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What's it all about, empathy?
What's it all about,
empathy?
Vincent Price and John Archbold
This paper investigates the concept of empathy, a core element of all helping relationships. A discussion of its prevalence in the nursing literature is traced, before a discussion ensues as to whether it is a naturally acquired ability which develops with maturity, or whether it is a skill that can be taught and learnt. It is concluded that empathy remains a poorly defined, multidimensional concept which still remains not fully identified.
W H A T IS E M P A T H Y ? Setting the scene Karl Menninger (1947) once wrote that it was hard for a free fish to understand what was happening to a hooked fish, because to appreciate this would require the free fish to put itself in the place of the hooked fish. In the same way, for human beings to experience empathy requires them to have the ability to put themselves into another's shoes so that they genuinely feel the way the other person does, with regard to a particular situation or problem.
Operational definitions of e m p a t h y Vincent Price RMN, RGN, ENB (CET) 810, MEd in Counselling, Senior Lecturer in Nursing, University of Northumbria at Newcastle, Gateshead,UK John Archbold RMN, Charge Nurse, Grange
Park Clinic, Priority Health Care Wearside, Sunderland, LJK (Requests for offprints to VP) Faculty of Health, Social Work & Education, Education Centre, University of Northumbria at Newcastle, Queen Elizabeth Hospital, Gateshead,Tyne & Wear, UK Manuscript accepted 17January 1996
Most research studies concerned with empathy have been undertaken in the USA and rely heavily on the work of counsellors and psychotherapists, and especially on the work of Carl Rogers (1951, 1961). Rogers (1957) defined empathy as the ability: 'to sense the client's private world as if it were your own without ever losing the "as if" quality' (Rogers 1957, p 95). The 'as if' you were in the other person's shoes, became 'being in' the other person's shoes, with his revised definition of empathy (Kogers 1975). Nurses in the USA interested in these concepts operated from the premise that all nurses, by choosing to enter the profession and to
Nurse Education Today (1997) 17, 106-1 FO
©
1997PearsonProfessionalLtd
remain in practice, care about their patients and hope to understand them (La Monica 1979). Not surprisingly, their definitions of empathy rely heavily upon P,.ogerian theory, as this literature was most readily available. Thus Gagan (1983) asserts that the most commonly used definition of empathy in the nursing literature is: 'The ability to perceive the meaning and feelings of another person and to communicate that feeling to the other' (Gagan 1983, p 53). Many contemporary nurse researchers would subscribe to these views (Kalisch 1973, Laytou, 1979, Sparling &Jones 1977, Stetler 1977). Today, the term empathy is frequently employed by authors exhorting nurses to develop interpersonal skills, where the ability to empathize is often equated with the ability to care for the person as an individual. Thus Bohart (1988) implies that empathy is the ability to provide psychological support, while Egan (1990) relates empathy to communication skills, particularly allowing clients freedom to express emotion, for example by crying or showing anger. This use of the term empathy, expressed almost in lay terms, is not helpful when attempting to operationalize a definition for research purposes: it is too vague and ignores the vast endeavour to determine the precise nature of the concept. Reynolds (1987) points out that as empathy is not a well-defined concept, ethical difficulties wilt inevitably arise for those responsible in teaching this skill.
The nature of e m p a t h y Empathy continues to draw the attention of theoreticians and researchers (Bohart 1988, Eisenberg & Strayer 1987, Emery 1987, Marks & Tolsma 1986, Miller 1989, Patterson 1984, 1985, 1988). However, there is still confusion as to just what empathy is. Some of the confusion comes from the distinction between empathy as a way of being and empathy as a communication process or skill, and from the way this distinction is played out in the helping process. Egan (1990) suggests that helpers enter the world of clients through attentive listening and 'being with' deeply enough to make a difference. He continues by stating that if attending and listening are the skills that enable helpers to get in touch with the world of their clients, then empathy is the skill that enables them to communicate their understanding of this world. Egan (1990) also feels that warmth has to be present if one person is to convey compassionate understanding to another. Behavioural warmth is what McKay et al (1983) might call 'total listening', or what Ivey (1971) refers to as 'effective attending'.
What's it all about, empathy?
If we accept, however, that empathy happens to us, can, then, empathy be taught?
C A N EMPATHY BE TAUGHT? Stein (1970) suggests that empathy happens to us after the fact, or we realize it after it has occurred. Is it, then, a way of being, a natural ability, and if so can it be enhanced, or is it purely a skill or art that can be taught? Empathy is the ability to see the world as another person sees it: to enter another's flame of reference. W e all view the world according to our own cultural background, educational experience, belief and value systems and personal experience. Empathy would therefore seem to be a communication process that develops as we mature. Cognitively and emotionally - mature people should be capable o f experiencing empathy, because it seems to develop along with cognition and emotions during puberty. With puberty comes the ability to realize what it might be like to be in another's shoes. Adolescents begin to make more meaningful plans for a career because they can envision more clearly what it would be like to be a journalist or a lawyer. Likewise, adolescents begin more fully to realize the effects o f their behaviour on others and can feel the hurt another feels as a result of their own actions, and thus are able to be genuinely sorry for what they say and do that is hurtful. Katz (1963) argues that some helpers, particularly those who are immature and inexperienced, might fail to empathize with others because o f personality clashes, differences o f age or social class. These situations seem to be well documented in nursing, where a considerable body of literature has been developed on the theme of the unpopular patient (Podrasky & Sexton 1988, Stockwell 1972). Several other studies support the suggestion that nurses dislike, and possibly, therefore, have made little attempt to empathize with, people w h o are different from themselves. Larson (1977) highlighted the fact that patients who are of a different culture, religious persuasion and social class seem poorly understood, while elderly patients are described in patronizing terms by learners (Fielding 1986), with nursing interaction being particularly low with elderly, confused people (ArmstrongEsther & Browne 1986). Schmid & Schmid (1973) reported that psychiatric patients engender fear amongst nursing students, as do patients labelled alcoholic (Wilkinson 1982), whilst Gellman (1959) describes h o w prejudice is held against people
107
described as disabled. People who are dying may still be left unsupported (Knight & Field 1981) because learners feel that, despite seminar and tutorial work, they are inadequately prepared to cope with the terminally ill and bereaved (Woolf 1985). C o m e r (1988) suggests that negative attitudes are held towards the treatment and care of those with malignant disorders, and Taylor et al (1984) found that nurses seem particularly unappreciative of the needs of people in chronic pain, especially where there is no obvious cause and the patient is young. Further evidence that nurses are best able to empathize with people on the basis of shared experience is provided by Holm et al (1989), who demonstrated that understanding o f patients in pain was greatest amongst nurses with personal experience of pain. People's intellectual and ethical development and an unfolding from a concrete, outer authority base, to an inner frame of reference, seem to be factors in one person's ability to empathize with another. The more concrete a person's intellectual and ethical development, the more similar to another person they must be to allow empathy to occur with that person. The more mature a person is, the more that person's imagination is able to see even the smallest o f minor similarities. Indeed, the process o f maturation can, in part, be charted by an increasing feeling of oneness with all human beings. Those with creative imaginations and a genuine interest in people of all types are likely to experience this to a greater degree. Davis (1990) illustrated this well when she questioned a young, but mature physical therapist athlete about his experience of empathy for his clients. He recounted an experience o f empathy with an elderly patient in intensive care, undergoing pulmonary percussion and drainage. He described experiencing the crossing-over stage of empathy as his patient, an elderly homeless person, rolled her eyes back into her head in sheer physical exhaustion. He was asked how he, a strong athlete, had even noticed this flail woman's response, let alone felt empathy for her. He smiled and replied that he ran the Boston Marathon each year, and knew what it was like to feel exhausted and out of breath. In this way, this mature professional illustrated that, by virtue of the fact that we all breathe, we have the capacity to experience the breathlessness o f another person, no matter h o w different that person appears. It seems that individuals readily appreciate the feelings o f others who are similar to themselves, or with w h o m they feel able to associate (Jourard 1971). It would appear the more self-aware a person is, the greater their ability to feel at one
108 NurseEducationToday with fellow persons and the greater the likelihood of this occurring. Surely then, teaching exercises in self-awareness must enhance the individual's ability to empathize. It is suggested that the qualities o f a good empathizer in human relations are similar in many respects to the qualities o f a gifted artist. A gifted artist may have been given a gi8 of natural talent, but how does this natural talent develop? One needs to learn about colours, shades, materials o f choice, sense of proportion, composition, lighting and the results o f these on one's work. These skills and a degree o f confidence in one's own ability are frequently developed by serving an apprenticeship with a great artist or by attending a course at an art college.
EMPATHY A N D THE INFLUENCE OF ROLE MODELLING Bandura (1977) proposed that self-efficacy, the degree o f confidence in our ability to behave in a socially skilled way, is dependent on prolonged exposure to graded modelling, the provision of reinforcement by a competent supervisor, and a situation where anxiety is kept to a minimum. Bandura also argued that possessing a skill does not necessarily lead to its use. Whether it is used or not depends to some extent on a cognitive factor, a belief in our capacity to perform well. It would therefore seem feasible to assume that the presence of non-threatening role models would reduce anxiety in trainees, thus enhancing their ability to empathize. Furthermore, the communication process and in particular the micro-counselling skills of attending behaviour, could be taught to learners by the use o f modelling by competent practitioners. According to Jourard (1971), anxiety operates as a barrier, almost acting as a protective shell in preventing the expression of one's feelings and the recognition of distress in others. Jourard suggests that this inability to self-disclose, or to be honest about one's emotions, is more prevalent amongst nurses than other groups because they are presented with poor role models at an early stage o f their professional development. He argues that individuals who retain the ability to self-disclose are happier because they achieve greater self-acceptance, and are more effective as practitioners because they help patients to self-disclose. Nurses who are unaware of their own feelings may experience greater anxiety when attempting to cope with clients' feelings. Trying too hard to be professional is seen as another barrier to empathy. Oakley (1984) contrasts the desirable qualities o f a 'good'
nurse (calm, efficient, nurturing, but not necessarily intelligent) with those of a 'good woman', but argues that to achieve professional status is not wholly desirable for nursing, as the specialist knowledge held to be a key feature o f all professions is never made available to the public they serve. Hoarding professional knowledge and being reluctant to promote health education and teach patients how to cope better with the physical and psychological effects of illness is ethically unsound. Nursing research, then, appears essential as unless we know h o w clients envisage their condition, we will remain unable to develop their knowledge or assist them in coping with the changes it brings (Benner & Wrubel 1989). The process of professionalization can be considered to commence before young people enter nursing, through impressions gained from parents, teachers and the media (Stoller 1978). However, once nurse education begins, it appears to operate as a form o f social control, commencing with the selection process which sieves through only those likely to fit the mould (Holloway & Penson 1987). As the course progresses, 'misfits' who do not meet the profession's stereotype of itself withdraw, leaving a homogenous, rather dull group to enter the qualified workforce (Wondrak 1989). Effective role modelling can encourage selfdisclosure and maintain a learner's individuality, thus increasing their self-efficacy. To be effective, empathizers must be individuals. They cannot rely on their membership of the team to see them through; their task calls for a solo flight. If one is born to be a pilot, some flying and navigation lessons seem crucial to prevent a hazardous journey. Natural ability is of prime importance in empathy and, without it, skills training alone will only achieve the first stage of Stein's (1970) empathic process - self-transposal - whereby I think myself in another person's shoes. To summarize, it is suggested that empathy is an art, a natural ability or way o f being that is a life-long process, and which develops as we mature. Self-awareness enhances that process and self-awareness skills can be taught. The 'natural ability' requires added ingredients - understanding o f and proficiency in specific microcommunication skills and awareness of how these fit into the helping process. These skills can be taught by modelling in real life situations or in simulated exercises and role play situations incorporated into a skills training programme. A study by Reynolds & Presly (1988) gives some credibility to this belief, along with the work of Aspy (1972) and Paxton et al (1988). Having attempted to clarify what empathy is, and h o w we get it, h o w then do we measure it?
What's it all about, empathy?
H O W DO WE MEASURE EMPATHY? Measuring empathy is fraught with difficulties (Gould 1990). Taft (1955)hypothesized, on the evidence of early rating instruments, that empathy might constitute a multidimensional concept, possibly incorporating objectivity, cognitive ability and abili W to understand h o w other people think. His review of 81 studies attempted to determine how individuals judge the feelings and behaviours o f others. Over the years, analysis of different scales purporting to measure empathy has repeatedly suggested that more than one construct may exist (Buckheimer 1963, Conklin & Hunt 1975, Rappoport & Chinsky 1972). As Deutsch & Mandle (1975) point out, until we have firmly identified those constructs comprising empathy, research results will remain of little value. There are many instruments purporting to measure empathy including: • self-rating scales • rating by judges or associates • client rating of empathy.
Rogers (1951) despaired of the notion that empathy could be broken down into a series of behavioural responses which could be learned and subsequently assessed, arguing that the functional aspects o f encounters would be analysed, rather than the demands of the whole situation. The instruments for measuring empathy have been developed independently and from different academic disciplines. The different approaches and their methodological flaws have been highlighted by Gagan (1983), whilst Masson (1990) points out that as confusion exists surrounding what constitutes empathy, every chance exists that the respective authors of these scales will have devised them. according to what they believe empathy encompasses.
CONCLUSION Empathy is a commonly used but poorly understood concept. It is difficult to define or measure as it appears to be a multidilT~ensional concept which has not been fully identified. It would seem that the real test o f empathic understanding is to appreciate the hopes and fears o f people with w h o m we are not similar. However, is it realistic to expect that those nurses in training, or recently qualified, who make up the major part o f the nursing workforce in the UK, to be able to empathize with all clients in the face of the difficulties discussed? To do this would be simply to accept
109
the media stereotype of the nurse as an angel, which the profession is determined to dispel. A starting point may be to accept that the ability to understand and to demonstrate understanding must always matter in a caring profession. Failure to be understood may be detrimental to chent welfare (Williams 1979), and may lead to frustration and disillusionment on the part of nurses, to the point where people leave the profession. In the past 3 decades, empathy has been touted as appropriate, desirable, therapeutic and the central component in the nurse-patient alliance. Nurse educationalists have universally accepted and incorporated the empathic model of communication into nursing curricula, whilst alteruative responses including sympathy, pity and commiseration have been devalued, labelled inappropriate and judged to be not beneficial, or even harmful, for use in the clinical setting (Forsyth 1980, Holden 1990, Kalisch 1973). The views concerning empathy, emanating from the field of psychotherapy, have been accepted uncritically; however, although alternative communication strategies have not been suggested or explored, the exclusive use and therapeutic efficacy of empathy have been questioned (Diers 1990, Gordon 1987). Nurses' attention, quite rightly, needs to focus on understanding others, and empathy can help to achieve this, but in isolation it seems an impractical 'fit' for the demands o f clinical practice. Perhaps we have reached a stage where we need to lay aside preconceptions of the meaning and measurement of empathy and look beyond our present horizons, as Morse et al (1992) have suggested. Finally, having started the article with a maxim, it seems apt to end with another: Life is a voyage in which we choose neither vessel nor weather, but much can be done in the management o f the sails and the guidance o f the helm. REFERENCES
Armstrong-EstherC A, Browne K D 1986 The influence of elderly patients' mental impairement on nurse-patient interaction.Journal of Advanced Nursing 11:379-387 AspyD 1972 Towards a technologyfor humanlsing education. Research Press, Illinois Bandura A 1977 Self-efficacy:towards a unifyingtheory ofhehaviour change. PsychologicalReview 84: 191-215 Benner IK, WrubelJ 1989 The primacyof caring and copingin health and illness. AddisonWesley, Menlo Park Bohart A C 1988Empathy:client-centred and psychoanalytic.AmericanPsychologist43:667-668 Buckheimer A 1963 The development of ideas about empathy.Journal of Counselling Psychology10: 60-71
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NurseEducation Today Conklin R, Hunt A 1975 An investigation of the validity of empathy measures. Counsellor Education and Supervision 15:119-127 ComerJ L 1988 Assessment of nurses' attitude towards cancer: a critical review of research methods. Journal of Advanced Nursing 13:640-648 Davis C 1990 What is empathy and can empathy be taught? Physical Therapy 70:701-715 Deutsch F, Mandle A IK 1975 Empathy: historic and current conceptualisations, measurement and cognitive theoretical perspective. Human Development 18:267-287 Diers D 1990 Response. Journal of ProfessionaI Nursing 6: 240-241 Egan G 1990 The skil]ed helper: a systematic approach to effective helping, 4th edn. Brooks-Cole, Pacific Grove Eisenberg N, StrayerJ (eds) 1987 Empathy and its development. Cambridge University Press, New York Emery E E 1987 Empathy: psychoanalytic and clientcentred. American Psychologist 42:513-515 Fielding P 1986 Attitudes revisited. Royal College of Nursing, London Forsyth G L 1980 Analysis of the concept of empathy: illustration of one approach. Advances in Nursing Science 2:33-42 GaganJ M 1983 Methodological notes on empathy. Advances in Nursing Science 1 (2): 53-61 Gellman W 1959 Roots of prejudice against the disabled. Journal of Rehabilitation 25:4-6 Gordon M 1987 Nursing diagnosis: process and application. Mcgraw-Hill, New York Gould D 1990 Empathy: a review of the literature with suggestions for an alternative research strategy. Journal of Advanced Nursing 15:1167-1174 Holden R J 1990 Empathy: the art of emotional knowing in holistic nursing care. Holistic Nursing Practice 5 (1): 70-79 HollowayJ, PensonJ 1987 Nurse education as social control. Nurse Education Today 7 (5): 235-241 Holm K, Cohen F, Judas S 1989 Effects of personal pain experience on pain assessment. Image 21 (2): 72-75 Ivey, A 1971 Micro counselling: innovations in interviewing training. C C Thomas, Springfield Jourard, S M i971 The transparent self, 2nd edn. Van Nostrand, USA Kalisch B 1973 What is empathy? American Journal of Nursing 73:1548-1552 Katz R L 1963 Empathy: it's nature and uses. CollierMacMillan, London Knight M, Field D 1981 A silent conspiracy: coping with dying cancer patients on an acute surgical ward. Journal of Advanced Nursing 6:221-229 La Monica E L 1979 Empathy in nursing practice. Issues in Mental Health Nursing 2:2-13 Larson P A 1977 Nurses' perceptions of patient characteristics. Nursing Research 26 (6): 416-421 LaytonJ M 1979 The use of modelling to teach empathy to nursing students. Research in Nursing Health 2: 163-176 McKay M, Davis M, Fanning P i983 Messenger: the communication book. New Horbinge Publications, Oakland Marks S E, Tolsma R J 1986 Empathy research: some methodological considerations. Psychotherapy 23: 4-20 Masson J 1990 Against therapy. Constable, London Menninger K 1947 The human mind, 3rd edn. Alien and Unwin, London Miller M J 1989 A few thoughts on the relationship
between empathy and counselling techniques. Journal of Counselling and Development 67:350-351 MorseJ M, BottorffJ, Anderson G, O'Brien B, Solberg S 1992 Beyond empathy: expanding expressions of caring. Journal of Advanced Nursing 17:809-821 Oakley A 1984 The importance of being a nurse. Nursing Times 80 (50): 24-48 Patterson C H 1984 Empathy, warmth and genuineness in psychotherapy: A review of reviews. Psychotherapy 21:431-438 Patterson C H 1985 The therapeutic relationship: foundations for an eclectic psychotherapy. BrooksCole, Pacific Grove Patterson C H 1988 The function of antomaficity in counsellor information processing. Counselor Education and Supervision 27:195-202 Paxton R, Rhodes D A, Crooks I 1988 Teaching nurses therapeutic conversion: a pilot study. Journal of Advanced Nursing 13:401-404 Podrasky D L, Sexton D L 1988 Nurses' reactions to difficult patients. Journal of Nursing Scholarship 20 (l): 16-20 Rappoport J, ChinskyJ M 1972 Accurate empathy: confusion of a construct. Psychological Bulletin 77: 400-404 Reynolds W J 1987 Empathy: we know what we mean, but what do we teach? Nurse Education Today 7: 265-269 Reynolds W J, Presly A S 1988 A study of empathy in student nurses. Nurse Education Today 8:123-130 Rogers C R 1951 Client centred therapy. Constabie, London Rogers C R 1957 The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology 21:95-103 Rogers C R 1961 O n becoming a person. Houghton Mifflin, Boston Rogers C R 1975 Empathic: an unappreciated way of being. Counselling Psychologist 5:2-10 Schmid N, Schmid D 1973 Nursing students' attitudes towards alcoholics. Nursing Research 22 (3): 246-248 Spading S L, Jones S L 1977 Setting: a contextual variable associated with empathy. Journal of Psychiatric and Mental Health Services 15:9-12 Stein E 1970 O n the problem of empathy, 2nd edn, translated by W Stein. Martinus Nijhoff,, The Hague Stetler C 1977 Kelationsliip of perceived empathy to nurses' communication. Nursing Research 26 (6): 432-438 Stockwell F 1972 The unpopular patient. Royal College of Nursing, London Stoller E P 1978 Perceptions of the nursing role: a case study of an entering class. Journal of Nursing Education 17:2-14 Taft E 1955 The ability to judge people. Psychological Bulletin 52:1-23 Taylor A G, SkehonJ A, ButcherJ 1984 Duration of pain condition and physical pathology as determinants of nurses' assessments of patient in pain. Nursing Research 33 (1): 4--8 Wilkinson D 1982 The effects of brief psychiatric training on the attitudes of general nursing students to psychiatric patients. Journal of Advanced Nursing 7: 239-253 Williams C L 1979 Empathic communication and its effect on client outcome. Issues in Mental Health Nursing 2:15-26 Wondrak R 1989 Uniform branch. Nursing Times 31 (85): 58-59 WoolfJ 1985 Equal to the task. Nursing Mirror 161 (1): 39-41
empathy?
Vincent Price and John Archbold
This paper investigates the concept of empathy, a core element of all helping relationships. A discussion of its prevalence in the nursing literature is traced, before a discussion ensues as to whether it is a naturally acquired ability which develops with maturity, or whether it is a skill that can be taught and learnt. It is concluded that empathy remains a poorly defined, multidimensional concept which still remains not fully identified.
W H A T IS E M P A T H Y ? Setting the scene Karl Menninger (1947) once wrote that it was hard for a free fish to understand what was happening to a hooked fish, because to appreciate this would require the free fish to put itself in the place of the hooked fish. In the same way, for human beings to experience empathy requires them to have the ability to put themselves into another's shoes so that they genuinely feel the way the other person does, with regard to a particular situation or problem.
Operational definitions of e m p a t h y Vincent Price RMN, RGN, ENB (CET) 810, MEd in Counselling, Senior Lecturer in Nursing, University of Northumbria at Newcastle, Gateshead,UK John Archbold RMN, Charge Nurse, Grange
Park Clinic, Priority Health Care Wearside, Sunderland, LJK (Requests for offprints to VP) Faculty of Health, Social Work & Education, Education Centre, University of Northumbria at Newcastle, Queen Elizabeth Hospital, Gateshead,Tyne & Wear, UK Manuscript accepted 17January 1996
Most research studies concerned with empathy have been undertaken in the USA and rely heavily on the work of counsellors and psychotherapists, and especially on the work of Carl Rogers (1951, 1961). Rogers (1957) defined empathy as the ability: 'to sense the client's private world as if it were your own without ever losing the "as if" quality' (Rogers 1957, p 95). The 'as if' you were in the other person's shoes, became 'being in' the other person's shoes, with his revised definition of empathy (Kogers 1975). Nurses in the USA interested in these concepts operated from the premise that all nurses, by choosing to enter the profession and to
Nurse Education Today (1997) 17, 106-1 FO
©
1997PearsonProfessionalLtd
remain in practice, care about their patients and hope to understand them (La Monica 1979). Not surprisingly, their definitions of empathy rely heavily upon P,.ogerian theory, as this literature was most readily available. Thus Gagan (1983) asserts that the most commonly used definition of empathy in the nursing literature is: 'The ability to perceive the meaning and feelings of another person and to communicate that feeling to the other' (Gagan 1983, p 53). Many contemporary nurse researchers would subscribe to these views (Kalisch 1973, Laytou, 1979, Sparling &Jones 1977, Stetler 1977). Today, the term empathy is frequently employed by authors exhorting nurses to develop interpersonal skills, where the ability to empathize is often equated with the ability to care for the person as an individual. Thus Bohart (1988) implies that empathy is the ability to provide psychological support, while Egan (1990) relates empathy to communication skills, particularly allowing clients freedom to express emotion, for example by crying or showing anger. This use of the term empathy, expressed almost in lay terms, is not helpful when attempting to operationalize a definition for research purposes: it is too vague and ignores the vast endeavour to determine the precise nature of the concept. Reynolds (1987) points out that as empathy is not a well-defined concept, ethical difficulties wilt inevitably arise for those responsible in teaching this skill.
The nature of e m p a t h y Empathy continues to draw the attention of theoreticians and researchers (Bohart 1988, Eisenberg & Strayer 1987, Emery 1987, Marks & Tolsma 1986, Miller 1989, Patterson 1984, 1985, 1988). However, there is still confusion as to just what empathy is. Some of the confusion comes from the distinction between empathy as a way of being and empathy as a communication process or skill, and from the way this distinction is played out in the helping process. Egan (1990) suggests that helpers enter the world of clients through attentive listening and 'being with' deeply enough to make a difference. He continues by stating that if attending and listening are the skills that enable helpers to get in touch with the world of their clients, then empathy is the skill that enables them to communicate their understanding of this world. Egan (1990) also feels that warmth has to be present if one person is to convey compassionate understanding to another. Behavioural warmth is what McKay et al (1983) might call 'total listening', or what Ivey (1971) refers to as 'effective attending'.
What's it all about, empathy?
If we accept, however, that empathy happens to us, can, then, empathy be taught?
C A N EMPATHY BE TAUGHT? Stein (1970) suggests that empathy happens to us after the fact, or we realize it after it has occurred. Is it, then, a way of being, a natural ability, and if so can it be enhanced, or is it purely a skill or art that can be taught? Empathy is the ability to see the world as another person sees it: to enter another's flame of reference. W e all view the world according to our own cultural background, educational experience, belief and value systems and personal experience. Empathy would therefore seem to be a communication process that develops as we mature. Cognitively and emotionally - mature people should be capable o f experiencing empathy, because it seems to develop along with cognition and emotions during puberty. With puberty comes the ability to realize what it might be like to be in another's shoes. Adolescents begin to make more meaningful plans for a career because they can envision more clearly what it would be like to be a journalist or a lawyer. Likewise, adolescents begin more fully to realize the effects o f their behaviour on others and can feel the hurt another feels as a result of their own actions, and thus are able to be genuinely sorry for what they say and do that is hurtful. Katz (1963) argues that some helpers, particularly those who are immature and inexperienced, might fail to empathize with others because o f personality clashes, differences o f age or social class. These situations seem to be well documented in nursing, where a considerable body of literature has been developed on the theme of the unpopular patient (Podrasky & Sexton 1988, Stockwell 1972). Several other studies support the suggestion that nurses dislike, and possibly, therefore, have made little attempt to empathize with, people w h o are different from themselves. Larson (1977) highlighted the fact that patients who are of a different culture, religious persuasion and social class seem poorly understood, while elderly patients are described in patronizing terms by learners (Fielding 1986), with nursing interaction being particularly low with elderly, confused people (ArmstrongEsther & Browne 1986). Schmid & Schmid (1973) reported that psychiatric patients engender fear amongst nursing students, as do patients labelled alcoholic (Wilkinson 1982), whilst Gellman (1959) describes h o w prejudice is held against people
107
described as disabled. People who are dying may still be left unsupported (Knight & Field 1981) because learners feel that, despite seminar and tutorial work, they are inadequately prepared to cope with the terminally ill and bereaved (Woolf 1985). C o m e r (1988) suggests that negative attitudes are held towards the treatment and care of those with malignant disorders, and Taylor et al (1984) found that nurses seem particularly unappreciative of the needs of people in chronic pain, especially where there is no obvious cause and the patient is young. Further evidence that nurses are best able to empathize with people on the basis of shared experience is provided by Holm et al (1989), who demonstrated that understanding o f patients in pain was greatest amongst nurses with personal experience of pain. People's intellectual and ethical development and an unfolding from a concrete, outer authority base, to an inner frame of reference, seem to be factors in one person's ability to empathize with another. The more concrete a person's intellectual and ethical development, the more similar to another person they must be to allow empathy to occur with that person. The more mature a person is, the more that person's imagination is able to see even the smallest o f minor similarities. Indeed, the process o f maturation can, in part, be charted by an increasing feeling of oneness with all human beings. Those with creative imaginations and a genuine interest in people of all types are likely to experience this to a greater degree. Davis (1990) illustrated this well when she questioned a young, but mature physical therapist athlete about his experience of empathy for his clients. He recounted an experience o f empathy with an elderly patient in intensive care, undergoing pulmonary percussion and drainage. He described experiencing the crossing-over stage of empathy as his patient, an elderly homeless person, rolled her eyes back into her head in sheer physical exhaustion. He was asked how he, a strong athlete, had even noticed this flail woman's response, let alone felt empathy for her. He smiled and replied that he ran the Boston Marathon each year, and knew what it was like to feel exhausted and out of breath. In this way, this mature professional illustrated that, by virtue of the fact that we all breathe, we have the capacity to experience the breathlessness o f another person, no matter h o w different that person appears. It seems that individuals readily appreciate the feelings o f others who are similar to themselves, or with w h o m they feel able to associate (Jourard 1971). It would appear the more self-aware a person is, the greater their ability to feel at one
108 NurseEducationToday with fellow persons and the greater the likelihood of this occurring. Surely then, teaching exercises in self-awareness must enhance the individual's ability to empathize. It is suggested that the qualities o f a good empathizer in human relations are similar in many respects to the qualities o f a gifted artist. A gifted artist may have been given a gi8 of natural talent, but how does this natural talent develop? One needs to learn about colours, shades, materials o f choice, sense of proportion, composition, lighting and the results o f these on one's work. These skills and a degree o f confidence in one's own ability are frequently developed by serving an apprenticeship with a great artist or by attending a course at an art college.
EMPATHY A N D THE INFLUENCE OF ROLE MODELLING Bandura (1977) proposed that self-efficacy, the degree o f confidence in our ability to behave in a socially skilled way, is dependent on prolonged exposure to graded modelling, the provision of reinforcement by a competent supervisor, and a situation where anxiety is kept to a minimum. Bandura also argued that possessing a skill does not necessarily lead to its use. Whether it is used or not depends to some extent on a cognitive factor, a belief in our capacity to perform well. It would therefore seem feasible to assume that the presence of non-threatening role models would reduce anxiety in trainees, thus enhancing their ability to empathize. Furthermore, the communication process and in particular the micro-counselling skills of attending behaviour, could be taught to learners by the use o f modelling by competent practitioners. According to Jourard (1971), anxiety operates as a barrier, almost acting as a protective shell in preventing the expression of one's feelings and the recognition of distress in others. Jourard suggests that this inability to self-disclose, or to be honest about one's emotions, is more prevalent amongst nurses than other groups because they are presented with poor role models at an early stage o f their professional development. He argues that individuals who retain the ability to self-disclose are happier because they achieve greater self-acceptance, and are more effective as practitioners because they help patients to self-disclose. Nurses who are unaware of their own feelings may experience greater anxiety when attempting to cope with clients' feelings. Trying too hard to be professional is seen as another barrier to empathy. Oakley (1984) contrasts the desirable qualities o f a 'good'
nurse (calm, efficient, nurturing, but not necessarily intelligent) with those of a 'good woman', but argues that to achieve professional status is not wholly desirable for nursing, as the specialist knowledge held to be a key feature o f all professions is never made available to the public they serve. Hoarding professional knowledge and being reluctant to promote health education and teach patients how to cope better with the physical and psychological effects of illness is ethically unsound. Nursing research, then, appears essential as unless we know h o w clients envisage their condition, we will remain unable to develop their knowledge or assist them in coping with the changes it brings (Benner & Wrubel 1989). The process of professionalization can be considered to commence before young people enter nursing, through impressions gained from parents, teachers and the media (Stoller 1978). However, once nurse education begins, it appears to operate as a form o f social control, commencing with the selection process which sieves through only those likely to fit the mould (Holloway & Penson 1987). As the course progresses, 'misfits' who do not meet the profession's stereotype of itself withdraw, leaving a homogenous, rather dull group to enter the qualified workforce (Wondrak 1989). Effective role modelling can encourage selfdisclosure and maintain a learner's individuality, thus increasing their self-efficacy. To be effective, empathizers must be individuals. They cannot rely on their membership of the team to see them through; their task calls for a solo flight. If one is born to be a pilot, some flying and navigation lessons seem crucial to prevent a hazardous journey. Natural ability is of prime importance in empathy and, without it, skills training alone will only achieve the first stage of Stein's (1970) empathic process - self-transposal - whereby I think myself in another person's shoes. To summarize, it is suggested that empathy is an art, a natural ability or way o f being that is a life-long process, and which develops as we mature. Self-awareness enhances that process and self-awareness skills can be taught. The 'natural ability' requires added ingredients - understanding o f and proficiency in specific microcommunication skills and awareness of how these fit into the helping process. These skills can be taught by modelling in real life situations or in simulated exercises and role play situations incorporated into a skills training programme. A study by Reynolds & Presly (1988) gives some credibility to this belief, along with the work of Aspy (1972) and Paxton et al (1988). Having attempted to clarify what empathy is, and h o w we get it, h o w then do we measure it?
What's it all about, empathy?
H O W DO WE MEASURE EMPATHY? Measuring empathy is fraught with difficulties (Gould 1990). Taft (1955)hypothesized, on the evidence of early rating instruments, that empathy might constitute a multidimensional concept, possibly incorporating objectivity, cognitive ability and abili W to understand h o w other people think. His review of 81 studies attempted to determine how individuals judge the feelings and behaviours o f others. Over the years, analysis of different scales purporting to measure empathy has repeatedly suggested that more than one construct may exist (Buckheimer 1963, Conklin & Hunt 1975, Rappoport & Chinsky 1972). As Deutsch & Mandle (1975) point out, until we have firmly identified those constructs comprising empathy, research results will remain of little value. There are many instruments purporting to measure empathy including: • self-rating scales • rating by judges or associates • client rating of empathy.
Rogers (1951) despaired of the notion that empathy could be broken down into a series of behavioural responses which could be learned and subsequently assessed, arguing that the functional aspects o f encounters would be analysed, rather than the demands of the whole situation. The instruments for measuring empathy have been developed independently and from different academic disciplines. The different approaches and their methodological flaws have been highlighted by Gagan (1983), whilst Masson (1990) points out that as confusion exists surrounding what constitutes empathy, every chance exists that the respective authors of these scales will have devised them. according to what they believe empathy encompasses.
CONCLUSION Empathy is a commonly used but poorly understood concept. It is difficult to define or measure as it appears to be a multidilT~ensional concept which has not been fully identified. It would seem that the real test o f empathic understanding is to appreciate the hopes and fears o f people with w h o m we are not similar. However, is it realistic to expect that those nurses in training, or recently qualified, who make up the major part o f the nursing workforce in the UK, to be able to empathize with all clients in the face of the difficulties discussed? To do this would be simply to accept
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the media stereotype of the nurse as an angel, which the profession is determined to dispel. A starting point may be to accept that the ability to understand and to demonstrate understanding must always matter in a caring profession. Failure to be understood may be detrimental to chent welfare (Williams 1979), and may lead to frustration and disillusionment on the part of nurses, to the point where people leave the profession. In the past 3 decades, empathy has been touted as appropriate, desirable, therapeutic and the central component in the nurse-patient alliance. Nurse educationalists have universally accepted and incorporated the empathic model of communication into nursing curricula, whilst alteruative responses including sympathy, pity and commiseration have been devalued, labelled inappropriate and judged to be not beneficial, or even harmful, for use in the clinical setting (Forsyth 1980, Holden 1990, Kalisch 1973). The views concerning empathy, emanating from the field of psychotherapy, have been accepted uncritically; however, although alternative communication strategies have not been suggested or explored, the exclusive use and therapeutic efficacy of empathy have been questioned (Diers 1990, Gordon 1987). Nurses' attention, quite rightly, needs to focus on understanding others, and empathy can help to achieve this, but in isolation it seems an impractical 'fit' for the demands o f clinical practice. Perhaps we have reached a stage where we need to lay aside preconceptions of the meaning and measurement of empathy and look beyond our present horizons, as Morse et al (1992) have suggested. Finally, having started the article with a maxim, it seems apt to end with another: Life is a voyage in which we choose neither vessel nor weather, but much can be done in the management o f the sails and the guidance o f the helm. REFERENCES
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