Norma E Crews

Developing empathy for effective communication

Empathy is an encouraging word, but more than that, expressing empathy also includes visual, auditory, and tac- tile communication. Part of empathy is the ability to imagine what another person is thinking and fee1ing.l It has been called the primary quality for ef- fective communication.

Empathy is more than a positive re- gard or a sense of caring. It is not neces- sarily innate in those who choose a help- ing profession like nursing. It is not the same thing as emotional involvement or compassion. It is not acting “warm” or “cool” at the hospital. Rather, empathy

Norma E Crews, PhD, is an instructor and private counselor at DeKalb Community Col- lege, Clarkston, Ga. She received a bachelor of science degree in education from Central College, Edmond, Okla, and master of educa- tion and doctoral degrees in educational psychology and counseling from the University of Oklahoma, Norman.

This article is adapted from a speech given at the 26th AORN Congress in St Louis.

is usually defined as projecting oneself into another’s place to understand him fully. The German word Einfiilung gets at the meaning by suggesting “infeel- ing.”

This kind of insight is a creative act of both mind and body. It is an intellectual act because i t requires appraisal of another person’s behavior-first, as he sees it and, secondly, as a reenactment of how you see it. Empathy is forming a thought and then an action with the benefit of both points of view.

Empathy in operating room nursing demands not only an understanding of the human situations encountered but a philosophical detachment as well. De- veloping both the detachment neces- sary for order and efficiency and the ability to relate to individuals in the operating room is a dual order. It is not a gift; it must be learned. In the same way a ballerina first masters seven basic steps and then turns them into a beauti- ful, creative concept, so empathy is a skill first and an art later.

An overreaction to empathy is de- scribed when the nursing student so identified with her geriatric patients that her own gray hairs flourished and wrinkles became obvious while her memory deteriorated and joints stiff- ened. On the surgical ward, she was sure of marked tenderness over the epigastric region after gal 1 bladder surgery. Later, she paled after adminis- tering a blood transfusion and was

dt 536 AORN Journal, September 1979, Vo l30 , No 3

checked for anemia. She described these maladies as bouts of “empathy.” To be sure, her ailments met the first half of our premise but failed on the last half. She had the “infeeling,” but she did not go back to herself before reacting. Em- pathy, then, is an insight that takes in the whole situation from both view- points.2

The empathizer feels his way into the other’s frame of reference. He is able to see the world of the patient staring up from the surgical table. Yet, the em- pathizer must also retain his own perspective.

Empathy is more than a tool of com- munication that makes the patient more comfortable. I t is actually a per- son-to-person relationship, although a very temporary one. In the operating room, this relationship transcends that of nurse to patient. Although partially or deeply anesthetized, the patient has sensory knowledge. An example is Fran, a psychologist who underwent open heart surgery. When she was in the deepest level of anesthesia, she re- called later, one surgeon had said to the other, “I hope we don’t lose her now.” Patients are aware of much more than they appear to be. Recognizing this, the nurse, by expressing empathy, has a unique opportunity to feel his or her work is meaningful and is more than scrubbing, attending, and going home.

Ashkinaze reports that patients want to know “why” most of all.3 They often don’t ask questions because the climate doesn’t seem conducive in the hall, but later they are disgruntled about not having asked. While nurses are preoc- cupied with other duties, the patient’s fears are not assuaged. The patient’s in- ability to ask questions does not mean the questions are not there.

According to Ashkinaze’s report, the most common question is “how much will it h ~ r t ? ” ~ But because we’re sup- posed to behave like adults, we’re usu-

ally afraid to ask that sort of question. Anticipating the questions and prepar- ing the patient ahead oftime causes bet- ter cooperation and, more than that, is much easier, according to patients. The typically overburdened staff, with 30 operations a day from 6:30 am to late afternoon, makes empathy training more rather than less important for everyone.

Empathizing sometimes includes examining causes of a patient’s aggres- sion or unruliness. Understanding this aggression is useful. The patient may actually be establishing priorities for survival by not giving in easily to the needles, the nurses, and the instru- ments. Perhaps the empathetic nurse ought to say, “Good for you for fighting this helplessness” rather than feel only the inconvenience of the behavior.

Patti was a close friend who survived eight operations for bone cancer before she died at the age of 21. The first opera- tion involved radical removal of her left leg, including the pelvic area. She fought and screamed and yelled, and the wise surgeon let her, rather than silenc- ing her with a hypodermic needle. He explained that he wanted her to fight because being angry is healthier than being depressed. At least she was al- lowed to focus her misery on someone other than herself for the few minutes before she was anesthetized. In my opin- ion, her surgeon knew the human spirit and understood empathy.

Argyle suggests the struggle against submission and abject dependency is the most basic reason empathy is needed in the OR.5 Being under the dominance and total control of OR per- sonnel is practically unbearable and can affect the rest of the patient’s life. The importance of the nurse dem- onstrating empathy by touching, holding, being near, and giving atten- tion and reassurance complements the skill of the surgeon. Being a skilled

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practitioner is important, but under- standing one’s relation to the patient makes the nurse a healer in the truest sense.

Doris was in an accident: a roof fell in on her at a restaurant. While she was in surgery, a lung collapsed. As she con- valesced in the hospital for a full month, only one therapy was effective. She was required to blow up a balloon every hour around the clock. Doris later described how it hurt. She had nurses around the clock, but her husband explained that only one in his opinion was truly em- pathetic. She was the night nurse, who badgered Doris into blowing up the balloon while watching her suffer. The nurse forced her again and again and again. The other nurses no doubt cared and were efficient in many ways, but they did not stay with Doris until she blew up the balloon. Empathetic be- havior can take many forms. We can behave empathetically by being tough or tender, as the situation demands.

Empathy is not feeling sorry. Sym- pathy is appropriate at times, but just feeling sorry can be condescending. Condescending behavior suggests the other person is inferior. Empathy suggests equality. Of course, the physi- cian, nurse, and other surgical team members have control in the operating room, but the empathetic surgical team uses this control in such a way that everyone on the team, including the pa- tient, is of equal worth.

Having defined the task, let us begin the training. McGoran states, “Most students, in my experience, find psy- chosocial nursing troublesome even though the psychosocial nursing skills- communication skills, self-aware- ness, observation-are basic to nurs- ing practice.”6

Studying psychosocial nursing can cause anxiety, fear, anger, avoidance, and even physical complaints. It is dif- ficult for any person to look seriously at

himself. To look at ourselves as we actually are and as others see us is un- comfortable for all of us and is impossi- ble for some of us because of our basic motives for being helpers.

Five areas of behavior can be im- proved and developed for operating room nurses and patients t o relate better. Self-awareness development, positive stress handling, self-concept building, effective communication techniques, and active listening skills are conducive to empathy training.

D e u e lop i ng se 1 f- a w a re n e ss . When nurses develop self-awareness, they are able to describe behaviors, pick up accurate nonverbal cues, and distin- guish among behaviors that respond to their own actions and those that re- spond to what is happening within the patient. Learning empathy, then, first requires a “mirror effect.” The process starts with self-observation through feedback from colleagues, reading and careful analysis, introspection, and talk- ing to an objective person knowledgeable in self-awareness. Denying a need for self-awareness precludes changing, and sophistication or prior knowledge of nurs- ing does not negate the need to look in the mirror. A brave self-encounter seems to be needed in all our lives and at all stages of our development. At the moment of greatest confidence, there is a tendency to lose empathy.

Handl ing stress positively. Hepner suggests there is an important differ- ence between nurses and laymen be- cause of the stress on helping persons.’ The daily cumulative stress and an- noyance experienced by operating room nurses can be dealt with in one of three ways, according t o Hepner. First, an in- dividual can completely adapt to the situation so he reacts only routinely. Stress turns persons into numbers. The next patient in the holding area be- comes the “third appendectomy this morning.” The helper with this reaction

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mpathy training involves E sharing in one’s mind the experience of others.

to stress is apt to become a bitter critic toward colleagues. If an outlet for his pent-up emotions doesn’t come, he is likely to escape through neurosis.

Second, one might handle stress by negative adaptation. This kind of stress handling assumes there is no hope of the stress ever getting any better, so the work can be done in a mechanical, spiritless manner. One negative adap- tation for medical personnel is turning to addictions, such as alcohol and drugs, or to constant partying to forget the seriousness of the hospital. “Alcoholism in the United States cuts across the pro- fession. . .; it is considered a serious problem among such seemingly un- likely candidates, surgeons.”* This es- cape route must be related t o the cumulative stress of the operating room.

The third method for dealing with stress is “insight-meaning.”

Insight-meaning is the empathetic method. Insight-meaning can be used every day and anyone who learns to apply this concept to the actions of people will soon develop a feeling of kinship toward them. The psycholog- ically intelligent person does not tell people how much he knows about them. Rather, he uses his insight into their situation to help them gain the satisfaction they seek. Having in- sight-meaning also relieves one’s own stress because it allows one’s own feelings to flow along with the other

544 AORN Journal, Septem

person and it is mutually h e l p f ~ l . ~ This concept is not easy, even when

feelings in ourselves are properly iden- tified. Because of our own experiences, it is possible to fear certain feelings to the extent that we can easily deny that others feel them. Avoiding the patient’s needs most likely comes from a fear of the situation if the roles were reversed. Also, there are undoubtedly feelings of inadequacy when one is often working in a life-or-death crisis.

B u i l d i n g a heal thy self-concept. Nurses, of all persons, need a good self- concept. All helpers are limited and have strengths and weaknesses. An empathetic person knows these attri- butes. Training, experience, and self- development in relation to others foster an equilibrium of self-liking. Physi- cians often do not add to this self-liking by forcing nurses into subordinate and supporting roles. But the nursing pro- fession is changing rapidly. New techniques are not the only area that is being updated. Physicians and nurses need to recognize they are persons who need each other. Teaching nurses to like themselves is basic. If the anxiety of a poor self-image goes unrecognized, posi- tive self-image and positive relation- ships are out of reach.

Practicing workable coniniunication. Before giving an explanation to a pa- tient, the techniques of reflection and clarification are appropriate.’() Often when a patient asks for an interpreta-

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tion that is better left to a physician, the patient actually wants a reflection or acknowledgement of his feelings. In- stead of responding, “Only the doctor can answer that,” an example of reflec- tion would be to say, “I hear you wonder- ing how long you will be in the operat- ing room.” A simple clarifying state- ment might be, “Most operations like yours take two hours if everything goes well.”

Empathizers do not include more in- formation than is needed to be descrip- tive and explaining, but curt “no” and

answers do not deal with the pa- tient’s fears. Sometimes, nurses find l i t

easier to be less than honest with pa- tients, but explaining as honestly and as fully as possible can be the difference between panic and control for the pa- tient. The chief complaints of surgical patients are tha t explanations con- tained a dearth of information. One woman I spoke with said she wanted someone to keep saying her name so she could know she was alive.

Empathetic persons experience V L -

cariously. Mary Kaufinann, an educator of nurses a t Mennonite Hospital School of Nursing in Bloomington, Ill, occa- sionally has her students wear an ileos- tomy bag, lie on a surgical table, or be prepped and transported through the OR to share what the surgical patient experiences. Empathy t ra ining in- volves sharing, in one’s mind a t least, the actual experience of others. It 11s mutually strengthening to share our anxieties and cares.

Achieving active listening. The prim- ary, indispensable tool of empathy is lis- tening. Genuine, active listening ILS

hard work. Active listening requires that we know the tools of communica- tion-verbalization, feeling, gestures, eye contact, facial animation, and touching. Total listening may well be our most potent means of ascribing worth and value to another person. If

one is really listening, he must exclude all else from his mind. It also involves perceiving what is not being said but is only hinted at and lies beneath what we hear with our ears. “We listen with our eyes and mind and heart and skin and guts as well.”ll

The quality of listening depends on involvement. Willingness to be in- volved makes the difference between the effective nurse and the ineffective one. Active listening is the basic art of communicating and maintaining effec- tive relationships. Few of us appreciate its power and influence and few of us do it well.

We have defined and redefined this ethical, rational, and emotional con- cept-empathy. This desirable charac- teristic can be attained by operating room nurses. Perhaps now, if we can know ourselves, feel our worth, build a support system to heal our own anx- ieties and unresolved conflicts, and master the tools of effective relating, we can then occupy ourselves with the task a t hand in the operating room. That task is more than following the physi- cian’s orders o r observing steri le technique. The reason you are there as nurses is for the patient’s sake. 0

Notes

Aldine Atherton, Inc, 1973) 39.

(May 25, 1978) 895.

‘why,’ ” The Atlanta Journal (Feb 1, 1979) 15-b.

1. Michael Argyle, Social Interaction (Chicago:

2. Eileen Kirkham, “Empathy,” Nursing Times 74

3. Carole Ashkinaze, “Patients deserve to know

4. lbid. 5. Argyle, Social Interaction, 39. 6. Saralee McGoran, “On developing empathy-

teaching students self-awareness,” American Jour- nal of Nursing 78 (May 1978) 859.

7. Harry Walker Hepner, Psychology Applied to Life and Work (Englewood Cliffs, NJ: Prentice-Hall, Inc, 1966) 189.

8. James Coleman, Abnormal Psychology and Modern Life, 5th ed (Dallas: Scott, Foresrnan and Company, 1976) 41 5.

9. Hepner, Psychology Applied, 189. 10. Alfred Benjamin, The Helping interview (Bos-

AORN Journal, September 1979, Vol30, No 3 545

ton: Houghton Mifflin, 1969) 50-51. New York: Ronald Press Co, 1966. Hackney, Harold; Nye, Sherilyn. Counseling

Strategies and Objectives. Englewood Cliffs, NJ:

Hodnett, Edward. The Art of Working with People.

Kinget, Marian G. On Being Human. New York: Har-

11. bid, 49.

Suggested reading Prentice-Hall, Inc, 1973. Bernard, Harold W; Huckins, Wesley C. Dynamics of

Personal Adjustment. Boston: Holbrook Press, Inc, 1971.

Blocher, Donald H. Developmental Counseling.

New York: Harper & Row, 1959.

court Brace Jovanovich, 1975.

EFM appropriate for high-risk deliveries Electronic fetal monitoring (EFM) carries "minimal risk to mother and infant," but it is not a "substitute for informed clinical judgment."

research review conducted by the American College of Obstetricians and Gynecologists' (ACOG) Committee on Obstetrics: Maternal and Fetal Medicine. The committee was chaired by Robert Cefalo, MD.

The committee was asked to respond to "advocate groups, third-party carriers, and federal government analysts" who have asked for evidence that "EFM in labor results in significant benefit to the fetus." A review of current research in this area was conducted to determine the most appropriate role for EFM.

found that

This is the conclusion of a year-long

As a result of its study, the committee

current data supports the use of continuous internal EFM for the high-risk obstetrical patient

0 it is not possible statistically to demonstrate EFM's beneficial effect on perinatal mortality or morbidity in low-risk pregnancy.

The committee recommends that if EFM is not used in low-risk situations, "auscultation of fetal heart tones should be performed at least every thirty minutes during the first stage, and at least every fifteen minutes during the second stage of labor, in both instances for a period of 30 seconds after the uterine contraction."

The committee based its conclusions on three controlled, prospective trials of EFM. To date, these are the only controlled studies that have been conducted on electronic fetal monitoring. Some retrospective reports have shown "the

frequency of intrapartum stillbirth is decreased two to threefold" in EFM labors, but the three studies the committee used indicated no significant difference in intrapartum stillbirths when EFM was used.

According to the committee report, in one statistical analysis of 14,846 live-born infants, Neutra, et al, determined that "benefits from EFM decreased as the inherent risk of the infant declined." Researchers concluded that EFM in high-risk pregnancy was "clearly of benefit," but that "its advantage is not proven in the completely normal pregnancy." They stress, however, that their study dealt only with infant mortality and not with morbidity.

"Effects of EFM on morbidity are even more difficult to ascertain," the committee observed. Two of the studies the committee used in its review'offered conflicting findings. In their research, Haverkamp, et al, showed "no differences between the EFM and non-EFM groups in terms of any of the usual parameters of neonatal outcomes," but Renou, et al, showed that a greater number of babies in their non-EFM group required intensive care following birth compared to the EFM group.

Acknowledging the disparity in research findings, the committee concluded, "It is clear that numerous intrapartum events may occur in the normal pregnancy which will substantially increase the risk to the infant. If these factors arise, continuous EFM is indicated."

548 AORN Journal, August 1979, Vol30, No 2