Gnanodaya College of Nursing, Sosale, T. Narasipura, Mysore, India
Forgetfulness in the elderly is often dismissed as a normal aspect of ageing, yet it can signal the onset of Alzheimer’s disease (AD). This progressive neurodegenerative disorder profoundly impacts patients and their caregivers. This pre-test–post-test study investigated the effects of a 10-day role-play intervention on empathy levels and quality of care among 10 female primary caregivers of home-dwelling AD patients in India. Empathy was assessed using Murthy’s Empathy Scale, while the quality of care was evaluated via a researcher-developed checklist that measured the presence and extent of physical and psychological care domains. Data were analysed using Wilcoxon signed-rank tests due to the small sample size. Results indicated significant enhancements in empathy scores from pre-test (mean = 70.10) to immediate post-test (mean = 81.40; Z = 2.807, p = 0.005) and one-month follow-up (mean = 92.30; Z = 2.807, p = 0.005), with further gains between immediate and follow-up assessments (Z = 2.805, p = 0.005). Psychological care (both presence and extent) improved significantly (p = 0.049 and p = 0.024, respectively), whereas physical care components and total quality of care scores did not reach statistical significance. These findings suggest that short-term role-play effectively boosts empathy and psychological caregiving but may require supplementation for physical care enhancements. Implications for caregiver training programs in resource-limited settings are discussed.
Dementia, encompassing Alzheimer’s disease (AD) as its most prevalent form, represents a significant global health challenge, particularly in ageing populations. According to the World Health Organisation, dementia affects over 55 million people worldwide, with projections estimating a tripling of cases by 2050, disproportionately burdening low- and middle-income countries like India [1]. Forgetfulness in the elderly is frequently attributed to normal ageing variations, but its true magnitude often emerges only in advanced stages, when family members and friends observe profound personality changes and disruptions in daily functioning [2]. Routine activities such as shopping, financial transactions, or household management become insurmountable, shifting responsibilities onto spouses or younger family members. Dementia is clinically defined as a syndrome characterised by cognitive decline in higher mental functions that substantially interferes with daily life activities [3]. AD, accounting for 60-70% of dementia cases, is a neurodegenerative disorder with insidious onset and progressive deterioration, leading to loss of autonomy and diminished quality of life [4,5]. Unlike typical ageing, AD is a pathological condition, classified alongside Parkinson’s and Huntington’s diseases in the International Classification of Diseases (ICD-10) as a central nervous system degenerative disorder [1]. Patients progressively experience confusion, disorientation, and physical decline, culminating in total dependence on caregivers in terminal stages. Caregiving for AD patients is predominantly shouldered by family members, with women comprising 70% of caregivers, often wives, daughters, or daughters-in-law [6]. These "hidden patients" face immense burdens, including eroded physical health, heightened morbidity and mortality risks, and profound psychological strain [7-10]. Up to 50% of dementia caregivers develop psychiatric symptoms, underscoring the need for targeted interventions to mitigate these effects [11]. Caregiving burdens manifest in physical (e.g., fatigue from assistance with activities of daily living) and psychological (e.g., emotional exhaustion from behavioural challenges) domains, necessitating multifaceted support strategies [12,13]. Interventions aimed at alleviating caregiver burden often target empathy, defined as the capacity to resonate with others' emotional states, encompassing affective [emotional sharing], cognitive [perspective-taking], and somatic [physical mirroring] components [14,15]. Originating from the Greek "empatheia" [in + feeling], empathy was formalised in German as "Einfühlung" [feeling into] and introduced to English by Edward Titchener [16]. In positive psychology, it involves imaginatively experiencing another's perspective, fostering prosocial behaviours like sympathy and concern for suffering [17,18]. Empathetic responses to distress can yield positive outcomes (e.g., increased helping behaviours) or negative ones (e.g., burnout), with cognitive and affective empathy playing distinct roles in caregiving [19,20]. Studies link higher empathy to reduced caregiver depression, enhanced life satisfaction, and better patient outcomes, influenced by factors like relational closeness and contact frequency [19,21-25]. In AD caregiving, empathy enables recognition of patient distress, emotional connection, and motivation to alleviate suffering, though it wanes under chronic stress [26]. Enhancing empathy requires interventions like role play, a technique involving behavioural enactment of social roles to practice responses [27]. Defined as assuming non-familiar roles to fulfil social or therapeutic goals, role play originated in social psychology experiments [e.g., Lewin, Milgram] and serves as a deception-free method for studying interpersonal dynamics [28-31]. Types include structured/unstructured, individual/interactive, and drama-based variants, often integrated into therapies like Gestalt [32]. In clinical contexts, role play builds skills for complex interactions, with durations varying from hours to months [33]. Prior studies in AD caregiving, such as the REACH program, combined role play with education and support, yielding reduced burden and improved self-efficacy over 6 months [34,35]. However, isolated short-term effects remain underexplored, particularly among Indian female caregivers. This study addresses gaps by examining role play's isolated impact on empathy and care quality, informed by consistent intervention trends emphasizing behavioural change (36) with objectives: 1. To assess the effect of role play in enhancing empathy among female primary caregivers of AD patients. 2. To evaluate the effect of role play on the quality of care (physical and psychological domains).
METHODOLOGY
Study Design
This is a pre-test–post-test single-group study that employed a 40-day timeline to evaluate intervention effects.
Population and Sample
The target population consisted of 100 female primary caregivers (spouses, daughters, or daughters-in-law) of diagnosed AD patients (aged >65 years) residing in home settings in Karnataka, Kerala, and Tamil Nadu states of India. Patient diagnoses were verified via medical records. Using the lottery method of random sampling, 10 caregivers were selected for the intervention group, ensuring representation of moderate-to-severe AD stages. Inclusion criteria: female caregivers aged 30-60 years, primary responsibility for >6 months, no prior empathy training. Exclusion: caregivers with psychiatric disorders. Ethical approval was obtained from the institutional review board. Informed consent was obtained, emphasising voluntary participation and confidentiality.
Tools and Techniques
Intervention
A structured 10-day role-play program was delivered individually at participants' homes (30-45 minutes/day). Scenarios simulated AD challenges (e.g., agitation during meals, sundowning). Caregivers alternated roles (patient/caregiver) with researcher facilitation, incorporating debriefing for reflection. Sessions built progressively: Days 1-3 (basic empathy building), Days 4-7 (psychological scenarios), Days 8-10 (integrated physical-psychological). Materials: Scenario cards, props (e.g., mock medications). Fidelity ensured via session logs.
Data Collection and Procedure
- Day 1: Pre-test (empathy scale + care observation over 2 hours).
- Days 2-10: Daily interventions + Day 10 immediate post-test (empathy).
- Day 40: Follow-up post-test (empathy + care observation). Observations were conducted unobtrusively during routine caregiving.
Ethical Considerations
Confidentiality was maintained; participants could withdraw anytime. No incentives provided.
Data Analysis
Descriptive statistics (means, SDs) summarised scores. Inferential analysis used non-parametric Wilcoxon signed-rank tests (α = 0.05) due to small n=10 and non-normal distribution (Shapiro-Wilk p<0.05). SPSS v.25 employed.
RESULTS
The data that was collected was scored, tabulated, and subjected to a non-parametric test, Wilcoxon’s Z value analyses, as the sample size was 10 female primary caregivers. Data from all 10 participants (mean age 48.2 ± 6.4 years; 60% wives, 40% daughters) were analysed. Baseline empathy mean = 70.10 ± 8.2; total care = 90.70 ± 12.5.
Table 1: Mean Empathy Scores of Female Primary Caregivers Pre-Test, Post-Test (Immediate) and Post-Test (Follow-Up) Sessions on Role Play Intervention and Results of Wilcoxon’s Signed Rank Tests.
|
Sl. No |
Pairs of Empathy |
Mean |
SD |
-ve mean ranks |
+ve mean ranks |
Wilcoxon’s Z Value |
P value |
|
1 |
Pre-test |
70.10 |
10.76 |
0 |
5.50 |
2.807 |
0.005 (S) |
|
Post- test Immediate |
81.40 |
6.45 |
|||||
|
2 |
Pretest |
70.10 |
10.76 |
0 |
5.50 |
2.807 |
0.005 (S) |
|
Post-test Follow-up |
92.30 |
6.34 |
|||||
|
3 |
Post- test Immediate |
81.40 |
6.45 |
0 |
5.50 |
2.805 |
0.005 (S) |
|
Post- test Follow up |
92.30 |
6.34 |
Table 1 illustrates a progressive and statistically significant enhancement in empathy scores across the three assessment points. All pairwise comparisons were significant at the 0.005 level. The absence of negative ranks and the presence of uniform positive ranks (mean positive rank = 5.50) indicate that empathy scores increased for all participants, demonstrating a consistent effect of the role-play intervention across the sample. The Z-values, all exceeding 2.8, further confirm the robustness of these findings. Empathy scores increased from a pre-test mean of 70.10 to 81.40 at the immediate post-test assessment. Wilcoxon’s signed-rank test revealed this increase to be statistically significant (Z = 2.807, p = 0.005), indicating a meaningful improvement in empathy following the 10-day role-play intervention. This represents an immediate enhancement in caregivers’ empathic responsiveness. At one-month follow-up, empathy scores showed a further increase, reaching a mean of 92.30. The comparison between pre-test and follow-up scores remained statistically significant (Z = 2.807, p = 0.005), suggesting sustained improvement over time. Additionally, empathy scores continued to rise significantly between the immediate post-test and follow-up assessments (Z = 2.805, p = 0.005), indicating ongoing consolidation of empathic abilities even after the intervention period had ended.
Figure 1: Empathy Scores of Female Primary Caregivers’ Pre-Test, Post-Test (Immediate) and Post-Test (Follow-Up) Sessions on Role Play Intervention.
Figure 1 depicts the upward trajectory of empathy scores across the three assessment points, visually reinforcing the statistical findings presented in Table 1. Empathy scores show a steady linear increase from pre-test to one-month follow-up, progressing from moderate baseline levels (mean = 70.10) to higher levels of empathy (mean = 92.30). This pattern suggests not only statistical significance but also clinical relevance, as caregivers moved toward more optimal empathic responsiveness. The continued rise between the immediate post-test and follow-up indicates cumulative effects of the intervention, likely reflecting reinforcement through real-life caregiving experiences. Notably, the absence of plateaus or declines supports the sustainability of the observed gains. Overall, the results demonstrate a significant improvement in total empathy scores among female primary caregivers following the role-play intervention. Significant differences were observed between pre-test and immediate post-test scores, pre-test and follow-up scores, and immediate post-test and follow-up scores, indicating both immediate and sustained effects of the intervention. These findings confirm that the 10-day role-play programme was effective in enhancing empathy among female primary caregivers of Alzheimer’s patients. Accordingly, the first hypothesis was fully supported
Table 2: Mean Pre-Test, and Post-Test (Follow-Up) Scores on Quality of Care of the Female Primary Caregivers Undergone Role-Play Intervention and Results of Wilcoxon’s Z Test.
|
Pairs |
Quality of Care |
Mean |
Std. Deviation |
-ve mean rank |
+ve mean rank |
Wilcoxon’s Z |
P value |
|
1 |
Presence of Physical Care |
3 |
3 |
-1.225 |
0.221 (NS) |
||
|
Pre-test |
7.80 |
2.04 |
|||||
|
Post-test |
8.40 |
1.26 |
|||||
|
2 |
Presence of Psychological Care |
3 |
5.57 |
-1.969 |
0.049 (S) |
||
|
Pre- test |
6.00 |
2.31 |
|||||
|
Post- test |
8.10 |
1.52 |
|||||
|
3 |
Extent of Physical Care |
3.5 |
5.54 |
-1.836 |
0.066 (NS) |
||
|
Pre- test |
39.6 |
6.65 |
|||||
|
Post-test |
49.70 |
11.63 |
|||||
|
4 |
Extent of Psychological Care |
2.0 |
4.86 |
-2.254 |
0.024 (S) |
||
|
Pre-test |
37.30 |
8.25 |
|||||
|
Post-test |
50.80 |
12.06 |
|||||
|
5 |
Quality of Care (Total) |
3.50 |
5.43 |
-1.840 |
0.066 (NS) |
||
|
Pre-test |
90.70 |
14.38 |
|||||
|
Post-test (Follow Up) |
117.00 |
25.66 |
|||||
*Significant at p<0.05
Table 2 presents changes in quality-of-care subscales and total scores from pre-test to one-month follow-up, revealing a mixed pattern of outcomes. Significant improvements were observed in psychological care domains (p < 0.05), with higher positive ranks indicating consistent gains among most participants. In contrast, physical care components and total quality-of-care scores showed numerical improvement but did not reach statistical significance, reflecting variability in caregiver responses. These findings suggest that psychological aspects of care were more responsive to the role-play intervention than physical care domains. The mean pre-test presence of physical care score increased modestly from 7.80 to 8.40 at follow-up; however, this change was not statistically significant (Z = 1.225, p = 0.221). Equal positive and negative ranks indicate that improvements were inconsistent across caregivers. Similarly, the extent of physical care increased from 39.60 to 49.70, but this change narrowly missed statistical significance (Z = −1.836, p = 0.066), suggesting variability in caregivers’ ability to translate the intervention into sustained physical caregiving practices. In contrast, psychological care showed significant improvement following the intervention. Presence of psychological care increased from a mean of 6.00 at baseline to 8.10 at follow-up (Z = 1.969, p = 0.049), indicating enhanced emotional support and engagement. Likewise, the extent of psychological care increased significantly from 37.30 to 50.80 (Z = −2.254, p = 0.024), reflecting deeper and more consistent psychological involvement in caregiving. Total quality-of-care scores increased from 90.70 at pre-test to 117.00 at follow-up; however, this change did not reach statistical significance (Z = −1.840, p = 0.066). Although the overall increase was substantial, the lack of significance appears to be influenced by limited changes in physical care domains. Overall, the findings indicate that the 10-day role-play intervention was effective in improving psychological aspects of caregiving, both in terms of presence and extent, but was insufficient to produce statistically significant improvements in physical care. Accordingly, Hypothesis 2 was partially supported.
DISCUSSION
The present findings demonstrate that a concise 10-day role-play intervention produced consistent and sustained increases in empathy among female primary caregivers of Alzheimer’s patients. Empathy scores increased by 16.1% immediately after the intervention and by 31.7% at one-month follow-up, with all participants showing improvement and no negative ranks (Table 1). The additional significant gain observed between the immediate post-test and follow-up (13.4%, p = 0.005) suggests that experiential learning through role play continued to deepen real-world perspective-taking beyond the formal intervention period. This pattern supports the premise that role play promotes lasting cognitive–affective restructuring rather than transient emotional arousal [14,37]. These findings are consistent with larger multicomponent caregiver interventions incorporating role-play elements [35,38–40]. Notably, the magnitude and rapidity of empathy enhancement observed with only 10 consecutive individual sessions compare favourably with programmes extending over 6–12 months [35,38,41]. The individual, home-based, and culturally congruent nature of the intervention may have contributed to this efficiency, particularly in the Indian context, where women caregivers often prefer private, flexible formats due to stigma and family responsibilities [42]. Significant improvements were also observed in psychological aspects of care, with increases in both presence (+35%) and extent (+36.2%). These findings align with the core mechanism of role play, which allows caregivers to embody patients’ fear, confusion, and disorientation, fostering deeper emotional attunement and more responsive communication [15,43,44]. Similar outcomes have been reported in drama-based dementia education studies, where role reversal facilitated enhanced understanding of patients’ subjective experiences [45,46]. In contrast, physical care domains showed numerical improvement but did not achieve statistical significance. Presence and extent of physical care increased by 7.7% and 25.5%, respectively, while total quality of care improved by 29%, narrowly missing conventional significance thresholds. This domain-specific pattern is theoretically expected, as effective physical caregiving requires motor skill acquisition, environmental adaptation, and sustained physical effort, which may not be adequately addressed through short-term role play alone [47–49]. Comparable dissociations between emotional and instrumental caregiving outcomes have been reported in prior skill-building trials [50–52]. Evidence from landmark studies further contextualises these findings. The REACH II multicomponent intervention demonstrated reductions in caregiver burden and improvements in self-efficacy over six months [35,38], while environmental skill-building programmes similarly reported faster gains in emotional than physical outcomes [50,51]. Studies focusing on direct skill training with demonstration and reinforcement have been more successful in producing significant improvements in activities of daily living [53,54]. Conversely, some studies have reported null effects when role play was diluted within longer, group-based psychoeducational formats [55,56]. Variations in intervention intensity, delivery mode, cultural context, and duration likely account for these discrepancies. The present intensive, one-to-one, culturally tailored approach appears particularly effective for Indian female caregivers. Theoretically, the findings are congruent with dual-process models of empathy [14,37] and mirror-neuron frameworks [15], which posit that role play preferentially activates affective and cognitive resonance rather than motor replication of physical tasks. From a practical perspective, these results underscore the potential of role play as a low-cost, scalable intervention that can be implemented by trained nurses or community workers in resource-limited settings.
LIMITATIONS:
Small sample size (n = 10) and absence of a control group limit causal attribution and generalisability. The borderline p-values for physical care and total quality of care (0.066) probably reflect insufficient power rather than the absence of effect. Observer-rated care measures, although reliable, carry potential subjectivity. A longer follow-up would clarify durability beyond one month.
Future research:
RCTs with larger, diverse samples; hybrid interventions blending role play with physical training; longer follow-up to assess longevity; cost-effectiveness analyses. Exploring mediators like caregiver-patient relationship quality could refine applications.
CONCLUSION
A 10-day individual role-play intervention dramatically and sustainably enhances empathy and the psychological dimension of caregiving among female primary caregivers of Alzheimer’s patients. While physical care domains require supplementary training, role play offers a highly effective, scalable, and culturally acceptable foundation for caregiver support programmes in resource-limited contexts.
ACKNOWLEDGMENTS
We thank the participating caregivers and patients for their invaluable contributions.
REFERENCE
Vijayalakshmi K.*, Effectiveness of Role Play on Empathy and Quality of Care Among Female Primary Caregivers of Alzheimer’s Patients During Caregiving, Int. J. Sci. R. Tech., 2026, 3 (2), 18-26. https://doi.org/10.5281/zenodo.18472131
10.5281/zenodo.18472131
