Midwifery empathy scale: development and validation for a greek sample
© The Author(s). 2016
Received: 1 June 2016
Accepted: 27 October 2016
Published: 17 November 2016
In recent years, a growing number of studies report on the importance of empathy to women’s care. The Midwifery Empathy Scale (M.E.S) was developed in order to study and record the levels of empathy of professional and student midwives. The purpose of our study was to validate this instrument and determine the factor structure and reliability.
The study sample (n = 242) consisted of professional (n = 114) and student midwives (n = 128) of 3 Maternity Hospitals (public and private) of Athens.
The exploratory factor analysis on the 25 item of Midwifery Empathy Scale (MES) revealed seven orthogonal factors (KMO Measure of Sample Adequacy = 0.817 and Bartlett’s test of sphericity = 1508.169, df = 300, p < 0.0001. The MES showed medium overall internal consistency (Cronbach’s alpha value: 0.546, p < 0.0001). The internal consistency characteristics of MES demonstrated good reliability. Our findings attest to the multidimensionality of MES, and the Confirmatory Factor Analysis (CFA) demonstrated that the 7 factor model offers a very good fit to our data.
Our data indicate that the Midwifery Empathy Scale (MES) is a reliable and valid tool for assessing the levels of empathy of professional and student midwives for both clinical and research practices.
KeywordsMidwives Compassionate Empathetic Emotional detachment Perspective taking Interpersonal relationship Tendencies
Studying the levels of empathy through a practical psychometric tool it is expected to improve the quality of the midwifery care. There are a few studies in the relevant literature exploring the levels of empathy in student midwives , and professional midwives [9, 10]. At the same time, there was no validated instrument designed to assess the levels of empathy specifically for midwives. The Midwifery Empathy Scale (MES), a 25- item psychometric scale, was developed to meet this challenge.
Therefore, the aim of the present study was to develop and determine the factor structure, validity and reliability of the MES by measuring student and professional midwives’ levels of empathy.
The 25-item MES was developed after extensive literature review, targeting only midwives. The midwifery underpinning philosophy, culture and clinical practice was taken into consideration. The scale was originally tested in a small pilot study with 7 midwives. In the process of cultural adaptation, we conducted in depth interviews to examine respondents’ understanding of the scale items. Participants provided their views about the clarity of each item, the relevance of the content to their situation, the comprehensiveness of the instructions and their ability to complete the scale on their own.
The research was approved by the Ethical Committees of the participant Hospitals (No51/27-2-2015 & No17/24-2-2015) and validation activities were initiated in the period of March to June 2015. Following written informed consent, students and professional midwives completed the scale. A cover letter explained the purpose of the study, provided the researchers’ affiliation and contact information and guaranteed confidentiality and anonymity.
Student midwives (n = 128) and professional midwives (n = 114) were recruited from 3 Hospitals of Athens municipality (public and private) and the midwifery Department of TEI of Athens. The inclusion criteria required fluency in spoken and written Greek language, being a student or a professional midwife and written informed consent.
The MES is a 25-item scale that consists of situations where empathetic responses are evaluated. Each item is scored on a 6-point Likert scale from 1-6 with response options that range from 1 (totally agree) to 6 (totally disagree). A total score for MES is calculated (25–150). Items that measure negative statements are reversely scored with lower scores indicating lower levels of empathy.
Statistical analysis was performed using IBM SPSS statistics version 20. Descriptive characteristics (including means, standard deviation, frequencies and percentages) were calculated for the socio-demographic variables.
Reliability coefficients, measured by Cronbach’s alpha, were calculated for MES to assess reproducibility and consistency of the instrument; a minimum value of 0.70 for group comparisons is considered acceptable .
The underlying dimensions of the scale were checked with an exploratory factor analysis using a Varimax rotation and Principal Components Method for analyzing group data  to determine the dimensional structure of MES using the following criteria: (a) eigenvalue > 1 , (b) variables loaded > 0.50 on only one factor and on other factors less than 0.40; (c) the interpretation of the factor structure was meaningful, (d) the screenplot was accurate when means of communalities were above 0.60 . Computations were based on a measurement scale . During factor analysis, a Barlett’s test of sphericity (p < 0.05) and a Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy of 0.817 were also implemented. A factor was considered as important if its eigenvalue exceeded 1.0 . Additionally, a confirmatory analysis –also called Structural Equation Modelling- of principal components was conducted by STATA 13.1 to confirm the scale items principally load on to that factor and correlate weakly with other factors. To assess tests for significance of factor loadings and orthogonality of factors [12, 14, 16] a model (based on a priori information of exploratory factor analysis)- was built in order to specify latent factors, their component variables and the intercorrelations of the response variables; maximum likelihood estimates, t-values, error terms, correlation of independent variables and goodness of fit-test for the specified model were performed.
During the recruitment period (March 2015-June 2015), 300 eligible student and professional midwives were invited to participate. Fifty eight of them did not participate for a range of reasons (19 refused, 24 missing values, 8 missed, 7 other). This resulted in a final sample of 242 student and professional midwives which was adequate for exploratory factor analysis [17–19]. The questionnaire response rate was 80,6 %.
According to the answers to questions, 234 from 242 respondents are women. The age of the midwives ranges from 19-58 (mean 28.68). Most of them (47.1 %) were graduates from direct entry midwifery school (TEI), while fewer (11.2 %) has post-graduate studies and 0.81 % had a PhD; 52.1 % were student midwives practicing in the public hospitals; 24.8 % of them were married (Table 1).
Psychometric characteristics of MES
The MES showed an overall medium consistency. Cronbach’s alpha was 0,546 p < 0,0001 for the total scale (Items 1–25).
Characteristics of the Study Sample
All participants No (%)
7 (2.9 %)
234 (96.7 %)
71 (29.3 %)
33 (13.6 %)
175 (72.3 %)
60 (24.8 %)
6 (2.5 %)
126 (52.1 %)
114 (47.1 %)
18 (7.4 %)
2 (0.8 %)
Descriptive Statistics of the MES items
1. I believe that empathy plays an important role in midwifery care.
2. Midwives should understand the emotional situation of the women and their families.
3. I can perceive the hidden feelings and thoughts of the women that are in my care.
4. During the taking of the medical history it is not important to pay attention to the women’s feelings.
5. Women’s emotions do not concern me.
6. Women feel better when they sense that they are understood.
7. I recognize the body language of a woman.
8. Body language is not as important as verbal communication for the understanding of the woman’s feelings.
9. I recognize when a woman is silent because of embarrassment.
10. I don’t get emotionally affected when I see women cry.
11. It is difficult for a midwife to see things from women’s perspective.
12. I try to stand in the woman’s shoes, so I can better understand her.
13. I show that I am willing to listen to the woman by always sitting near her.
14. I would spend time to take care of women after my work hours.
15. Midwife’s touch encourages the woman.
16. I avoid to touch the woman I am caring for, in order to keep a distance.
17. I think it is important to touch a woman when I am caring for her.
18. Very sensitive women irritate me.
19. There were times that I witnessed a woman cry and I got emotional.
20. Many times I left work and I kept thinking of a woman I was caring for.
21. I don’t think part of my job to occupy myself with the problems of the woman I care.
22. I feel satisfaction when women feel better with my care.
23. If I realize that a woman is afraid, I spend time trying to reassure her.
24. I could go against hospital rules in order to help a woman.
25. I usually stay emotionally detached from the women that are in my care.
Exploratory factors and Explained Variance after rotation for MES
Rotation Sums of Squared Loadings
% of Variance
Factor 1 (Compassionate Care)
Factor 2 (Empathetic Ways)
Factor 3 (Emotional Detachment)
Factor 4 (Perspective Taking)
Factor 5 (Interpersonal Relationship)
Factor 6 (Standing in the woman’s shoes)
Factor 7 (Empathetic Tendencies)
According to MES validation, 3 out of the 25 items, which were not relevant for the Greek midwives (Items: 2, 4, 5).
Confirmatory factor analysis
Compassionate Care (6,12,13,15,20): 0.731
Empathetic Ways (14,18,21,24): 0.577
Emotional Detachment (10,19,25): 0.405
Perspective Taking (1,3,7): 0.592
Interpersonal Relationship (22, 23): 0.767
Standing in the woman’s shoes (8,11): 0.515
Empathetic Tendencies (9,16,17): 0.572
The MES is a scale designed to measure the empathy of professional and student midwives. It was developed to meet the challenge of developing a psychometric tool tailored to assess the levels of empathy for midwives. The results of this research showed that the major formative factors of the empathy levels in midwives are: 1) Compassionate Care 2) Empathetic Ways 3) Emotional Detachment 4) Perspective Taking 5) Interpersonal Relationship 6) Standing in the Woman’s Shoes 7) Empathetic Tendencies. According to MES validation study, 3 out of 25 items were excluded from the analysis, which were not relevant for our sample.
A Barlett’s test of sphericity with (p < 0.0001) and Kaiser-Meyer-Olkin (KMO) measure of simplicity adequacy of 0.817 were used in performing this factor analysis. A factor was considered important if its eigenvalue exceeded 1 (Kaiser 1960). As factor analysis found 7 independent subscales, subsequent Cronbach’s alpha were separately carried out for each subscale, to highlight how the items group together. According to factor analysis 7 subscales have been revealed within the MES. Cronbach’s alpha was 0.731 for the first subscale, 0.577 for the second, 0.505 for the third, 0.592 for the fourth, 0.767 for the fifth, 0.515 for the sixth and 0.572 for the seventh.
Our findings confirm the multidimensionality of the MES, demonstrating a seven-factor structure, while the sub-scales of the Greek MES showed very good values for Cronbach’s alpha. Significant differences in item-factor loadings characteristics may be explained by the varied cultural backgrounds of our study population. The confirmatory factor analysis demonstrated that the seven factor model based on the exploratory factor analysis offered a very good fit to the our data. All goodness of fit statistics were found to be very good.
This study was not without limitations. The MES was pilot-tested and validated using samples of midwives and student midwives from the two largest public maternity hospitals in Athens and fewer midwives who work in the private sector where included and independent midwives were not included at all. This sample may not be representative of the population of midwives in Greece and the majority of our subjects were female. Another limitation of the research concerns the fact that the recruited midwives work in a hospital setting (public, private) and there were time availability issues in regards to completion of the questionnaires. For similar reasons as well as stress related factors colleagues of the Central Delivery Units were not invited to participate to the study. Finally, the authors didn’t use patient assessments of their midwife's empathy, such as Stewart Mercer's CARE (consultation and relational empathy) scale, a well-validated and reliable measure, as a complementary method of assessing the empathy of midwives that participated to the study [20, 21].
The MES studied in a sample of 242 student and practicing midwives, showed satisfactory reliability and factor analysis indicated seven components. Therefore, we assert that this validated scale may be reliably used for identifying the levels of empathy of student and professional midwives, in order to improve the quality of midwifery care.
Midwifery empathy scale
We are grateful to all the midwives and student midwives who contributed with their valuable perspectives and time. We would also like to acknowledge the contributions by Prof Christos Lionis, Prof Katerina Lykeridou and Antigoni Sarantaki for the fruitful discussions about measuring the levels of empathy in midwifery clinical practice.
The authors declare that they have no funding for the research reported.
Availability of data and materials
The materials described in the manuscript are readily reproducible, including database and all relevant data. The Midwifery Empathy Scale is freely available to any scientist willing to use it. Software, databases, MES as described in the manuscript are available for testing by reviewers in a way that preserves the reviewers anonymity. Authors wish to share MES and could email the pdf version to any scientist who will contact the corresponding author.
All authors have made substantial contributions to this study; VV, PF, AC, PG and NT were responsible for the study design. PF and AC collected the data, VV was responsible for the initial data analysis and the writing of manuscript. All authors took part in the interpretation of data and drafting of the manuscript. All authors critically revised, read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent and consent for publication was provided by the participants of the study.
Ethics approval and consent to participate
Ethical approvals by the Ethical Committees of the Hospitals (No51/27-2-2015 & No17/24-2-2015) were obtained.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Campbell-Yeo M, Latimer M, Johnston C. The empathetic response in nurses who treat pain: concept analysis. J Adv Nurs. 2007;61(6):711–9.View ArticleGoogle Scholar
- Neumann M, Bensing J, Mercer S, Ernstmann N, Ommen O, Pfaff H. Analyzing the “nature” and “specific effectiveness” of clinical empathy: A theoretical overview and contribution towards a theory-based research agenda. Patient Educ Couns. 2009;74:339–46.View ArticlePubMedGoogle Scholar
- Matthew DA. A perspective on cultivating clinical empathy. Complement Ther Clin Pract. 2009;15:76–9.View ArticleGoogle Scholar
- Tarkka M-T, Paunonen M, Laippala P. Importance of the midwife in the first-time Mother’s experience of Childbirth. Scand J Caring Sci. 2000;14:184–90.View ArticlePubMedGoogle Scholar
- Hodnett E, Osborn R. Effects of continuous intra-partum professional support on childbirth outcomes. Res Nurs Health. 1989;12:259–97.View ArticleGoogle Scholar
- Tarkka M-T, Paunonen M. Social support and its impact on mothers’ experiences of childbirth. J Adv Nurs. 1996;23:70–5.View ArticlePubMedGoogle Scholar
- Pascoe JM, French J. The reliability and validity of the maternal social support index for primiparous mothers : a brief report. Fam Med. 1989;22:228–30.Google Scholar
- McKenna L, Boyle M, Brown T, Williams B, Molloy A, Lewis B, Molloy L. Levels of empathy in undergraduate midwifery students: An Australian cross-sectional study. Women Birth. 2011;24(2):80–4.View ArticlePubMedGoogle Scholar
- Williams B, Brown T, McKenna L, Palermo C, Morgan P, Nestel D, Brightwell R, Gilbert-Hunt S, Stagnitti K, Olaussen A, Wright C. Student empathy levels across 12 medical and health professions: an international study. J Compliance Health Care. 2015;2:4.Google Scholar
- Williams B, Brown T, Boyle M, McKenna L, Palermo C, Etherington J. Levels of empathy in undergraduate emergency health, nursing and midwifery students: a longitudinal study. Adv Med Educ Pract. 2014;5:299–306.View ArticlePubMedPubMed CentralGoogle Scholar
- Cormack D. The research process in nursing. Oxford: Blackwell Science; 2000.Google Scholar
- Tabachnick B, Fidell L. Using multivariate statistics. 3rd ed. N.Y.: Addison- Wesley- Longman; 2007.Google Scholar
- Kaiser HF. The application of electronic computers to factor analysis. Educ Psychol Meas. 1960;20:141–51.View ArticleGoogle Scholar
- Hakstian AR, Rogers WD, Cattell RB. The behaviour of numbers factors rules with simulated data. Multivar Behav Res. 1982;17:193–219.View ArticleGoogle Scholar
- Morrison DF. Multivariate statistical methods. 2nd ed. New York: McGraw-Hill; 1976.Google Scholar
- Joreskog KG, Sorbom D. LISREL VI: analysis of linear structural relationships by maximum likelihood, instrumental variables, and least squares methods. Sweden: Department of Statistics, University of Uppsala; 1986.Google Scholar
- Anderson JC, Gerbing DW. The effect of sampling error on convergence, improper solutions, and goodness of fit indices for maximum likelihood confirmatory factor analysis. Psychometrika. 1984;49:155–73.View ArticleGoogle Scholar
- Bentler PM, Chou CP. Practical issues in structural equation modelling. Sociol Methods Res. 1987;16:78–117.View ArticleGoogle Scholar
- Marsh HW, Balla JR, MacDonald RP. Goodness of fit indexes in confirmatory factor analysis: the effect of sample size. Psychol Bull. 1988;88:245–58.Google Scholar
- Mercer SW, Watt GCM, Maxwell M, Heaney DH. The development and preliminary validation of the Consultation and Relational Empathy (CARE) Measure: an empathy-based consultation process measure. Fam Pract. 2004;21(6):699–705.View ArticlePubMedGoogle Scholar
- Murphy DJ, Bruce DA, Mercer SW, Eva KW. The reliability of workplace-based assessment in postgraduate medical education and training: a national evaluation in general practice in the United Kingdom. Adv Health Sci Educ. 2009;13:219–32.View ArticleGoogle Scholar