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ORIGINAL ARTICLE • Rev. bras. educ. med. 50 (01) • 2026 • https://doi.org/10.1590/1981-5271v50.1-2023-0181.ING linkcopy

Preparation and validation of a clinical empathy classification instrument: ICEC-MES

Authorship SCIMAGO INSTITUTIONS RANKINGS

Introduction: Empathy is the ability to put yourself in the other’s shoes, understand and respond appropriately to their needs. In the clinical context, empathy is related to better therapeutic results and greater satisfaction for patients and health professionals. Demonstrated clinical empathy can present different dimensions of perception, ranging from simple emotional sharing to understanding the biomedical, psycho emotional and even social aspects of the patient.

Objective: To develop an instrument that allows the classification of clinical empathy demonstrated by medical students when using the Health Empathy Map (MES).

Methodology: This is a study with a mixed (qualitative and quantitative) and descriptive approach, developed in three stages. (1) Initially, an empathy classification model was proposed, which was the basis for the development of the clinical empathy classification instrument (ICEC-MES); (2) Assessment of the instrument’s content validity; (3) Evaluation of the instrument’s criterion validity and accuracy. To determine the level of agreement between the evaluating professors in relation to the classification of the student’s empathy in the proposed categories, the Fleiss Kappa index (p < 0.05) and the Gwet AC1 statistic were used when there was a significant imbalance and descriptive analysis of the results. data.

Results: The results showed that the instrument was able to identify the dimensions of clinical empathy, proved to be easy to understand and made it possible to classify the perception of empathy shown by the student. The concordance analysis revealed Gwet’s kappa/AC1 ranging from 0.872 to 0.209, with the highest indices being obtained in the ability to put oneself in the other’s shoes and the lowest indices in the affective dimension.

Final considerations: The study concluded that the tool presents evidence of reliability. The ICEC-MES makes it possible to identify and classify the clinical empathy demonstrated by the student, being considered, by the study participants, a useful tool to help the development of clinical empathy in care teaching settings.

Keywords:
Empathy; Classification; Medical students. Medical education

Classification of the empathic dimension	Description of the characteristics of the answers
Primary empathy	Demonstrates having been affected by the other person’s story
Pre-dimensional empathy	Fails to reflect on or address any of the dimensions (biomedical, affective or social)
One-dimensional extended empathy	Put themselves in the other person’s shoes, perceive one of the dimensions (biomedical, affective or social) and devises behaviour only for one dimension
Two-dimensional extended empathy	Put themselves in the other person’s shoes, perceive two of the dimensions (biomedical, affective or social) and/or devises behaviour geared towards two dimensions
Multidimensional extended empathy	Put themselves in the other person’s shoes, perceive the three dimensions (biomedical, affective or social) and/or devise behaviour geared towards the three dimensions

Tool Data	1st version (Initial)	2nd version	3rd version (Final)
Instructions at the start of the Tool	“The responses in each of the quadrants of the Health Empathy Map (HEM) should be assessed according to the presence or absence of the items described in the response characteristic. In quadrants Q1 and Q3, which assess the presence or absence of Extended Empathy and Primary Empathy respectively, you should tick yes or no with no need to score. In quadrants Q2 and Q4, which assess the patient’s needs and desires and behaviour in the face of the condition, respectively, the presence of the dimensions should be marked, with each YES answer corresponding to 1 point, in order to identify the presence of one or more dimensions per answer in each of the quadrants. At the end, the Q4/Q2 ratio will be calculated, with the score obtained in each quadrant to identify whether the student was able to address all the patient’s needs and wishes in their behaviour.”	“The responses to each of the quadrants of the Empathy in Health Map (MES) should be assessed according to the presence or absence of the items described in the “response characteristic” column of the table below. At the end, you should use the information described in the note to identify the structure of the clinical empathy demonstrated by the student.”	“The responses in each of the quadrants of the Empathy Map in Health (MES) should be assessed in accordance with the descriptions contained in the table below. At the end, you should use the information obtained to identify the classification of clinical empathy demonstrated by the student.”
Central part	4x4 table	3x4 table	3x4 table
	Columns:	Score column deleted	-In the 3rd column, the word “Points” has been added, with a score for each Yes in quadrants Q2 and Q4 and, just below, a space for the points total
	- MES quadrants
	- Response characteristic
	- Indicate your perception
	Yes and No for all quadrants
	- Score: only in Q2 and Q4
Note	“To assess the structure of clinical empathy observed through the reflections of students at the MES, the following concepts of empathy should be considered”	No changes	“For the classification of the empathic dimension , the sum of the scores obtained in quadrants Q2 and Q4 should be considered, according to the table below”
Tool Data	1st version (Initial)	2nd version	3rd version (Final)
Dimension Response characteristic	3X5 table	Two tables	Two tables
	- Dimensions	1st table 2x5	1st table 3x5
	- Response characteristic	Columns:	Columns:
	- Response obtained by quadrant	- Perceived dimensions	- Score/dimension/quadrant separates Q2 (perception) and Q4 (behaviour)
	Classified as	- Response characteristic	- Zero Pre-dimensional, 1 point One-dimensional, 2 points Two-dimensional and 3 points-Multidimensional
	1 point - Pre-dimensional	Two-dimensional classification added
	2 points - One-dimensional	2nd table 3x4
	3 points - Multidimensional	Score column deleted	2nd table 3X1
	Q2/Q4 ratio: >=1 point indicates that the student addressed the patient’s needs in their behaviour (this data will be more relevant for Q4 scores ≥ 2 points and < 1 point indicates lower mobilisation than observed (the teacher should assess the reasons and provide feedback)	Columns:	Columns:
		- Q2/Q4 ratio	- Q2> Q4
		- Dimensions	- Q2=Q4
		- Empathetic direction	- Q2<Q4
		Q2> Q4 Does not address all perceived needs in behaviour; Q2=Q4 addresses all perceived needs in behaviour and Q2<Q4 Addresses more needs than perceived in behaviour	- Q2<Q4
Empathy Classification	Option to tick Primary and Extended and space to fill in the total points in Q2 and Q4 and whether the Q4/Q2 ratio was higher or lower	Option to tick yes or no for primary and extended, one-dimensional, two-dimensional and multidimensional in Q2 and Q4 and for higher, lower or equal Q2/Q4 ratio	Primary and Extended have been excluded.

INSTRUCTIONS: The responses in each of the quadrants of the Empathy Map in Health (MES) should be assessed in accordance with the descriptions contained in the table below. At the end, you should use the information obtained to identify the clinical empathy shown by the student.
MES quadrants	RESPONSE CHARACTERISTIC	Points/Presence
Q1: How would you feel if you were in this person’s shoes?	Evaluates imaginary transposition (extended empathy)	( ) no	( ) yes
Q1: How would you feel if you were in this person’s shoes?	The answer should indicate that the student has put themselves in the patient’s shoes and reflected on their feelings if they were in the patient’s shoes	( ) no	( ) yes
Q2: What is your perception of this person’s current and future needs?	Evaluates the perceived dimensions of the patient’s NEEDS
	Biomedical dimension: the answer shows that the student has identified the patient’s needs related to the disease and/or biomedical aspects	( ) 0. no	( ) 1. yes
	Affective dimension: the answer shows that the student has identified the patient’s affective and/or emotional needs	( ) 0. no	( ) 1. yes
	Social dimension: the answer shows that the student has identified the patient’s needs related to their social and/or family context	( ) 0. no	( ) 1. yes
		Total pts.
Q3: How does this person’s story make me feel?	Evaluates embodied resonance (primary empathy)	( ) no	( ) yes
Q3: How does this person’s story make me feel?	The answer indicates that the student has described their feelings on learning the patient’s story	( ) no	( ) yes
MES quadrants	RESPONSE CHARACTERISTIC	Points/Presence
Q4: How can I help this person?	Evaluates BEHAVIOUR in relation to the dimensions perceived by the student
	Biomedical dimension: the answer shows that the student proposes behaviour(s) aimed at addressing the disease and/or biomedical aspects	( ) 0. no	( ) 1. yes
	Affective dimension: the answer shows that the student proposes behaviour(s) aimed at the patient’s affective and/or emotional needs	( ) 0. no	( ) 1. yes
	Social dimension: the answer shows that the student proposes behaviour(s) aimed at the patient’s social and/or family context	( ) 0. no	( ) 1. yes
		Total pts.

Score	0 points	1 point	2 points	3 points
Empathetic dimension	Pre-dimensional	Empathy. One-dimensional	Empathy Two-dimensional	Multidimensional empathy
Q2	Does not identify any of the patient’s needs	The answers consider only one of the dimensions of the patient’s illness process	The answers consider two dimensions of the patient’s illness process	The answers consider three dimensions of the patient’s illness process
Q4	Does not address any of the patient’s needs in the behaviour	The behaviour is aimed at only one of these dimensions	The behaviour is aimed at two of these dimensions	The behaviour is aimed at three dimensions
Q2/Q4 ratio	Q2/Q4 ratio
	Q2 > Q4	Q2 = Q4		Q2 < Q4
	Does not address all needs perceived in their behaviour	Addresses all needs perceived in their behaviour		Addresses more needs than perceived in their behaviour
CLASSIFICATION OF DEMONSTRATED CLINICAL EMPATHY
DIMENSION
Q2		Q4	Q2/Q4 ratio
( ) ONE-DIMENSIONAL		( ) ONE-DIMENSIONAL	Q2 = Q4
( ) TWO-DIMENSIONAL		( ) TWO-DIMENSIONAL	Q2 < Q4
( ) MULTIDIMENSIONAL		( ) MULTIDIMENSIONAL	Q2 > Q4

Quadrant/Dimension		Fleiss’ Kappa / Gwet’s AC1	Assessment of agreement	Descriptive analysis
Quadrant/Dimension		Fleiss’ Kappa / Gwet’s AC1	Assessment of agreement	5 raters	4 raters	3 raters
Q1	0.872	Almost perfect	95 %	100 %	100 %
Q2	biomedical	0.479/0.419	Moderate:	67 %	95 %	100 %
	affective	0.209	Weak:	20 %	62.5 %	100 %
	social	0.563	Moderate:	52.5	85 %	100 %
	dimensionality	0.350	Reasonable	17.5 %	60 %	92.5 %
Q3	0.446/0.473	Moderate:	65 %	90 %	100 %
Q4	biomedical	0,713	Strong	75 %	92.5 %	100 %
	affective	0.440	Moderate:	50 %	67.5 %	100 %
	social	0.269	Reasonable	62.5 %	90 %	100 %
	dimensionality	0.350	Reasonable	32.5 %	62.5 %	92.5 %

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