Implementing Peer Tutoring for the Original article Development of Empathy Check for updates in Nursing Education David Durán Gisbert1 https://orcid.org/0000-0002-0640-3834 Anabel Vázquez Rivas2 https://orcid.org/0000-0002-5873-5371 Implementing Peer Tutoring for the Development of Empathy in Nursing Education Abstract Objective. This research sets out the effects of a training 1 Educational Psycologist. Ph.D. Associate Professor, Universitat Autònoma de Barcelona, Spain. method based on peer tutoring, aimed at developing Email: david.duran@uab.cat empathy among nursing students at the University of 2 Nurse. Ph.D. Adjunct Professor, Universitat de Bar- Barcelona (Spain). Methods. After initial training, students celona, Spain. Email: anabelvazquezrivas@ub.edu are matched in pairs with similar level of empathy, exchanging the role of tutor and tutee in every session, Conflicts of interest: None. during 12 sessions. Before the session, the tutor prepares Receipt: February 1, 2021. the activities to work with his or her tutee, following this Approved: May 10, 2021. structure: exploration of prior knowledge, explanation, How to cite this article: Duran D, Vázquez A. Imple- menting Peer Tutoring for the Development of Empathy practical activities, feedback, and reflection. Jefferson in Nursing Education. Invest. Educ. Enferm. 2021; Scale of Empathy was administered as pre-test and post- 39(2):e07. test to 76 nursing students, 40 in the intervention group, DOI: https://doi.org/10.17533/udea.iee.v39n2e07. and 36 in the comparison group. Following a mixed- methods sequential explanatory design, a quantitative study (a quasi-experimental design with a comparison group) was combined with a qualitative study (interaction https://creativecommons.org/licenses/by-nc-sa/4.0/ Vol. 39 No.2, May-August 2021 • ISSNe: 2216-0280 analysis of the 12 videotaped sessions). Results. The results revealed statistically significant improvements in empathy in the intervention group. Subsequent analysis of the peer tutoring interaction highlighted the specific actions that had resulted in these improvements and generated a context in which the tutee was able to understand complex concepts, while enabling both students to participate, reflect and discuss. Conclusion. Peer tutoring is an effective method for the development of empathy in nursing students. Descriptors: education, nursing; empathy; learning; peer group; psychology; students, nursing. Implementación de tutoría entre iguales para el desarrollo de la empatía en la educación de enfermería Resumen Objetivo. Esta investigación evaluó los efectos de un método de formación basado en la tutoría entre iguales, destinado al desarrollo de la empatía en estudiantes de enfermería de la universidad de Barcelona (España). Métodos. Después de la formación inicial, los estudiantes son emparejados con compañeros con un nivel similar de empatía, intercambiando el papel de tutor y tutorado en cada sesión, durante 12 sesiones. Antes de cada sesión, el tutor prepara las actividades para trabajar con su tutorado, siguiendo esta estructura: exploración de conocimientos previos, explicación, actividades prácticas, retroalimentación y reflexión. Se administró la Escala de Empatía de Jefferson, en forma de pre y postest a 76 estudiantes de enfermería: 40 en el grupo de intervención y 36 en el grupo de comparación. Siguiendo el método mixto de diseño explicativo secuencial, se combinó un estudio cuantitativo (un diseño cuasiexperimental con grupo de comparación) con un estudio cualitativo (análisis de interacción de las 12 sesiones grabadas en video). Resultados. Los resultados revelaron mejoras estadísticamente significativas en la empatía en el grupo de intervención. El análisis posterior de la interacción en las parejas de tutoría entre iguales puso de relieve las acciones específicas que habían dado lugar a estas mejoras y generando un contexto en el que el tutorado era capaz de entender conceptos complejos, al tiempo que permitía a ambos estudiantes participar, reflexionar y discutir. Conclusión. La tutoría entre Invest Educ Enferm. 2021; 39(2): e07 Implementing Peer Tutoring for the Development of Empathy in Nursing Education iguales es un método eficaz para el desarrollo de la empatía en los estudiantes de enfermería. Descriptores: educación en enfermería; empatía; aprendizaje; grupo paritario; psicología; estudiantes de enfermería. Implementação de tutoria entre pares para o desenvolvimento da empatia na educação de enfermagem Resumo Objetivo. Esta pesquisa avaliou os efeitos de um método de treinamento baseado em tutoria entre pares, com o objetivo de desenvolver empatia em estudantes de enfermagem da Universidade de Barcelona (Espanha). Métodos. Após a formação inicial, os alunos são colocados em pares com pares com um nível de empatia semelhante, trocando o papel de tutor e estudante em cada sessão, durante 12 sessões. Antes de cada sessão, o tutor prepara as atividades para trabalhar com o seu estudante, seguindo esta estrutura: exploração dos conhecimentos anteriores, explicação, atividades práticas, feedback e reflexão. A Escala de Empatia de Jefferson foi administrada em forma de pré e pós-teste a 76 estudantes de enfermagem: 40 no grupo de intervenção e 36 no grupo de comparação. Seguindo o método misto de desenho explicativo sequencial, um estudo quantitativo (um desenho quase experimental com um grupo de comparação) foi combinado com um estudo qualitativo (análise de interação das 12 sessões gravadas em vídeo). Resultados. Os resultados revelaram melhorias estatisticamente significativas na empatia no grupo de intervenção. A análise subsequente da interação nos pares de tutoria de pares destacou as ações específicas que levaram a essas melhorias e gerou um contexto em que o estudante foi capaz de compreender conceitos complexos, permitindo que ambos os alunos participassem, refletissem e discutissem. Conclusão. A tutoria entre pares é um método eficaz para desenvolver empatia em estudantes de enfermagem. Descritores: educação em enfermagem; empatia; aprendizagem; grupo associado; psicologia; estudantes de enfermagem. Invest Educ Enferm. 2021; 39(2): e07 David Durán Gisbert • Anabel Vázquez Rivas Introduction E mpathy is a complex, cross-dimensional interpersonal skill. It is particularly essential for nursing professionals to help them care for patients and their families in a holistic manner and establish a therapeutic relationship.(1) Despite the difficulty to define the concept, many studies coincide in describing empathy as the skill to put oneself in the patient’s shoes, while retaining one’s own point of view, and ensuring that the patient knows that his/her point of view has been understood. (2) In the sphere of healthcare, considering empathy as a multi-dimensional element, Hojat(3) defines it as a predominantly cognitive attribute (rather than an emotional one), involving the comprehension (rather than the feeling) of patients’ experiences, concerns, and perspectives, combined with the skill to convey this comprehension to them. Empathy therefore constitutes a basic element in the therapeutic relationship between the patient and the professional healthcare, beneficial both for patients and their families, as well as for nursing staff themselves and the health institution as a whole. Studies have demonstrated that patients that are cared for by highly empathetic nursing staff show reduced levels of anxiety and depression, lower hostility towards healthcare professionals and increased degree of satisfaction with the care received.(4) For nursing professionals, the contact with the patient’s suffering, tackling difficult and stressful emotional situations, overwork and lack of social support make them vulnerable to burnout and anxiety.(5) Furthermore, if the nursing staff has institutional and social support, they are less likely to be susceptible to burnout, anxiety, depression, and hostility.(6) The complex nature of empathy as a multi-dimensional concept makes it difficult to gauge.(7) Most studies measure it using quantitative methods such as the Jefferson Scale, given its wide acceptation among the scientific community, its extensive use in different health specialities, and its translation into different languages.(3) Even though it is widely recognised that empathy should be further developed in healthcare professionals, during initial training there are few deliberate education opportunities with effective methods to develop empathy.(8) However, empathy can be developed through different types of activities, based on active methodologies –for example, experiential activities using real or simulated patients,(9) or peer tutoring.(10) In a formal training context, peer tutoring is described as a peer learning method based on the creation of pairs, with an asymmetric relationship (the role of tutor and tutee and their respective tasks) and a common and shared objective, which is the acquisition or improvement of some curricular competence, through structured interactions planned by the teacher.(11) Peer tutoring meta-analyses present numerous positive effects,(12,13) as well as being a potentially useful and effective methodology to improve cognitive, social, and communicative skills.(14) Invest Educ Enferm. 2021; 39(2): e07 Implementing Peer Tutoring for the Development of Empathy in Nursing Education Peer tutoring may involve fixed roles (the tutor and report a greater degree of empathy, obtaining tutee always play the same role), or reciprocal ones statistically substantial differences in the Jefferson (the tutor and tutee interchange their roles). (11) In Scale (Spanish version JSPE-S questionnaire,(19) this study, a reciprocal role type is proposed to give between the pretest and posttest, while the each student the chance to perform both roles. comparison group is not expected to reveal any statistically significant changes. In order to explain In the field of nursing education, peer learning is the possible quantitative changes, the qualitative presented as an educational model highly suitable work, focused on analysing the process, aims to for clinical placements, due to the increasing number reveal which elements in the interaction contribute of students and a limited number of preceptors.(15) to the development of empathy in students. To do Research on recent practices that use peer learning this, three questions are formulated: (1) In the in clinical practice education shows positive effects first part of the peer tutoring session, where the on nursing students’ self-efficacy(16) and professional tutor explains basic concepts to the student, what competence.(17) Irvine et al.(18) carried out a review actions of the pair help or hinder the development of 29 studies, between the years 1990 and 2017, of conceptual knowledge of empathy and why?; and reported benefits of peer teaching in creating (2) In the second part of the peer tutoring session, a safe supportive learning environment, learners where the different activities designed are put into viewing near-peer teachers as effective role models, practice, what actions of the pair help or hinder and increased confidence experienced by learner the emotional development of empathy and why?, and teacher. The reviewed studies mainly focused and (3) In the final part of the peer tutoring session, on cognition with little emphasis on metacognition where there is joint and individual reflection on or affective behaviours, and lacked training what has been learned and undertaken, which provided to tutors or peer teachers. The authors aspects help raise awareness of the development concluded that it is imperative that faculty embed of empathy itself and why? near-peer teaching into the curriculum, but more Research Design. This research opts for studies are needed in order to provide definitive a mixed-methods sequential explanatory evidence supporting this pedagogical approach design,(20) combining a quantitative study (a and a theoretical framework for its implementation, quasi-experimental design with a comparison particularly from educational psychology. Given the group); and a qualitative study (an analysis of importance of empathy as an integral part of the the data extracted from the interactions between skillset required for nursing staff, and the need to each pair of students) to explain the quantitative find ways of developing it during the initial training changes detected.(21) period of these professionals, the objective of this study is to design a pedagogic project based on Sample. The sample consists of 76 third-grade peer tutoring and explore its potential to develop nursing students in clinical internships at the empathy both in terms of positive aspects and University of Barcelona. To preserve the ecological areas of improvement, with a view to incorporating validity of the study, two groups of students from it into initial nursing staff training. equivalent degrees, consisting of 40 and 36 students, were randomly assigned as comparison Methods or intervention group. The 40-student class became the intervention group and the 36-student class was set as comparison group. This objective is summarised as a hypothesis Intervention: Training Programme and Procedure. and three questions. The hypothesis is that the Prior to the sessions, an initial training session is students participating in the project will self- held, explaining the programme and what peer Invest Educ Enferm. 2021; 39(2): e07 David Durán Gisbert • Anabel Vázquez Rivas tutoring entails, and students are administered an and asks questions if necessary. Then the tutee initial assessment using the JSPE-S test. Based must explain the situation as if it had happened on the scores, the pairs are formed, having the to him/her. This enables the tutee to perform an student with the highest empathy score paired activity of reflection based on empathy towards with the student with the second highest score, the partner. In the case of videos and role plays, and so on consecutively. Therefore, a similar level several aspects that are essential for building an of skill is guaranteed among the two members of empathic therapeutic relationship are analysed, the pair, which –as indicated by extant literature– such as appropriate use of verbal and non-verbal is essential for the use of reciprocal peer tutoring, communication, developing a good relationship or in which the roles of tutor and tutee alternate. understanding, and the professional’s implication (11) The programme is designed based on the with the patient.(23) The randomly assigned systematic review of actions favouring empathy comparison group is provided with the same development and consists of six one-hour sessions learning content, not through peer tutoring but in of reciprocal peer tutoring in two sessions per a teacher-centred explanation for the whole group week.(2,22) Working in pairs, the students are given of students. two different dossiers (one for student A and one for student B) specifying what needs to be done Instruments. To quantitatively measure empathy throughout the session guided by an activity clock. the Spanish version of the Jefferson Scale of This dossier contains the materials (in the form of Physician Empathy for Healthcare Science text or audio-visual resources) that tutors need to Students - JSPE-S-(19) was used (internal prepare prior to the session. Student A acts as consistency of 0.74). This self-questionnaire the tutor during the first hour, and B during the is comprised of 20 items and a Likert scale of second hour, to give them both the chance to seven categories, where 1 means completely perform each role. disagree and 7 completely agree. A high score on the JSPE-S suggests a higher degree of self- Sessions are structured by means of an activity perceived empathy. The theoretical structure clock: graphical structure that serves as a guideline of the questionnaire is based on 3 dimensions: so that students learn a work routine in each perspective taking (point of view that makes the session and can be increasingly more autonomous professional unbiased when actively listening when controlling each activity’s timeline. Each to the patient’s concerns and offering empathic session has the following time frames: ‘Prior responses); compassionate care or treatment Training’ (5 minutes): the tutor explores what (the human connection based on care between his/her tutee knows about the subject before the patient and healthcare professional); and skill session begins; ‘Explanation’ (10 minutes): tutor to put oneself in the patient’s shoes (ability to uses the teaching material he/she has prepared perceive and understand others’ feelings, entering to explain what he/she knows to the tutee; into the others’ subjective world). ‘Practical Session’ (30 minutes): tutor guides the activities using role play, visualisation and Concerning the qualitive study, to analyse the video analysis, and written activities; ‘Feedback pair interaction during the project sessions and between Pairs’ (5 minutes); and ‘Reflection and answer the first three research questions, a End of Session’ (10 minutes): the pairs answer category system based on extant literature but the Self-assessment questions from the dossiers. situated ad hoc was created. The procedure An example of a practical activity is to share a was performed as follows. After recording all personal experience of emotional significance that the sessions (240 hours), an initial observer created an internal conflict. The tutor explains created the category system analysing 25% of the experience while the tutee listens to him/her total time recorded (60 hours). To verify reliability Invest Educ Enferm. 2021; 39(2): e07 Implementing Peer Tutoring for the Development of Empathy in Nursing Education and validity, two previously trained researchers compassionate care and putting oneself in the individually coded these videos. The level of patient’s position). Qualitative data were gathered coincidence between them reached a value of 0.8 by means of video recording the 6 peer tutoring in Pearson coefficient, which indicates that the sessions from 10 pairs –20 students–. Video tapes category system is reliable. The category system were analysed by means of the Atlas.Ti software. is comprised of 16 dimensions, which are in turn subdivided into factors evaluated with a binary Ethical Issues. This study does not involve any answer (Yes/No). The evaluation of each factor conflict of interests or ethical conflict, and all is gradual and cumulative, that is, the higher students’ names were anonymised to ensure the factor evaluated with a Yes, the better the confidentiality. Explicit consent from each of the student’s preparation and explanation offered to students was required and they signed a document the tutee. The dimensions and factors drawn up to authorise data collection for research purposes to analyse the degree of empathy are split into the in an anonymous and voluntary manner. 3 segments that make up the peer tutoring session that will be analysed: conceptual approximation, comprised of 8 dimensions and 30 factors; the practice, comprised of 5 dimensions and 19 factors; and finally, the reflection, comprised of 3 Results dimensions and 13 factors. Quasi-experimental Study Results Data analysis. For the quantitative data, we First, the homogeneity of both groups was analysed opted for analysis of variance (ANOVA) for by means of Student’s t-test for independent repeated measures, with the purpose of studying samples, comparing the different pretest scores the variation over time of both groups regarding between intervention and comparison group, the dimensions studied (perspective taking, presented in Table 1. Table 1. Scores by student t test for independent samples of each dimension between Comparison and intervention groups pre-test p-value Difference Typical error of Dimensions t gl (2-tailed) between means the difference Perspective taking 2.129 74 0.037 3.164 1.486 Compassionate care 2.587 74 0.012 2.786 1.077 Putting oneself in the pa- 0.661 74 0.511 0.389 0.589 tient’s shoes The results indicate that, except for the are not homogeneous because they are part of “Putting oneself in the patient’s shoes” score, different pre-test situations, which is not a problem there are statistically significant differences for because the study aimed to analyse the variation both the dimensions “Perspective taking” and of different groups even though their initial scores “Compassionate care”. This means that groups are different. The results obtained with ANOVA Invest Educ Enferm. 2021; 39(2): e07 David Durán Gisbert • Anabel Vázquez Rivas regarding the “Perspective taking” dimension in the the total scores of the tests, results show that pre-test-/post-test from the intervention group and the variation over time is statistically significant the comparison group are presented in Table 2. between both groups (p<0.0005); the total score decreased in comparison group and increased The results obtained reveal statistically significant significantly in intervention group. differences between intervention and comparison groups (p=0.001). There is an increase in These results show that both groups have intervention group scores, unlike the non-variation different pretest scores, with a higher mean in comparison group. In relation to the dimension in the comparison group (119.14) than in the “Compassionate care”, the scores variation over intervention group (112.8). However, the variation time is statistically different between both groups over time of both groups is different; intervention (p=0.004). There is an increase in the intervention group obtains a higher mean in the posttest group scores, but not in the comparison group (118.58), with an increase of more than 5.78 scores. As regards “Putting oneself in the patient’s points from the pretest, while the comparison shoes” dimension, there are no differences over group shows a lower posttest mean (116.08) time between both groups (p=0.432). Taking with a decrease of 3.06 points from the pretest. Table 2. Evolution of dimensions of the Scale of Physician Empathy for Healthcare Science Students over time in the comparison and intervention groups Dimension Pre-test Post-test Perspective Taking* n mean S.D. mean S.D. Comparison Group 36 60.89 6.02 60.69 6.38 Intervention Group 40 57.73 6.84 62.30 5.36 Compassionate Care† Comparison group 36 43.61 4.795 41.28 4.82 Intervention group 40 40.82 4.590 41.98 4.95 Putting oneself in the patient’s shoes‡ Comparison Group 36 43.61 4.795 41.28 4.82 Intervention Group 40 40.82 4.590 41.98 4.95 Total scale Comparison Group 36 119.14 10.81 116.08 11.09 Intervention Group 40 112.80 11.33 118.58 10.59 Time*group interactions (Huynh-Feldt correction): *: F= 1.91; p=0.001; †: F= 8.675; p=0.004; (‡): F= 0.623; p=0.432; §: F= 15.350; p<0.005 Invest Educ Enferm. 2021; 39(2): e07 Implementing Peer Tutoring for the Development of Empathy in Nursing Education Results of the Interaction Analysis each factor, frequencies and percentages are using the Dimensions System obtained. Results are presented following the three questions. The category system designed to analyse the interaction of the video-taped pairs has 16 A) In the conceptual approach segment, which dimensions, subdivided into factors that are actions in the pair help or hinder the development evaluated using a dichotomous response (Yes/ of the conceptual understanding of empathy? No). The category system is divided into 3 To answer the first question, the first 15 minutes segments that configure the peer tutoring of all conceptual understanding sessions were session: the conceptual approach (with 8 analysed (‘Prior Training’ and ‘Explanatory Part’), dimensions and 30 factors); the practical session assessing the pair interaction based on the first (5 dimensions and 19 factors); and finally, the eight dimensions created for the analysis. Results reflection (3 dimensions and 13 factors). For are summarized in Table 3. Table 3. Results of Conceptual Approach Segment (20 pairs of students, 12 sessions) Dimension / Factors f % 1. Preparation of sessions 1.1 The tutor did not bring the materials 1 1.2 1.2 The tutor brought the materials 56 70 1.3 The tutor brought the materials with underlining 14 17.5 1.4 The tutor brought the materials with underlining and notes on the underlined parts 9 11.2 2. Use of materials during the session 2.1 The tutor used the extra material provided such as further information 29 36.2 2.2 The tutor created synthesis material (charts, graphs, material in notebooks or paper) 50 62.5 2.3 The tutor created teaching material (additional material such as photos, other documents or 1 1.2 resources) 3. Conceptual understanding by the tutor 3.1 Incorrect comprehension of the concepts 1 1.2 3.2 Correct comprehension of the concepts but in a literal way 5 6.2 3.3 Correct and appropriate comprehension (using own words) of the concepts without using examples 14 17.5 3.4 Correct and appropriate comprehension using examples 60 75 4. Action taken by the tutor to detect tutee’s prior knowledge 4.1 No questions asked to detect prior knowledge 5 6.2 4.2 The tutor asked the student without subsequently giving an answer 15 18.7 4.3 The tutor asked questions and provided answers 3 3.7 4.4 The tutor asked questions and gave feedback to the tutor 16 20 4.5 The tutor asked questions, assessed the response and helped prompt the tutee’s prior knowledge 41 51.2 (giving clues, examples) 5. Building on knowledge through pedagogical guidance 5.1 The tutor transmitted information 41 51.2 Invest Educ Enferm. 2021; 39(2): e07 David Durán Gisbert • Anabel Vázquez Rivas Table 3. Results of Conceptual Approach Segment (20 pairs of students, 12 sessions) (Cont) Dimension / Factors f % 5.2 The tutor used the tutee’s prior knowledge and improved on it 30 37.5 5.3 The tutor recognised the tutee’s prior knowledge and together they built on the framework/ idea/ 9 11.2 concept 5.4 The tutor and the tutee built new knowledge based on their prior knowledge 0 0 6. Tutor’s verification of tutees’ knowledge 6.1 No questions asked on understanding 22 27.5 6.2 The tutee was the one asking questions and the tutor simply answered them 28 35 6.3 Both tutor and tutee asked questions on their understanding 15 18.7 6.4 The tutor asked questions on the tutee’s understanding 15 18.7 7. Guiding the interaction 7.1 The tutor did not guide the interaction 5 6.2 7.2 The tutor guided the interaction during the conversation but did not anticipate the structure of the 54 67.5 activity during the session 7.3 The tutor guided the interaction, anticipated the structure of the activity during the session, and 13 16.2 guided the conversation 7.4 The tutor guided the interaction by providing guidelines on the activity during the session by reca- 8 10 pitulating and concluding different blocks 8. The tutor stimulates and maintains the tutee’s interest 8.1 The tutor did not stimulate any interest in the tutee 3 3.7 8.2 The tutor stimulated the interest of the tutee in the task 11 13.7 8.3 The tutor stimulated the interest of the tutee and maintained it 66 82.5 Based on these results, it was considered that those related to stimulating their tutee’s prior students were able to understand not only the knowledge, avoiding transmission of information concept but also what being empathetic and without rebuilding it with their tutees or checking establishing a therapeutic relationship entails. the progressive understanding of the concepts, Furthermore, tutors were able to formulate and guiding the session. questions, assess the answers, and help prompt the tutees’ prior knowledge (by giving clues or B) In the practical activity, which of the pair’s examples). It was also considered that they were actions help or hinder the emotional development able to synthesise and tell information to their of empathy? peers in their own words –which indicated that The following 30 minutes of all practical sessions their understanding had been fully interiorised. were analysed by examining pair interaction, based However, it seems that some actions from the on the 5 dimensions created for the analysis. The tutors have room for improvement, especially results are shown in Table 4. Invest Educ Enferm. 2021; 39(2): e07 Implementing Peer Tutoring for the Development of Empathy in Nursing Education Table 4. Results of practical session (20 pairs of students, 12 sessions) Dimension / Factors f % 9. Tutor’s involvement in the practical activity 9.1 The tutor showed little collaboration and prevented the practical activity from being performed 0 0 correctly 9.2 The tutor showed little collaboration and made it difficult to perform the practical activity 1 1.2 9.3 The tutor showed little collaboration but completed the practical activity together with the tutee 2 2.5 9.4 The tutor collaborated when the tutee asked for help, and completed the practical activity correctly 8 10 9.5 The tutor collaborated during the practical activity, helping where the tutee required, and allowing 69 86.2 the practical activity to be performed correctly 10. Helpfulness: explanation 10.1 The tutor did not explain the concepts 6 7.5 10.2 The tutor provided explanations when the tutee asked for them 17 21.2 10.3 The tutor provided explanations without the tutee asking for them 57 71.2 11. Helpfulness: questions 11.1 No interrogation or questions 17 21.2 11.2 Only the tutee asked questions 14 17.5 11.3 The tutor asked questions to the tutee 2 2.5 11.4 The tutor asked questions to the tutee and provided feedback 47 58.7 12. Guidance provided in practical activity 12.1 The tutee explained the activity to the tutor 4 5 12.2 The tutor did not explain the activity, both tutee and tutor waited for the teacher to explain the 58 72.5 activity 12.3 The tutor explained the activity to the tutee, but the tutor did not provide guidance during the 5 6.2 activity 12.4 The tutor explained the activity to be done to the tutee and guided the activity considering the 13 16.2 objectives proposed in the dossier 13. Objectives specified in the dossier 13.1 The tutor did not consider the objectives that needed to be reached 2 2.5 13.2 The tutor considered some of the objectives that needed to be reached and the tutee reached them 18 22.5 13.3 The tutor considered the objectives that needed to be reached and the tutee reached them 60 75 It seems that the tutors did consider the objectives of The final 15 minutes, defined as the ‘reflection the activity to help the tutees meet them. Tutors also segment’ (feedback plus reflection) were analysed prompted their tutees by asking questions and offering by examining pair interaction, based on the feedback, and generally collaborated throughout the three final dimensions designed. The results, practical session by helping their tutees. summarized in Table 5, show that students were able to create environments, generate time for C) In the segment of reflection, which reflection and expression, and actively listen to the elements favoured their awareness on empathy respective points of view, which are all essential development itself? for the practice of empathy. Invest Educ Enferm. 2021; 39(2): e07 David Durán Gisbert • Anabel Vázquez Rivas Table 5. Results on Reflection Segment (20 pairs of students, 12 sessions) Dimension /Factors F % 14. Mutual understanding of the questions on reflection 14.1 Tutee responded to questions on reflection and tutor gave his/her point of view, but no common 2 2.5 reflection was made 14.2 Tutor reformulated questions to the tutee to understand his/her point of view and/or to delve 10 12.5 into the answers given by the tutee 14.3 Tutor and tutee listened to and understood each other and gave each other time to think and 68 85 explain their point of view 15. Reflection on meaning of concepts 15.1 No assimilation of concepts was shown 2 2.5 15.2 Tutor and tutee understood and discussed the concepts following the conceptual approach and 15 18.7 practical activity 15.3 Tutor and tutee understood and discussed the concepts learnt and justified them or gave ex- 45 56.2 amples 15.4 Tutor and tutee were able to reconstruct the meaning of the concept 12 15 15.5 Tutor and tutee were able to construct the meaning of the concept by changing the initial ideas 6 7.5 16. Self-assessment as a part of reflection 16.1 No self-assessment was carried out 30 37.5 16.2 Self-assessment was carried out individually 12 15 16.3 Tutor assessed tutee 1 1.2 16.4 Tutee assessed tutor 7 8.7 16.5 Tutor and tutee assessed each other mutually 30 37.5 But not all the tutors’ actions are in good experimental study show statistically significant direction. Results indicate that their reflections improvements in the intervention group which on the meaning of the concepts were limited did not occur in the comparison group, especially to discussion, indicating that it was correct but in the “Perspective Taking” and “Compassionate superficial. Students’ self-assessment could Care” dimensions. This suggests that this peer also be improved to include mutual assessment tutoring intervention can be effective in promoting more frequently. social experiences that enhance empathy. The result reinforces the idea that empathy, as a Discussion complex social skill, can be developed through teaching methods based on cooperation.(10) The analysis of pair interaction in the peer Given the need to help nursing students develop tutoring sessions that consist of three segments their empathy, a peer-tutoring intervention has –conceptual approach, practical activity and self- been designed to generate favourable social reflection– can help us better account for the exchange spaces. The results of the quasi- quantitative results. The reported improvement Invest Educ Enferm. 2021; 39(2): e07 Implementing Peer Tutoring for the Development of Empathy in Nursing Education in the “Perspective taking” and “Compassionate the teacher’s help. This problem has also been Care” dimensions may be due to the creation of detected in peer tutoring practices in contexts an environment that enabled students (in both where the teacher’s role is very relevant, and roles, tutors and tutees) to understand complex students are not used to offering pedagogical concepts, fostered a high level of participation, help.(11) One possible solution to help solve this and provided opportunities for joint reflection problem might involve offering more autonomy to and discussion. It seems that peer tutoring the pairs of students, which appears to be highly was effective given that tutors developed their linked to the opportunities available to reflect on conceptual learning of empathy by means of their own actions, through self-assessment. The preparing materials for the session and using results suggest that it is also necessary to help them to explain and question their tutees, which pairs develop quality self-assessment practices. is known as learning by teaching.(24) However, results could probably be better in all dimensions, This study is limited by the small, non-probabilistic provided that tutors are encouraged to explain in sample and by the specific cultural context where their own words, adjust the explanations to the it was carried out. However, both limitations offer interest and characteristics of their tutees and lines of future work: improving how students are ask and answer deep questions.(25) Nevertheless, assigned to intervention or comparison group, it seems that tutees also increased their learning and increasing the number of students, the type through the help received, which was personalised of subjects and especially cultural and geographic and adjusted by their tutor. contexts. Empathy is a cross-dimensional skill that all students from the healthcare sector However, some actions were identified to have should develop, as a key tool to care for patients hindered the conceptual development of empathy, and their families. That is why this peer tutoring and these have been highlighted as elements to programme has been created. However, not only be improved on. For instance, it is important to is empathy important for nursing students, but help tutors in using tutees’ prior knowledge to also for any citizen in the 21st century. Thus, the build new knowledge, in ensuring the effective project reported in this article lays the foundation comprehension of what has been explained, and stone to adopt an expanded, innovative standpoint in guiding the session. The qualitative analysis of that leads to an evidence-based empathy training the interaction in the final segment of the peer programme that could be adjusted and applied in tutoring session (self-reflection) seems to indicate any university, but also implemented in primary actions that must be rectified to improve the and secondary education. dimension referring to “Putting oneself in the patient’s shoes”. Even though the tutor involves Funding. This project has not received funding the tutee in the activity, they do not appear to from any advertising or sales agency or from any sufficiently lead the activity but instead wait for other entity. Invest Educ Enferm. 2021; 39(2): e07 David Durán Gisbert • Anabel Vázquez Rivas References 1. Mullan BA, Kothe E J. Evaluating a nursing communication skills training courses: the relationship between self- rated ability, satisfaction, and actual performance. Nurse Educ. Pract. 2010; 10(6):374-8. 2. 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