A total of 419 articles were identified: 283 from PubMed, 82 from CINAHL, 42 from PsycArticles, 12 from Cochrane and 0 from PsycINFO. Fifty-seven duplicates were removed using the Rayyan detection tool.22 One further duplicate was removed manually.

The screening process led to 307 articles being excluded based on the inclusion/exclusion criteria, leaving 54 articles included. After examining the full text of the remaining articles, 28 articles were excluded based on the inclusion/exclusion criteria, leaving 26 articles included in the review (figure 1). See online supplemental table 4.

PRISMA diagram representing the scoping review literature search. PRISMA, Preferred Reporting Items for Systematic reviews and Meta-Analyses.

Eleven studies (42%) were conducted in Europe,23–33 six (23%) in Asia,34–39 five (19%) in North America,40–44 three (12%) in Brazil45–47 and one (4%) in Australia.48 Twenty-one studies (81%) were published in or after 2017,23–25 27 28 31–36 39–48 with the earliest studies being published in 2014.26 29 37

Sixteen studies (62%) were cross-sectional studies,23 25–29 32 35 37 43 45–47 49–51 four (15%) were qualitative studies,24 34 44 48 three (12%) were mixed-methods studies,30 31 40 and there was one (4%) prospective cohort study,42 one quasi-experimental study39 and one (4%) randomised controlled trial.36

‘Empathetic’ and ‘empathic’ were assumed to be equivalent terms, where empathic was used in the recorded definition this was left unchanged in online supplemental table 4. None of the 26 examined studies included an explicit definition of ‘empathetic communication’. However, 21 studies defined empathy at least once,23–29 32–39 42–44 46–48 with a total number of 36 definitions of ‘empathy’ (see online supplemental table 4). Each of these 21 studies provided a definition of empathy that referenced communication in some way as a component of empathy. Most definitions of empathy were described as ‘empathy’, though others defined ‘physician empathy,27 29 42 ‘medical empathy’,27 44 ‘clinical empathy’,44 ‘relational empathy’,23 ‘nursing empathy’34 and ‘ therapist empathy’.34 These all referred specifically to empathy from the provider to the patient in a provider–patient relationship, and otherwise appeared to be the same as the other definitions of empathy. Two studies also defined empathic episodes32 48; one describing the processes that allow someone to recognise the emotional state of another both on an intrapersonal level and behaviourally,32 and the other as a four-component linear process leading to someone responding to the experiences of another.48 One study referred to empathy as ‘perceived warmth’.47

Two definitions of empathy appeared to be identical to a definition by Kurtz et al,39 44 52 where it is defined as a two-phase process where the first involves understanding and appreciating another’s feelings and emotions and the second communicating understanding back in a supportive way. Two definitions simply described empathy as the essence of all nurse–client communication and nurse–patient interaction, respectively,34 48 which appear to be identical. Most notably, 6 of the 36 definitions cited an article by Mercer and Reynolds,23 25 26 29 42 46 53 which concludes that empathy is an ability that involves three components—understanding a patient, communicating that understanding, and acting on that understanding with the patient in a helpful way. Three definitions appeared to be identical to this definition23 26 29; however, two of these definitions in two articles by Steinhausen et al26 29 further develop the definition of empathy by emphasising that ‘the physician’s sensitivity to patient concerns’ is also essential. Like many of the definitions, Mercer and Reynolds53 characterise empathy as an ability to communicate rather than a dynamic process of ‘empathetic communication’. Treating the definition by Steinhausen et al as distinct from, but similar to, Mercer and Reynolds’ definition, results in 33 unique definitions of empathy.

Communication is clearly recognised as an important aspect of empathy. Twenty-three of 33 (70%) unique definitions referenced communication as part of the definition,23–29 32–39 42–44 46–48 using verbs like ‘communicate’, ‘convey’and ‘share’. Thirteen (57%) of these referred to empathy being an ability or capacity to communicate in some way,23 25–29 33 35 36 43 46 47 while nine (39%) referred to communication being a dynamic process or behaviour of empathy.24 27 34 37–39 42 44 One (3%) unique definition describes empathy differently—describing it as ‘the essence of all nurse–client communication’.34 48

Three of 33 (9%) unique definitions described empathy as a linear step-by-step process.39 48 54 For example, first understanding and appreciating another’s feelings and then communicating back to them in a supportive manner.39

Eleven of 33 (33%) unique definitions explicitly mention cognitive empathy, which is also described as perspective taking,32 48 and affective/emotional empathy as separate components of their definition.24 32 34 37 44 46–48 However, many of the definitions mention features of cognitive empathy, but do not explicitly define it. Cognitive empathy is described as having an ability to understand someone else’s perspective, feelings or emotions in the identified definitions,32 34 46–48 and 15 of 22 (68%) definitions that did not explicitly mention cognitive and emotional empathy, mentioned understanding someone else’s perspective, feelings or emotions in their definition.23 25–29 32–39 43 44

Emotional and affective empathy were considered to be equivalent by Savieto et al,46 describing them as ‘the ability to put oneself in another person’s shoes’, and Wu34 considered affective empathy as partaking in the same feelings as someone else is experiencing them, and both of these appear to be similar. However, a definition mentioned by Gerace et al48 describes emotional empathy as being part of ‘emotional reactions to another person’s experiences’, and a definition mentioned by Brooke et al47 describes an affective component of empathy being the ability to share the emotions of others. Another definition mentioned by Moreno-Poyato et al32 considers affective empathy to consist of two dimensions—the ‘tendency to experience feelings oriented towards others such as compassion and concern’ or ‘empathic concern’, and the tendency to emotionally react based on another’s suffering, which is consistent with the definition noted by Gerace et al.48 These multiple definitions suggest that there are possibly inconsistencies in how emotional and affective empathy are defined.

Furthermore, two authors’ definitions mention behavioural empathy as another component, defining it as ‘effectively communicating the understanding of the situation’46 and having a ‘cognitive and affective part, and is the expression of understanding the patient’s perspective with recognition of the patient’s situation and a feeling of identification with the patient’s suffering”.24 One definition of ‘therapist empathy’ is split into other components, including ‘sharing empathy’: ‘sequences where the therapist displays that he/she has something in common with the patient’ and ‘nuturant empathy’: ‘characterised by the therapist being supportive, security providing or totally attentive’ as well as cognitive and affective components.34

No studies explicitly defined communication. However, one study described that both ‘health communication and the doctor–patient relationship’ are ‘the means by which the physician can convey the intended information to the patient’.33 While it appears that the provider–patient relationship is fundamental to communication, the authors do not elaborate on what this means.

Despite the lack of a formal and consistent definition of ‘empathetic communication’, there were a number of studies that measured ‘empathetic communication’ in some way. Of the 26 studies, 21 (81%) measured empathetic communication from another person’s perspective.23–30 33–35 39–48 Twelve studies (57%) used the Consultation and Relational Empathy (CARE) Measure,23 25–27 29 30 35 42 43 45–47 a 10-question patient-completed questionnaire used to evaluate provider empathy in a consultation.55 Five studies (24%) recorded provider empathy qualitatively.24 34 40 44 48 Three studies (14%) used the Jefferson Scale of Patient’s Perceptions of Physician Empathy (JSPPPE),28 33 45 a five-question patient-completed questionnaire like CARE used to evaluate provider empathy.56 One study used both JSPPPE and CARE,45 and one study used both CARE and Warmometer,47 a tool used to measure the perceived warmth (considered to be equivalent to empathy by the study) of the patient–provider relationship from the patient’s perspective. One study used the Active Empathetic Listening Scale,41 an 11-item tool evaluating three subscales of someone else’s listening—sensing, processing and responding. One study’s research team designed a Global Rating Scale for assessing empathetic communication,39 which was based on four strategies of an empathy model by Pehrson et al.4: that included recognising or eliciting a patient’s empathetic opportunity, working towards a shared understanding of the patient’s emotion/experience, empathetically responding to the emotion/experience and facilitating coping and connecting to social support.

The CARE measure was created based on numerous concepts of empathy, including the definition of empathy by Mercer and Reynolds,53 55 which was the most frequently cited definition found in this scoping review. The JSPPPE was developed based on various literature sources; however, these sources were not specified by the original authors.56 The Warmometer was developed based on theoretical assumptions about warmth between humans, though the original paper notes that it found that ‘physician warmth’ is a broader and more genuine concept than physician empathy as it combines multiple personality attributes.57 This seemingly contradicts the study included in this scoping review that translates and validates the JSPPPE for use in Brazil,47 which appears to define empathy as ‘perceived warmth’, the ability of someone, either the healthcare provider or patient, to share and understand the emotions of others.