Efficacy of empathy enhancement tutorials embedded in smoking cessation training for increasing postgraduate nursing students' empathy and achieving the learning outcomes of smoking cessation interventions

Abstract

Tobacco use, a preventable behavioral risk factor for non-communicable diseases, contributes to 8 million deaths annually worldwide. The WHO Framework Convention on Tobacco Control recommends that healthcare professionals employ the 5 A’s skill (Ask, Advise, Assess, Assist, and Arrange) to deliver smoking cessation interventions. As the largest group of healthcare providers, nurses frequently encounter smoking patients in clinical practice, necessitating empathetic and personalized approaches to cessation support. However, empathy as a learning outcome remains underexplored in smoking cessation training. This study evaluated the efficacy of empathy enhancement tutorials embedded into smoking cessation training to improve postgraduate nursing students’ empathy and competence in delivering cessation interventions. First, three literature reviews identified gaps in existing evidence on smoking cessation training and empathy enhancement. Then, a randomized controlled trial (RCT) (ClinicalTrials.gov: NCT05440877) was conducted to test the efficacy of an empathy enhancement tutorial among 26 postgraduate nursing students. All students participated in case-based discussions and role-play, while the intervention group additionally accessed narrative videos and mini-virtual reality (VR) games depicting smokers’ cases. Negative outcomes were observed, potentially due to inadequate reflection. A second RCT (NCT05864339) was then designed based on the first RCT and the Experiential Learning Theory, involving 56 students assigned to either a theory-based empathy tutorial or conventional training. Both groups viewed narrative videos, engaged in case-based discussions, and participated in role-play using smokers’ scenarios. Additionally, the intervention group received a 20-minute empathy lecture and utilized the Health Empathy Map. Empathy was assessed using the Comprehensive State Empathy Scale at pre- and post-tutorial, while attitudes, self-efficacy, and 5A’s practice were evaluated using the ‘Providers’ Smoking Cessation Training Evaluation’ at baseline, post-tutorial, and 2-month follow-up. Linear mixed models analyzed group and time interactions, with effect sizes measured using Cohen’s f2. Last, a qualitative study was conducted to collect participants’ feedback via focus groups. The first RCT revealed that case-based discussions and role-play enhanced participants’ self-efficacy in smoking cessation counseling using 5A’s skills. However, narrative videos depicting smoking scenes and reluctance to quit, along with simple mini-VR games, appeared to weaken students’ empathy toward smokers. After refining the empathy enhancement tutorial, the second RCT demonstrated that the intervention group achieved greater improvements than the control group, with small-to-medium effect sizes in empathy (Cohen’s f2 = 0.084, p = 0.017), self-efficacy (Cohen’s f2 = 0.022, p = 0.049), and the ‘Advice’ behavior of the 5A’s (Cohen’s f2 = 0.031, p = 0.049). The ‘Ask’ behavior showed a medium-to-large effect size (Cohen’s f2 = 0.201, p = 0.002). Qualitative themes highlighted that the value of empathy toward smokers, acquirements of empathy skills, and the Health Empathy Map facilitated reflection, enabling students to better understand smokers’ challenges and develop tailored cessation strategies. This study is the first to demonstrate that a theory-based empathy enhancement tutorial effectively improves postgraduate nursing students’ empathy toward smokers, self-efficacy, and competence in the ‘Ask’ and ‘Advice’ behavior of the 5A’s. These findings provide empirical evidence supporting the application of the Experiential Learning Theory in smoking cessation training for nursing education.