The call to action from Taylor et al [1] underscores the need for nurse educators to practice empathy-based teaching methods that foster students’ empathic stance during these unprecedented pandemic times. Without a specific direction in their basic education, students struggle to respond well [2,3]. Thus, to remain resilient in today’s care environment, students and new graduates need to be equipped with self-awareness and emotional self-regulation (the ability to tolerate difficult emotions when confronted with someone else's distress without becoming overwhelmed by those emotions). These skills are salient to the empathic stance [1]. Unfortunately, students, new graduates, and experienced clinicians tend to be prescriptive instead of being empathetic with patient decision-making [4]. Being prescriptive instead of empathetic causes patients to feel unsupported and nonautonomous in the process. Therefore, students require innovative empathy-related strategies to learn self-awareness and emotion regulation not only for practicing empathy but also for self-care to prevent burnout in taxing health care environments [1].

Students often ask, “Can empathy be taught?” Fortunately, reviews indicate that yes, empathy is a skill that is responsive to educational interventions [5,6]. The positive impact of empathy interventions on health care providers was demonstrated by 3 meta-analyses of randomized controlled trials [7-9]. Traditional empathy training in nursing education consists of lectures, workshops, and courses [10]. It can include patient narratives and interviews, creative arts, writing and communication skill training [11], and interviews with a simulated patient followed by clinician or simulated patient feedback [12]. However, these methods are restricted in terms of the number of people who can participate at a time and can be costly. With advancements and extensive adoption of web applications and mobile devices (eg, smartphones, laptops, and tablets), web-based educational methods are supplemental avenues to explore.

Before the pandemic, the Canadian Digital Learning and Research Association found growth in web-based learning across universities and colleges [13]. Web-based learning platforms have several benefits for students and institutions, such as cost-effectiveness, flexibility, accessibility, engaging, and self-paced characteristics [14]. Since the COVID-19 pandemic, web-based learning has become more centric, allowing the leveraging of students’ motivation toward and confidence in using technology to practice empathy. Web-based course interventions have a sustained positive influence on empathy; for example, over 2 months of intervention in psychology students had a medium effect size improvement of Hedges g=0.66 [15] and over 10 weeks of internship in physical therapy students had a large effect size improvement of Cohen d=1.14 [16]. Mobile devices have also been used to provide instructor feedback in nursing skill training. For example, a Chinese smartphone study examined the use of WeChat (Tencent Holdings Ltd) and QQ (Tencent Holdings Ltd) by nursing students to receive instant instructor feedback on their recorded nursing skill performance. Student comments supported the incorporation of video feedback in mobile technology to improve nursing skills in an economical and accessible manner [17]. Thus, there is some evidence of the benefits and acceptance of using mobile technology in higher education.

Interestingly, in this study, some web applications offered targeted exercises to foster the cognitive empathic process of perspective taking [18]. Perspective taking plays an essential role in the clinical understanding of patients [19]. Perspective taking is the imaginative ability to step inside someone else’s shoes to understand their thoughts and feelings, validate the understanding, and act on the understanding in a helpful manner [14]. The range and availability of web applications to cultivate perspective taking are growing in the areas of health, mood states, social connections, games, and social changes [20].

Many perspective-taking apps are geared toward children and youth (eg, Toca Pet Doctor [21] and Peek a Zoo [22]) and use stories and games. For adult users, a smaller number of web applications focus on promoting the real-life impact of perspective taking. For instance, the ecological momentary assessment intervention provides prompts and exercises for students to integrate empathy-related exercises into daily life. A web-based exercise cultivates accurate perceptual understanding through training in accurate emotion recognition [23]. A commercial product called In Their Shoes enables students to live and understand the life of a person with chronic disease through scenarios delivered by smartphone technology and an avatar [24]. Another example is HeartChat, a mobile app with a chat feature where physiological data are shared between participants to foster social interaction, connectivity, and awareness. The goal of sharing heart rates is to help people implicitly understand each other’s context (eg, location and physical activity) and emotional state and spark curiosity on special occasions [25]. A final example is the commercially available Empathy Set app, which enables participants to identify and track what they and others feel and need through the use of web-based situation-specific flashcards. It also allows them to brainstorm potential solutions and prepare “I” statements so that they can communicate positively [26]. Further advances can be made to existing empathy apps, for example, by providing video feedback on dialogue communication and one’s perspective-taking skills.

Mobile technology enables dialogue partners to record their communication approaches and immediately receive an automatically calculated perceptual understanding score (ie, an “empathic accuracy” score). An empathic accuracy score reflects one’s ability to accurately infer another person’s thoughts and feelings by comparing one’s inferences with another’s self-reports. Empathic accuracy is the outcome of engaging in a perspective-taking process. It has been argued to be a more ecologically valid measure of thought and feeling recognition that requires the real-time integration of visual, auditory, and linguistic information [27]. Empathic accuracy may be a more sensitive measure for the detection of changes in the skills underlying empathy, such as the recognition of thoughts and feelings, that constitute the more cognitive components of empathy. To incorporate the features of video capture and feedback, Lobchuk et al [28,29] created a novel web-based prototype of an empathy-related video feedback intervention called In Your Shoes (IYS) to improve perspective-taking skills and empathic accuracy outcomes.

IYS was adapted from the research paradigm of Ickes et al [30,31]. This paradigm provides a practical, reliable, and objective method for measuring one’s ability to accurately infer another person’s thoughts and feelings during a video-recorded interaction. Quasi- and full-scale intervention studies conducted in the laboratory of Lobchuk et al [28,29] provide evidence to support the work of Ickes et al [30,31] and this study: (1) moderate effect size (Cohen d=0.43) difference, where nursing students reported increased empathy in the posttest condition; (2) increased empathic accuracy; and (3) reduced judgment. However, this version of IYS requires attendance in a laboratory setting and a desktop and commercial video analysis software program. To promote accessibility, we transformed our existing in-laboratory desktop method into a unique interactive IYS web application for easy use on any computer or mobile device.

This work-in-progress paper focuses on the development and assessment of a theoretically based educational version of an interactive software application for undergraduate nursing students. The aim of the app is to help nursing students learn how to engage in perspective taking with their patients. Both the desktop and mobile application versions foster perspective taking by providing students the opportunities to practice self-awareness of personal values and emotions that can thwart empathy [28,29], receive instruction [32] and feedback [33], experience empathy [23], and engage in self-evaluation with video feedback [34]. University instructional designers conducted an accessibility check based on World Wide Web Consortium standards and offered pedagogical suggestions, which we addressed in the application. The IYS web application allows students to engage in video capture and annotation and to receive objective empathic accuracy scores to enhance their understanding of patients’ needs, preferences, and beliefs related to care.

Full details of the application development process have been reported elsewhere [35]. The IYS web application consists of the following features and tasks for students to learn and practice their perspective-taking skills in the order in which they have been presented in this section:

Our aim was to evaluate the usability of the IYS web application for teaching perspective taking in a self-directed and engaging manner to nursing students. This study entailed capturing student participants’ preferences and prioritization of features and functionality. The research question was as follows: “How do nursing students perceive and experience the IYS web-based empathy training portal application?”

We used a mixed methods design in this 3-phase formative usability study (Figure 7). Phase 1 entailed “live” remote monitoring and analysis of the participants’ video-recorded 1-hour “performance” of requested tasks on the participant’s own device and in the participant’s own environment. This was followed by an analysis of the participants’ feedback and then adjustments to the application.

Phase 2 immediately followed with different participants and involved a “live” remote monitoring and analysis of the participants’ 1-hour video-recorded interactions on the participants’ own device and in the participants’ own environment with the adjusted application [36]. After phase 2, based on the analysis of participant feedback, more adjustments were made to the application. For phases 1 and 2, the trained observers used metrics (described later in the Data Collection, Phases 1 and 2 section) developed by Tullis and Albert [36].

In phase 3 (“real-life application testing”), different participants independently used the application on their own devices for 1 week without being monitored in their own environment. This was followed by a 30-minute video-recorded, scripted interview that covered participants’ “satisfaction” [36] by focusing on participants’ experiences with, and expectations for, the IYS web application; language understandability; and visual-interactional appeal. Participants also completed a quantitative measure about their experiences with the application. The feedback we received from participants aided in the development of a minimum viable prototype of the IYS application for testing its commercial readiness and reliability for providing training on perspective taking.

Ethics approval (HS24965; R1-2021-082) and access approval were obtained from the College of Nursing before commencing any study protocols. Before commencing the study, participants were provided with a written study invitation and an informed consent form. Participants were informed that their participation was voluntary and that they could withdraw without prejudice up to 2 days after the exit interview. Participants received a university bookstore gift card worth CAD $50 (US $36.32) at the time of consent. Participants were told that they could keep the gift card even if they decided to withdraw. The consent form explained that the participants' identity would not be revealed under any circumstances. The video recording and closed captions of participants’ responses would not be seen or used by anyone other than the research assistants and lead author for the sole purpose of this project. Pseudonyms (eg, “participant”) were used when direct quotations from the usability test sessions and exit interviews were used to report usability project findings.

This 1-year study took place in mid-2021 at an undergraduate nursing program located in the University of Manitoba. The initial sample size target was 5 participants per phase (3 phases), amounting to a total of 15 participants. This target was based on sampling and recruitment guidelines for usability studies to maximize the expected level of problem discovery [37]. Owing to recruitment and scheduling challenges, the sample comprised 3 third-year undergraduate nursing students and 5 fourth-year students (N=8) who had access to a camera-equipped PC, an Apple desktop computer (Apple Inc), or a tablet device and any browser. Two second-year students and 1 third-year student consented to participate but were difficult to reach to schedule a user-testing session. Each phase comprised the following participants: phase 1 included a fourth-year woman, a third-year man, and a third-year woman (3/8, 38%); phase 2 included a third-year woman, a fourth-year man, and a fourth-year woman (3/8, 38%); and phase 3 included 2 fourth-year women (2/8, 25%). The faculty’s research office coordinator sent an initial email invitation to all undergraduate students (around 800), followed by 2 email reminders at 1-week intervals. Students emailed the research assistant to ask questions about the study. A suitable time was arranged for those who were willing to participate.

Undergraduate students in computer science and computer engineering were hired as research assistants. One of the research assistants was the lead remote moderator, who facilitated the testing sessions using the Microsoft Teams screen-and-audio sharing tool (Microsoft Corp). Two research assistants served as remote silent observers. They watched and recorded the participants’ behaviors during the tasks and made application refinements based on participants’ input. An expert in human-computer interaction trained the research assistants on conducting observations, record keeping in Excel (Microsoft Corp), prompting participants to think aloud while performing tasks, and conducting exit interviews. The remote moderator gave participants task scenarios to perform in realistic steps (eg, setting up an account) [38]. A pilot test was conducted by the remote moderator and remote observers with 2 nursing students. Planning ensured good lines of communication and coordination of “testing” protocols between the research personnel. A detailed description of the role expectations for, and experiences of, the remote moderator and remote observers is provided elsewhere [35].

Participants differed in each phase. Before engaging in testing protocols, participants completed the informed consent form and a demographic tool in the Qualtrics survey software (Qualtrics International Inc).

Descriptive statistics comprised sample characteristics, performance metrics, and the System Usability Scale scores. ML conducted content analysis and used constant comparison techniques to identify, code, categorize, classify, and label the primary patterns in the transcribed data [41]. On a weekly basis, the research assistants reviewed the transcribed feedback for discussion with ML and to prioritize application refinements before advancing to the next phase.

Of the 8 participants, 6 (75%) were women. Participants’ ages ranged from 20 to 35 years. Participants used a range of devices (laptop, smartphone, tablet, and desktop computer), but most (6/8, 75%) used a laptop daily. An Apple device with a Mac operating system was most often used daily (11/19; 58%). All participants reported conducting research, emailing, instant messaging, learning via the web, shopping, paying bills, banking, performing multimedia projects, and interacting with social media on their devices. The least common activities were gaming (3/8, 38%) and engaging with databases (3/8, 38%) and spreadsheets (4/8, 50%). Most participants reported uploading and downloading videos (5/8, 63%) and using a web application daily as part of their web-based education (6/8, 75%). During the testing sessions, all students (8/8, 100%) used Wi-Fi, and most (6/8, 75%) used their laptops, which were most often a MacBook (5/6, 83%; refer to Multimedia Appendix 2 for demographics).

Owing to this study’s small sample size, a caveat regarding the representativeness of the qualitative and quantitative results is warranted. A cursory analysis of gender differences revealed equal proportions of men and women in years 3 and 4 of their study programs. In comparison with the women, the men stated that they seldom or never uploaded or downloaded videos. In addition, one man said that he used a web application for web-based education daily, whereas the other man stated that he “seldom” did. All women stated that they used web applications for web-based education.

This study addresses the gap in technology development where health care educators need more innovative tools to supplement classroom methods to engage students in learning empathy. The IYS application was designed to expand accessibility, ease self-directed learning, and provide compelling exercises for self-reflection and perspective taking and feedback on the student’s inferencing ability. Student participants’ feedback was addressed in application refinements before advancing to the next study phase. Input gathered in this manner signals a solid integrative knowledge translation approach, as we examined student participants’ responses to refine the application for future uptake in educational curricula.

Health sciences education has always attracted students with varying characteristics (eg, age and gender) that impact their expectations, values, norms, and learning behaviors [43]. This study’s sample consisted of men and women aged 20 to 35 years from an undergraduate nursing program located at the University of Manitoba. All student participants used a laptop daily to research information, send emails and messages, and engage with web-based education applications. Rising application use among students suggests greater acceptance of technology-based learning in nursing education [44].

Participants’ technology prowess was evident in their expectations to navigate quickly, encounter interactive web pages, and readily access resources while using the application, especially during the video annotation exercise. Several participants wanted to use the application quickly, similar to an on-demand service. However, IYS is an educational application that requires users to take time to contemplate content and perform exercises. We need to better harness students’ attention spans with more appealing content and a compelling environment where they feel committed to engaging fully with the app. Extrinsic motivators (reward points, badges, and leader boards) can foster engagement in learning [45].

Furthermore, not all participants were skilled in uploading or downloading videos as part of using the application. This was most evident in the wide variation in the System Usability Scale scores provided by the 2 phase 3 users (ie, 65% and 90%) who had expressed varied comfort levels working with technology. Because one score was lower than 68 (indicating marginal usability), additional design adjustments are warranted. The think-aloud comments provided by the low-scoring user indicated their limited computer technology skills, particularly working with videos, which made them feel hesitant to use the application. Both phase 3 users recommended the provision of instructions on how to convert a video to MP4 format. Supplemental instructions need to be provided on basic technology skills that we cannot assume are held by all students (eg, how to convert a video to MP4 format and video compression). On the application’s landing page, we should include a section called “Skills Needed to Use the App” on skills such as creating, uploading, and converting videos. To accommodate all users (with varied technology skills) and their varied contexts of use, we need to provide them with clear options. First, we can provide a standardized MP4 video of a prerecorded dialogue in the application for easy understanding of how to perform a video analysis. Second, users who wish to perform a video analysis of their own dialogue can be instructed to video record a “live” conversation that is done on the web (in light of any in-person restrictions) or in person with any dialogue partner. All users should be able to easily access the application’s full functionality for a meaningful learning experience and use it in varied contexts.

Participants valued perspective taking to better understand their clients or colleagues and expressed interest in their empathic accuracy scores. This is not surprising because this empathic process is “the subject of lifelong and continuous education” of nurses [46]. Similar sentiments were reported in the IYS pilot study with students [28,29]. However, 13% (1/8) of participants said that they will have no use for the app once they are better skilled in comprehending others. Sherf and Morrison [47] described that self-efficacy can “stand in the way” of engaging in perspective taking or seeking feedback because of the threat to one’s ego or one’s image (appearing incompetent), low perceived value in feedback, faulty assumptions about one’s inferencing abilities, or perceived effort to step outside of one’s usual cognitive routine. Their evidence also shows that when individuals were nudged to engage in perspective taking, they saw value in receiving “diagnostic information” and made corrections to their inferences about clients. Unfortunately, participants in this study did not immerse themselves as perspective takers in a “live” recorded dialogue with a partner, perform video analysis, or receive feedback because of the COVID-19 protocols, which would have brought greater meaning to using the application [6]. The experiential aspects of the application need to challenge students in their self-reliant thinking and assumptions about their empathy skills and promote appreciation for others’ viewpoints. Furthermore, the provision of empirical information on the unreliability of self-reports on empathy skills [48] and the value in seeking corrective feedback [47] could ignite curiosity and motivation to test one’s empathy skills.

Participants held strong preferences for how they wanted to learn perspective taking (reading documents, viewing videos, or both). One of the participants liked learning using a combination of technology use and in-person interaction. Clearly, different preferences for how to learn and engage with content and technology require our ongoing attention [49], as guided by the adaptive e-learning process. The adaptive e-learning process provides users with a choice in how and when they access and learn content to enhance their satisfaction with the application [50]. Student insights help (1) make the application more user centered [51], (2) increase popular uptake by ensuring fit between student contexts and the application [52], (3) provide options for users to consume educational content in different ways [53], and (4) ensure easy and convenient access to the content [54]. Students’ input has been vital in refining the application’s structured learning activities, technology features, and functionality to create a compelling learning experience that arms them with essential clinical empathy and technology skills [55].

Owing to limited funding and scheduling challenges, we were unable to recruit a larger sample as planned. The small sample resulted in low statistical power to test for differences in performance metric indicators between phases 1 and 2 and to more rigorously analyze System Usability Scale responses in phase 3. Owing to the COVID-19 restrictions, participants did not gain a full appreciation for the application’s main use cases: (1) to learn and practice perspective taking in a “live” recorded in-person dialogue and (2) to subsequently perform video annotation and receive feedback on their performance. This requires follow-up research with a larger sample of student participants, as determined by a power analysis. We found recruiting through posters and mailing list advertisements to be less successful than recruiting in class and providing course credit [29]. Therefore, we recommend that future research explore these alternative methods. Despite these limitations, this study’s findings were helpful for application refinements.

Our study aimed to contribute to the field of web-based empathy education. Student participants’ feedback provided preliminary evidence that the theoretically based IYS application is a helpful tool that extends the empathy learning journey from the classroom to the web. However, the overall findings of this study should be considered with caution because of its small sample size. Further testing is required with a larger sample of students who will fully immerse themselves in the application’s main functionalities of providing users with the opportunity to analyze themselves in a “live” video-recorded dialogue and providing feedback on their perspective-taking performance. Before advancing to this step, we will refine the application’s educational materials, insert more instructional pop-up messages and interactive images on web pages, provide linkages to resources on how to convert and compress videos, and fix minor glitches based on student feedback. Improvements such as these make IYS and other similar applications a better educational experience.