Name: Jefferson Scale of Empathy – Health Profession Students’ Version (JSPE-HPS)
• Target Population: Students matriculating in non-medical professional healthcare education programs (nursing, pharmacy, dentistry, occupational therapy, physical therapy, physician assistant, clinical psychology, paramedicine, and allied public health).
• Administration Format: Self-administered paper-and-pencil or secure electronic web survey.
• Completion Time: Approximately 5 to 10 minutes.
• Total Number of Items: 20 items.
• Response Scale: 7-point Likert-type response scale ranging from 1 (“Strongly Disagree”) to 7 (“Strongly Agree”).
• Scoring and Directionality:
  • Directly Scored Items (10 items): Items 2, 4, 5, 9, 10, 13, 15, 16, 17, and 20 are positively phrased. They are scored directly as marked (Strongly Disagree = 1, Strongly Agree = 7).
  • Reverse Scored Items (10 items): Items 1, 3, 6, 7, 8, 11, 12, 14, 18, and 19 are negatively phrased to control for acquiescence response bias. They must be inverted prior to aggregation: (1 becomes 7, 2 becomes 6, 3 becomes 5, 4 remains 4, 5 becomes 3, 6 becomes 2, and 7 becomes 1).
• Total Score Range: 20 to 140 points. Higher aggregate scores indicate a stronger orientation toward empathic clinical engagement and patient-centered communication.
• Missing Data Handling: Standard scoring guidelines stipulate that if four or more items (i.e., >15% of the instrument) are left blank, the entire protocol is considered invalid and excluded from analysis. If one to three items are missing, they may be replaced by the mean score of the completed items for that individual.

Permissions & Fee and Test Year

The original Jefferson Scale of Physician Empathy was established in 2001 by Mohammadreza Hojat and his research team at Thomas Jefferson University, with subsequent validation and release of the adapted Health Profession Students’ version (JSPE-HPS) in the late 2000s and early 2010s.

The Jefferson Scale of Empathy (all editions, including the S, HP, and HPS versions) is copyrighted by Thomas Jefferson University. It is not in the public domain and may not be reproduced, copied, or modified without formal written authorization. Academic institutions, researchers, and educators wishing to use the scale must complete a user registration agreement and pay licensing/scoring fees managed by the Asano-Gonnella Center for Research in Medical Education and Health Care. Fee structures typically operate on a per-use or institutional study package basis, which may include standardized comparative scoring against established normative national distributions.

References

• Fjortoft, N., Van Winkle, L. J., & Hojat, M. (2011). Measuring empathy in pharmacy students. American Journal of Pharmaceutical Education, 75(6), Article 109. https://doi.org/10.5688/ajpe756109
• Hojat, M. (2016). Empathy in health professions education and patient care. Springer International Publishing. https://doi.org/10.1007/978-3-319-27778-3
• Hojat, M., Gonnella, J. S., Mangione, S., Nasca, T. J., Veloski, J. J., & Erdmann, J. B. (2002). Empathy in medical students as related to academic performance, clinical competence and gender. Medical Education, 36(6), 522–527. https://doi.org/10.1046/j.1365-2923.2002.01234.x
• Hojat, M., Mangione, S., Kane, G. C., & Gonnella, J. S. (2005). Relationships between scores of the Jefferson Scale of Physician Empathy (JSPE) and the Interpersonal Reactivity Index (IRI). Medical Teacher, 27(7), 625–628. https://doi.org/10.1080/01421590500069744
• Hojat, M., Mangione, S., Nasca, T. J., Cohen, M. J. M., Gonnella, J. S., Erdmann, J. B., Veloski, J., & Magee, M. (2001). The Jefferson Scale of Physician Empathy: Development and preliminary psychometric data. Educational and Psychological Measurement, 61(2), 349–365. https://doi.org/10.1177/00131640121971158
• Kane, G. C., Gotto, J. L., Mangione, S., West, S., & Hojat, M. (2007). Jefferson Scale of Patient’s Perceptions of Physician Empathy: Preliminary psychometric data. Croatian Medical Journal, 48(1), 81–86. PMC2080498
• Shariat, S. V., Eshtad, E., & Ansari, S. (2010). Empathy and its correlates in Iranian physicians: A preliminary psychometric study of the Jefferson Scale of Physician Empathy. Medical Teacher, 32(10), e417–e421. https://doi.org/10.3109/0142159X.2010.498488
• Ward, J., Cody, J., Schaal, M., & Hojat, M. (2012). The empathy enigma: An empirical study of decline in empathy among undergraduate nursing students. Journal of Professional Nursing, 28(1), 34–40. https://doi.org/10.1016/j.profnurs.2011.10.007
• Williams, B., Brown, T., Boyle, M., & Dousek, S. (2013). Psychometric testing of the Jefferson Scale of Empathy Health Profession Students’ version with Australian paramedic students. Nursing & Health Sciences, 15(1), 45–50. https://doi.org/10.1111/nhs.12003

Items of the Scale