CLINICAL COMMUNICATION

Empathy in the nurse patient relationship

Lesley Raillie RGN, BA(Hons), ONC, RNT, Is a Nurse Teacher, Buckinghamshire College of Nursing and Midwifery.

This article has been subject to

double-blind review.

KEYWORDS

► NURSE-PATIENT RELATIONSHIP

> COMMUNICATIONThee key words correspond with entries in the RCN Nursing Bibliography.

The autloor explores the me of empathy in nursing, and seeks answers to questions such as whether empathy is a natural or learned quality, and whether we should seek to nurture it in nursing students.

According to Muetzel, the crucial determinant of whether nursing is therapeutic is ‘the quality of the relationship between nurse and patient' (1). Reynolds (2) states it is widely held that empathy is the most important facilitator of such a thera­peutic relationship. This article examines the nature of empathy and its place in nursing, illus­trated by a case study (Box 1).Formation of the nurse-patient relationship Peplau (3) describes nursing as an interpersonal process in which a human relationship develops between an individual in need of help and a nurse who is able to identify and respond to this need. She recognises that nurse and patient are strangers when first meeting, and that the relationship begins in the initial orientation phase.

In the case study, the orientation phase was rapid and had to be developed through the nurse's verbal and non-verbal responses. Peplau emphasises the importance of accepting the ‘stranger’ as he is, and trying to say whatever it is the patient wants to hear. The initial friendly greeting to Paul was imjxtrtant in initiating the nurse-patient relationship (4).The importance of empathy in nursing Many authors believe that empathy is an essential fea­ture in the nurse-patient relationship (5-7) and is of fundamental importance to nursing (8, 9). Morse (10) describes how, on first meeting the nurse, the patient is looking for signs of kind­ness and empathy; the presence or absence of these will determine whether a relationship is formed or not.

Showing understanding is also considered to be an important feature of caring (11-13) and, according to Brykczynska (14), empathic approaches in nursing care are the key to better caring. Kalisch (5) states that the nurse's willing­ness and desire to understand how the patient feels will imply that the patients view is of value.

Erasers study (4) supports these views, sug­gesting that patients appreciate nurses’ sensitivity to their situation. Sherwood (15) also found that patients valued nurses’ expressions of empathy, which they felt showed understanding of their experience. The case study illustrates how the expression of empathy led to the defusion of Paul’s anger and the formation of a bond between him and the nurse.

Definitions of empathy Gagan (16) states that the most commonly used definition of empathy in nursing literature is: 'the ability to perceive the meanings and feelings of another [terson, and to communicate that feeling to the other.' Earlier, Kalisch (5) defined empathy as ‘the ability to enter into the life of another person, to accurately perceive his current feelings and their meaning’. This ‘entering into the life of another’ also seems important to Rogers (17), who describes empa­thy as ‘a way of being with another person, entering into their world, communicating those sensings’. The concept of‘being with’ another [terson is emphasised by Tschudin (18), who sees this not only as a key aspect ofempathy, but also as explaining why empathy is more than a skill.

Two levels of empathyThe importance of the understanding conveyed being accurate, as referred to by Kalisch (5), is also discussed in the counselling literature by- Egan (19), who identifies two levels of empathy. Primary level accurate empathy occurs when the helper communicates the initial basic under­standing of what the client is feeling. Advanced accurate empathy applies not only to what is being clearly stated by the client, but also what is being implied. In the case study, Paul did not actually state that he was tired, yet the nurse understood it, and communicated this to him.Natural trait or learned skill? Reynolds (2) found that some teachers saw empathy as a form of interaction which could be taught, while others saw it as an inherent trait or perceptive quality which could not be taught or measured. These differing views seem supported by Alligtxxl (7) who differentiates between what he terms basic empathy, which is a natural and involuntary uni­versal human characteristic, and empathy which is deliberate, taught or professionally trained.

The notion that empathy can be taught is cer­tainly accepted by some writers: for example, Clay (20) discusses the development of nurses’ empathic interaction skills. That empathy is a skill seems assumed by Authier (21), who stresses the behavioural components of empathy in contrast with Daniel’s view that empathy is intuitive in nature (22).

These two perceptions of empathy have also been identified by Zderad (23), but she believes they can coexist and be linked. She terms basic- empathy as a ‘natural empathic capacity’, and claims this can be used as the basis to develop a

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CLINICAL COMMUNICATION

Box 1. Case study.

It was eight o’clock one weekday morning, when a man (whom I will call Paul), aged approximately 30 years, arrived in the accident and emergency department. He was carrying a baby, about two months old, and he looked hurried, anxious and stressed.

Noticing that the baby looked alert and well, the nurse greeted Paul in a friendly manner, asking if she could help. He spoke rapidly and loudly with some anger, saying that he had been ‘up all night' with his baby who was ‘constipated and crying’. This morning he had phoned his GP who had responded that this was not an urgent problem, and that he could take his baby to the surgery at nine o’clock. Paul was furious - why should he wait until then, he asked. His baby had been crying all night. He had two other young children at home too, whom his wife had stayed with.

The nurse listened to him attentively and felt for this father who was so tired and anxious. She remembered being up at night herself with crying babies, and the anxiety, tiredness and loneliness which accompanied this. She responded, instinctively, ‘You must be really tired'. He immediately seemed to relax at this statement and said more quietly, ‘Yes, I am actually’.

During the nurse’s assessment which followed, the interaction between Paul and the nurse was warm and friendly. When Paul and his baby left the department an hour later, he thanked the nurse ‘for everything’ and left looking calm, rested and entirely different to when he had arrived in the department a short time previously.

‘clinical empathic prcxess’ which can clearly be identified as a skill. Burnard (6) also appears to express this view in suggesting that training can enhance nurses’ natural empathic qualities.

Forsyth’s study (8) suggests that nurses can express empathy without actually feeling it. Morse et al (24) fear that when therapeutic- empathy is discussed in the nursing literature, the behavioural skills aspect hits been emphasised and the role of emotional empathy diminished. Empathy and its appropriateness in nursing As a communication strategy in nursing, empathy appears to have arisen from the counselling pro­fession. Morse et al (24) question the appropriate­ness of‘borrowing’ the empathy model without question in the nurse-patient relationship, par­ticularly in view of the demands of clinical prac­tice. This view is also referred to by Tschudin (18), who states that in many helping situations, particularly where the person is numbed or shocked, it is nurturing, not counselling, that is needed - sympathy, not empathy.

The notion that sympathy could be helpful seems to contrast with the views of Burnard (6) and Kalisch (5). Burnard believes that sympathy involves ‘feeling sorry' for’ or trying to imagine how we would feel in the patient’s situation, rather than trying to lay aside our own percep­tions and attempting to understand how the other person is thinking or feeling. Empathy, Burnard states, is the basis for tmly understand­ing another jrerson, and must be differentiated from sympathy, which he considers to be rarely valuable. Kalisch seems to share this view. Empathy, he believes, allows a more accurate per­ception of the patient's feelings.

Alligood (7) thinks there are difficulties in drawing parallels between the nurse-patient relationship and the psychotherapist-patient relationship. Gould (9) suggests these two ty[ies of relationship may have very' different intended outcomes, and Egan (19) states that the goal of counselling is to help clients to handle difficult and problem situations, not to establish close relationships. The value of a close relationship between patient and nurse is becoming increas­ingly accepted, however, particularly through developments such as primary- nursing. Benner and Wrubel (25), while stating that ‘over- involvement’ may be detrimental, claim detach­ment is only possible if the nurse does not care. If a characteristic of empathy is a lack of involve­ment, then its applicability in nursing should perhaps lie challenged.

The importance of being able to understand, and to demonstrate this to the patient, however, seems well accepted (9). Benner and Wrubel (25) claim it is easy to overkxik the human impor­tance of understanding, which can lx- therapeutic and healing, as the understanding shown to Paul appeared to be. Taylor (26), while analysing a comforting encounter between a patient and nurse, found that the nurse’s understanding of

the patient was an important aspect of the comfort given.

Morse et al (24) believe there is a place for ‘emotional empathy’, the intuitive sensing and response of the nurse to the patient's distress. If such responses are not valued in nursing, natural empathic qualities may be suppressed rather than enhanced during the process of becoming a nurse. Morse et al describe such responses as 'first level’ and state that these occur when the nurse becomes ‘engaged’ with the patient’s experience of suffering. This leads to an ‘empathic insight’, which in turn triggers a spontaneous expression of verbal comfort. This may take the form of sympathy, pity, compassion, commiseration, consolation or reassurance (24).

Automatic responsesThe nurse’s response to Paul in the case study seemed instinctive rather than planned. Morse et al state that such responses may be almost auto­matic and are naturally comforting to the sufferer (24). The sense of relief which Paul seemed to feel may have occurred because he felt comfort­ed by the response and knew he was understtxxl.

The authors also refer to ‘therapeutic empathy’, a learned communication skill consisting of cog­nitive and behavioural components, as consti­tuting ‘second level’ learned responses. They believe therapeutic empathy de-emphasises emo­tional involvement, but argue that it is the emo­tional engagement with the patient, leading to first level responses, which is the essence of the nurse-patient relationship.Prerequisites for empathy The nurse in the case study resjionded as one parent to another, and first level responses are more likely when the nurse is able to identify with the sufferer (24). It is suggested by Gould (9) that nurses are best able to empathise with people on the basis of shared experience. She therefore questions whether nurses can be expected to express empathy in all situations.

Brykczynska (14), while feeling that com­passion towards a stranger is a prerequisite for true caring, questions whether it is really possible to know what an experience is like for another person. She further indicates that to empathise with a patient should not depend on our own personal experiences but rather on our own level of sensitivity and common human understand­ing of life and life events. Nurses will constantly encounter patients experiencing life events of which they have no personal knowledge, one obvious example being dying. In such situations it is vital that nurses can harness their natural empathic qualities as the importance of showing understanding to patients seems indisputable. Nevertheless, Carper (27) identifies personal knowledge, such as being a parenc, as a source of knowledge used in nursing.Implications for nurse education If a natural

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References1. Muetzel PA. Therapeutic nursing. In Pearson A (Ed). Primary Nursing: Nursing in the Burford and Oxford Nursing Development Units. London, Chapman and Hall. 1988.2. Reynolds W. Empathy: we know what we mean but what do we teach? Nurse Education Today. 1987. 7, 6, 265-269.3. Peplau HE. Interpersonal Relations in Nursing. Basingstoke, Macmillan Education Ltd. 1988.4. Ersscr S. A search for the therapeutic dimensions of nurse- patient interaction. In McMahon R, Pearson A (Eds). Nursing as Therapy. London, Chapman and Hall. 1991 -5. Kalisch BJ. What is empathy? American Journal of Nursing. 1973. 73, 9, 1548-1552.6. Burnard P. Empathy: the key to understanding. Professional Nurse. 1988. 3, 10, 388-391.7. Alligood MR. Empathy: the importance of recognizing two types.

Journal of Psychosocial Nursing. 1991. 30, 3,14-17.8. Forsyth GL. Exploration of

CLINICAL COMMUNICATION

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ability to empathise is important in nursing, then there are surely implications for selection. Is it possible to recognise natural empathic qual­ities, and if so, should not educationalists be looking for this when selecting student nurses?

Both Reynolds (2) and Burnard (6) discuss how empathy can be enhanced during nurse education, but neither address how natural empathic ability can be recognised, despite acknowledging its importance. A number of scales have been developed to measure empathy, but most have been designed by and for non­nursing disciplines; Alligood (7) therefore ques­tions whether such instalments should be used to measure empathy in nursing.

Research cited by Buckingham and Mayock (28) identified empathy as one of 11 themes and subthemes of attributes which characterised indi­viduals with ability to become nurses. A semi- structured selection interview schedule was developed based on these findings. The validity

of this will be measured over a number of years, so whether empathy can be identified in this manner has yet to be demonstrated.

An alternative approach for assessing natural empathic qualities could be through discussion of, for example, case studies or video snapshots. Such methods', however, may be interpreted more subjectively than an interview schedule.

Clay (20) believes chat when an ability to empathise is present in student nurses, it is not always seen as a resource to be actively developed, and may be allowed to diminish. Nurse educa­tionalists need to consider not only how they can recruit students with a natural ability to empathise, but how this quality can then be nur­tured. This requires them to value empathy as an attribute, rather than encouraging the detached so-called ‘professional' manner which Gould (9), among others, believes may act as a barrier to empathy.Conclusion The importance of empathy in the nurse-patient relationship, an example of which is illustrated in the case study, seems widely sup­ported in the nursing literature. While behav­ioural aspects of empathy can be learned and may be effective, it seems important to recognise and value nurses’ natural empathic qualities. Perhaps the ability to empathise should be specifically looked for during nurse selection, and subse­quently reinforced and encouraged.

Peplau (3) terms the last phase in the nurse- patient relationship as resolution, in which ‘the patient feels refreshed that in his time of troubles and helplessness, aid was forthcoming’. While empathy as a learned skill has a place in nursing, the case study demonstrates that there is also a place for instinctive emotional empathy; it was this which was therapeutic as it led Paul to feel understtxxl and cared for 9

empathy in nurse-client interaction. Advances in Nursing Science. 1979. 1,2, 53-61.9. Gould D. Empathy: a review of the literature with suggestions for an alternative research strategy .Journal of Advanced Nursing. 1990. 15, 11, 1167-1174.10. Morse J. Negotiating commitment and involvement in the nurse-patient relationship. Joz/nw/ of Advanced Nursing. 1991. 16,4,455-468.11. Lciningcr MM. Care: The Essence of Nursing and Health. Detroit MI, Wayne State University Press. 1988.12. Appleton C. The meaning of human care and the experience of caring in a university school of nursing. In Leininger MM, Watson J (Eds). The Caring Imperative in Education. New York NY, National League for Nursing. 1990.13. Roach MS. The call to consciousness: compassion in today's health world. In Gaut DA, Leininger MM (Eds). Caring: The Compassionate Healer. New York NY, National League for Nursing. 1991.14. Brykczynska G. Caring - a dying

art? In Jolley M, Brykczynska G (Eds). Nursing Care: The Challenge to Change. London, Edward Arnold. 1992.15. Sherwood G. Expressions of nurses' caring: the role of the compassionate healer. In Gaut DA, Leininger MM (Eds). Caring: The Compassionate Header. New York NY, National League for Nursing. 1991.16. Gagan JM. Methodological notes on empathy. Advances in Nursing Science. 1983. 5, 2, 65-72.17. Rogers C. A Way of Being. Boston MA, Houghton Muffin. 1980.18. Tschudin V. Counselling Skills for Nurses. Third edition. London, Bailliere Tindall. 1991.19. Egan G. The Skilled Helper.Second edition. California, Brooks/Colcs Publishing Company. 1982.

20. Clay M. Development of an empathic interaction skills schedule in a nursing context. Journal of Advanced Nursing. 1984. 9, 343-350.21. Authic-r J. Showing warmth and empathy. In Hargie O (Ed). A Handbook of Communication Skills. London, Routledge. 1986.

22. Daniel J. 'Sympathy' or ‘empathy’? Journal of Medical Ethics. 1984. 10,2, 105.23. Zderad L. Empathic nursing: realisation of a human capacity. Nursing Clinics of North America. 1969.4,4,655-662.24. Morse J et al. Beyond empathy: expanding expressions of caring. Journal of Advanced Nursing. 1992. 17,7,809-821.25. Benner P, Wrubel J. The Primacy of Caring: Stress and Coping in Health and Illness. Boston MA. Addison- Wesley. 1989.26. Taylor BJ. Relieving pain through ordinariness in nursing: a phenomenological account of a comforting nurse-patient encounter. Advances in Nursing Science. 1992. 15,1,33-43.27. Carper BA. Fundamental patterns of knowing in nursing. Advances in Nursing Science. 1978. 1, 1, 13-23.28. Buckingham GL, Mayock A. An objective selection system to identify the qualities for a career in nursing. Nurse Education Today. 1994. 14,3, 159-254.

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