Can a virtual learning module foster empathy in dental undergraduate students?

Abstract Background Empathy is an essential part of patient‐centred health care, which positively benefits both patients and clinicians. There is little agreement regarding how best to design and deliver training for healthcare trainees to impart the skills and behaviours of clinical empathy. The study aimed to inform the field by sharing an educational intervention where we aimed to improve empathy amongst dental undergraduate students in Trinity College Dublin using a virtual learning module. Methods Adopting pre–post‐repeat pre‐experimental design, dental professional students completed the Jefferson Scale of Empathy (JSE) for Health Professional Students immediately prior to and after a three‐week virtual programme designed to increase clinical empathy. Using a three‐factor model described for the JSE in the literature, scores were evaluated for internal consistency and paired tests were performed on scores appropriate to their distributions. Seven‐point Likert scales were scored to record student experience of training and technology, which are reported descriptively. Results Most of the 37 participants were female (76%) and represented dental science (N = 27) and dental hygiene roles (N = 7). Results revealed a mean JSE‐HPS scale score rise from 110.0 (SD = 10.4) to 116.4 (SD = 11.1), which represented a rise of 5.8% (t (36) = 3.6, p = 0.001). The three factors associated with cognitive empathy, namely perspective‐taking (T(36) = 3.931, p < 0.001; walking in the patient's shoes T(36) = 2.093, p = 0.043); and compassionate care (Z = 2.469, p = 0.014) were all found to have increased after the intervention. Students reported a positive experience of discipline‐specific and generic videos as part of the module. Conclusion The study demonstrated that a virtual educational module was associated with an increase in empathy amongst dental undergraduate students. The design of a blended module incorporating the Massive Open Online Course (MOOC) and virtual learning are beneficial and have a promising future.


| INTRODUC TI ON
Empathy, as an emotion, can be difficult to define and deeply personal, having been proposed as "the almost magical emotion that persons or objects arouse in us as projections of our feelings and thoughts". 1 Moving beyond Spiro's question of "can empathy be taught?" to "how can empathy be fostered and maintained" has prompted healthcare educators to develop resources to keep empathy teaching in the curriculum. Clinical empathy is not simply "detached concern" but rather emotional atonement, 2 and it describes the clinical skill of emotional resonance and curiosity about the meaning of a clinical situation for the patient. 3 It is a clinical skill involving the active assessment of a patient's emotions and responding to patient cues. 4 Most recently proposed as "empathic concern," clinical empathy can be understood as "the attitude of genuine interest towards the experience of the other" which comes from an "engaged curiosity". 5 Clinical empathy is an effective means of enhancing patients' experiences and outcomes of care. When practised appropriately, empathy builds rapport with the patient, facilitates the healthcare interview, increases the efficiency of gathering information in history taking and examination, increases adherence to treatment recommendations and health outcomes, and improves patient satisfaction. [6][7][8] Unsurprisingly, empathic healthcare practitioners may also benefit through high work satisfaction, well-being and low levels of burnout. 4 Empathy is considered such an essential aspect of care 4 that its absence impairs the clinicianpatient relationship so much that it is associated with medical errors and other difficulties in care. 9 Therefore, cultivating clinical empathy is one of the most important goals when training healthcare professionals.
Despite the obvious importance of empathy in health care, trainee health professionals consistently demonstrate a decline in empathy during their training. [10][11][12] This seems to occur as students move into clinical years of their training, as trainees adapt to their professional roles , . 13,14 This may relate to the time when they begin seeing patients more frequently in their clinical years and demonstrate less metacognitive efforts. 15 For dental students, it has been suggested that this decline could be attributed to a focus on the more technical demands of intensive training and the curriculum at dental schools being more procedurally focused rather than patient-centred. 10 Recognising the significance of this dramatic drop in empathy, healthcare curricula seek to impart empathy as a core attribute for the next generation of healthcare professionals. 16 Whilst there is no agreed format with which to best foster empathy, there are three imperative factors that are believed to constitute empathy: "perspective-taking," "compassionate care" and "walking in the patients' shoes" and these account for the development of a metacognitive side when interacting with patients. 17 There are examples of good practice with various approaches, ranging from the use of an E.M.P.A.T.H.Y tool to improve doctorpatient communication, 18 through to the use of video clips about patient encounters to achieve sustainable increases in empathy score amongst medical students. 19 With no clear "best" way to foster clinical empathy, it is important to develop and evaluate approaches to impart empathy skills during health professional training. For this reason, we developed our undergraduate curriculum for dental care professional students (DCPs) to include a specific module on clinical empathy, which focused on how to recognise and understand the patient's feelings and experiences (perspective-taking and walking in the patient's shoes) and how to communicate this understanding to their patients (compassionate care). With this in mind, our aim for this study was to assess whether completing this module could improve empathy. Within the context of the COVID-19 pandemic, we designed and delivered a virtual learning module with this objective. We adopted a virtual experience primarily; this gave us the ability to maintain social distancing during learning. However, virtual learning also possesses many features that facilitate student learning. Online formats such as discussion boards help trainees participate on equal grounds, especially those reluctant to engage because they feel "socially awkward". 20 Greater involvement and engagement in peer learning and collaboration in virtual formats can contribute to deeper understanding and learning of the subject matter. 21 The theoretical basis for this advantage can be drawn from social constructivism 22 which is based on collaborative group work where knowledge is constructed through social interaction, and from experiential learning models, where learning is acquired through experience alone or by group, for example role play case studies. 23 Moreover, utilising a community of inquiry framework, which represents a process of creating a deep and meaningful (collaborative constructivist) learning experience through the development of social, cognitive and teaching presence 24 can enhance online learning and the student experience.
We aimed to evaluate the effectiveness of this educational intervention by assessing students' empathy scores before and after training using the Jefferson Clinical Empathy Scale, with particular attention to the subtest scores. We also explored student perceptions of components of the intervention to explore the impact and acceptance of the disparate elements involved.

| Design
A pre-experimental educational evaluation was carried out using repeat measures immediately before and after a two-week training module aiming to investigate, first, changes in student's empathetic responses and second, effectiveness of the empathy training educational intervention. The evaluation was non-controlled and non-

| Sample
In April 2021, dental students who were enrolled in undergraduate inter-professional learning at the School of Dental Science in Trinity College Dublin were invited to participate in the study (N = 62).
Research participants included fourth-year dental, second-year dental hygiene and second-year dental nursing students.

| Intervention description
The virtual empathy module included two elements: asynchronous (two hours) and synchronous (two hours), distributed over three weeks (see Table 1).

| Element 1: Virtual Asynchronous
Following an initial tutorial about the programme, the Element 1 was  Step one provided an exploration of the definition, meaning and importance of empathy in health care, followed by a case study that asked participants to consider how they would respond to a patient in distress. Participants were encouraged to reflect on their own experiences of empathic communication and how they recognise empathy from others. In Step two of Element 1, participants learned how to identify and respond to empathic opportunities by recognition of both verbal and non-verbal cues. Challenges to empathic communication and skills for maintaining empathy in teleconsultations were also addressed. The course provided access to recommended reading, videos, audio recordings, and includes short quizzes to test knowledge and cognitive learning.
Participants were encouraged to reflect, ask questions and post comments for other learners in the discussion board moderated by healthcare educators. Utilising a collaborative-constructivist approach, discussion activities within the MOOC encourage learners

Session Learning Outcome(s) Delivery Element
Week 1 Element 1 Step 1 Describe the material to be covered in the module, the learning outcomes and trainers. Access training resources. group. 26 Trained moderators provided the "teacher presence," which has been associated with learner satisfaction and engagement. 27

| Element 2: Virtual Synchronous
The synchronous element was specifically designed for dental professionals to transfer general concepts introduced in the MOOC to the dental context and their future practice. This element bookended the module and included an introductory session at the beginning and was followed two weeks later by an interactive session after students completed Element 1 (MOOC). This provided a content overview, specific dental video scenarios and discussion groups ( Table 1).
The learning outcomes for this section were designed specific to the dental context and are listed in Table 1 week 3.

| Data Collection
Participants completed an anonymous online survey immediately before and after the module. Attendees were advised that the data would serve primarily as a course evaluation but were asked to specifically opt-in to have their responses included in this research study.
This survey consisted of (1) demographic information, (2)  students. 13,29,30 The content of the questionnaire addresses three factors: perspective-taking "view of patients perspective" and "emotions in patient care" (10 items), compassionate care "understanding patient's experiences" (8 items) and walking in patient's shoes "thinking like the patient" (2 items). The "perspective-taking" has been described as the central cognitive ingredient of empathy and empathetic engagement. 31 The second factor "compassionate care" describes the importance of the patient conveying his or her emotion, and the practitioner recognising and translating these feelings.
The third factor "walking in patient's shoes" expresses a view of the situation from the patient's perspective. 31 Post-module survey additionally included a set of statements on experience of content delivery, learning activities and technology use regarding the MOOC element of training and their value to the training. This is described in more detail in the course feedback section.

| Pre-post-measures
At baseline, the JSE-HPS scores ranged from 84.0 to 135.0 with a mean score of 110.0 (SD 10.4). After training, the scores ranged from 81.0 to 135.0 with a mean score of 116.4 (SD 11.1) ( Table 3).
Internal consistency of the pre-and post-scores was measured using Cronbach's alpha 35 ; these were 0.74 and 0.78, respectively, which are acceptable. The difference between post-and pre-scores was also calculated, and its distribution was summarised. When pre-and post-scores were compared using a paired Student's t-test, they were found to be different with a mean difference of 6.4 (t (36) = 3.6, p = 0.001) or 5.8% and effect size d = 0.59 ( Table 4).

| Course feedback
With respect to the value of learning activities, students were most likely to agree that videos added value, particularly dental-specific videos, whereas reading articles was least likely to add value

| DISCUSS ION
This study intended to measure change in empathy in dental professional students before and after a bespoke virtual training module, as well as the effectiveness of the virtual module as an educational intervention. Overall, the study found a rise in JSE-HCP scores of 5.8% by the end of training. More specifically, the three factors associated with cognitive empathy: "perspective-taking," "compassionate care" and "walking in the patients' shoes," 37 have increased on post-interventions p < 0.001, p = 0.014 and p = 0.043 respectively.
These findings suggest that the virtual training module fostered clinical empathy. Our findings are consistent with past literature that describes modest increases in empathy scores amongst various disciplines such as pharmacy, biomedical science, radiography, radiation therapy, nursing, paramedics and medicine students following educational interventions. 11,19,38 The virtual learning module in this study adopted a blend of learning technologies, including online case-based discussion and role-modelling through videos specifically scripted to promote perspective-taking and an enhanced understanding of the patient's experience and feelings. Whilst students rated all aspects and media as valuable to their learning, videos (general medical and dentalspecific) were most often considered valuable, followed by discussion groups, whereas the self-sourced reading was least often reported as valuable. This may be because observing patient's reactions and body language as well as listening to their story does help students These findings overall support the integration of our elements including a MOOC into bespoke modules and promote the interdisciplinary production of learning modules between communication and dental experts.

| LIMITATI ON S AND S TRENG TH S
Our study is limited by design, single post-test and sample size. The lack of a control group limits our ability to directly attribute outcomes to the training. It was not possible to generate a control group from the convenience sample within the chosen educational framework.
The long-term stability of the observed changes is unknown, as only a single post-test was conducted. The small sample size within a single institution also limits inferences. This smaller sample was partially due to our decision to only include those with matched data, which allowed for more conservative analyses of paired data with increased precision. The main strengths of this study come from the robust intervention and evaluation. The intervention used a multidisciplinary approach in development and incorporated a blend of virtual educational technologies. The use of a validated tool and the demonstration of acceptable internal consistency within our sample suggests that our outcomes are reliable.

| Implications of our findings
This study provides useful information that may benefit educators for both practice and research. Our findings suggest that training in clinical empathy using a virtual module may improve clinical empathy in the short term amongst dental professional students. The results of this study indicate that video vignettes with scenarios that encourage perspective-taking for empathic skill training, such as identifying opportunities for empathic engagement and appropriate responses, had the highest value for trainees. Although general scenarios were valued, some thought should be given to provide context-specific scenarios in order to maximise learning impact.
Readers are invited to consider our videos as exemplars or for use in their own programmes (Developing Clinical Empathy -Online Course -FutureLearn; Video 1 -YouTube; Video 2 -YouTube). Regarding research, our use of the Jefferson scale is an additional demonstration of internal reliability amongst dental professional students.
Future research that incorporates a control group, head-to-head comparisons of alternative learning interventions and randomisation with delayed post-test will help to further define learning impact.

| CON CLUS ION
A virtual educational module to teach clinical empathy, incorporating a MOOC and bespoke training materials, was associated with an increase in empathy scale score amongst dental care professional students. These results provide evidence for the advocating inclusion of empathy training in dental education. The results suggest that a virtual module incorporating MOOCs is beneficial and have a promising future in helping healthcare students to sustain empathy scores for longer time periods. More research is needed to increase confidence in this assumption and understand which element of training is most influential in improving cognitive empathy.

ACK N OWLED G EM ENT
Open access funding enabled and organized by IREL. [Correction added on 10 May 2022, after first online publication: IREL funding statement had been added.]

CO N FLI C T O F I NTE R E S T S
The authors have no conflicts of interest to disclose.

DATA AVA I L A B I L I T Y S TAT E M E N T
Research data are not shared.