Background

Empathy is considered a key parameter in compassionate care and understanding its nature can be of great significance for women’s care [1–3] and for the midwives [4–7].

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 [8], 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.

Methods

Pilot study

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.

Data collection

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.

Participants

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.

Instrument

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.

Data analysis

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

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 [11].

Factor structure

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 [12] to determine the dimensional structure of MES using the following criteria: (a) eigenvalue > 1 [13], (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 [14]. Computations were based on a measurement scale [15]. 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 [16]. 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.

Results

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 %.

Sample characteristics

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

Reliability

The MES showed an overall medium consistency. Cronbach’s alpha was 0,546 p < 0,0001 for the total scale (Items 1–25).

Factor structure

Exploratory factor

The exploratory factor analysis of the 25 items of the MES revealed seven orthogonal factors (KMO measure of sampling adequacy = 0.817 and Barlett’s test of sphericity = 1508.169 df = 300 p < 0.0001). Communalities for MES questions are presented in (Table 2). The Screeplot (Fig. 1) and Component Plot in Rotated Space (Fig. 2) that are 7 factors in the model, with these factors explaining 57,065 % of the data (Table 3). The first factor (Compassionate Care) includes the following items: 6,12,13,15,20, the eigenvalue was 6.158 and accounted 24.632 % of the variance. The second factor (Empathetic Ways) includes the items : 14,18,21,24, the eigenvalue was 1.792 and accounted for 7.169 % of the variance. The third factor (Emotional Detachment) is composed of items: 10, 19, 25, the eigenvalue was 1.443 and accounted for 5.771 % of the variance. The fourth factor (Perspective Taking) is composed of items: 1, 3, 7 had an eigenvalue 1.366 and accounted for 5.464 % of the variance. The fifth factor (Interpersonal Relationship) includes the items: 22, 23 had an eigenvalue of 1.287 and accounted for an additional 5.149 % of the variance. The sixth factor (Standing in the woman’s shoes) includes the following items: 8, 11 had an eigenvalue of 1.205 and accounted for an additional 4.821 % of the variance. Finally, the seventh factor (Empathetic Tendencies) consists items: 9, 16, 17 with an eigenvalue of 1.015 and accounted for an additional 4.059 % of the variance (Table 3).

Table 1 Characteristics of the Study Sample
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Table 2 Descriptive Statistics of the MES items
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Fig. 1
figure 1

Screeplot

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Fig. 2
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Component Plot in Rotated Space

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Table 3 Exploratory factors and Explained Variance after rotation for MES
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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

Confirmatory factor analysis was conducted to determine whether data are consistent with the a priori specified model that has been suggested by Exploratory Factor Analysis in order to evaluate whether the data fit the model adequately. The seven factor-model was based on correlated factors that derived from the factor analysis using principal component analysis with varimax rotation by SPSS 20. The seven latent variables Compasionate Care (Questions 6, 12, 13, 15, 20), Empathetic Ways (Questions 14, 18, 21, 24), Emotional Detachment (Questions 10, 19, 25), Perspective Taking (Questions 1, 3, 7), Interpersonal Relationship (Questions 22, 23), Standing in the woman’s shoes (Questions 8, 11) and Empathetic Tendencies (Questions 9, 16, 17) were strongly correlated with method Maximum Likelihood. Estimates, standard error, t-values, error terms and r2 for all the questions that consisted each latent variables are presented at Fig. 3. The error terms correlated significantly and Goodness of Fit Statistics were also estimated; Discrepancy Chi-Square = 2340.841, p = 0.000; Standardized Root Mean Square Residual (SRMR) = 0.323; CD = 1.000 (Fig. 4).

Fig. 3
figure 3

Estimates, standard error, t-values, error terms and r2 for items of MES

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Fig. 4
figure 4

Confirmatory Factor Analysis for the Midwifery Empathy Scale (MES

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Validity

Construct validity

Cronbach’s alpha was calculated for each of the following subscales of the MES, with the questions indicated constituting the items of each subscale:

  1. 1.

    Compassionate Care (6,12,13,15,20): 0.731

  2. 2.

    Empathetic Ways (14,18,21,24): 0.577

  3. 3.

    Emotional Detachment (10,19,25): 0.405

  4. 4.

    Perspective Taking (1,3,7): 0.592

  5. 5.

    Interpersonal Relationship (22, 23): 0.767

  6. 6.

    Standing in the woman’s shoes (8,11): 0.515

  7. 7.

    Empathetic Tendencies (9,16,17): 0.572

Discussion

Main findings

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.

Limitations

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].

Conclusion

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.