Journal of Advanad Nursmg, 1990,15,1167-1174
Empathy: a review of the literature with suggestions for an alternative research strategy Dmah Goidd BSc MPhil RGN DipN CertEd
Senior Lecturer tn Nursir^, Dejutrtment of Commumty Health and Nurstng Studtes, Sotdth Bank Polytechnic, 103 Borough Road, London SEl OAA, England
Accepted for publicahon 20 February 1990
GOULD D (1990) Jourrtai of Advanced Nurstng 15, 1167-1174 &npathy: a review of the literature with suggestions for an alternative research strategy Although empathy is regarded as a necessary component of good quality nursing care, defining and measunng empathy have both been fraught with problems A histoncal overview helps to explain these difificulties, as nurses have tended to accept the views of psychotherapists uncnhcally, and have used scales developed for clients m counsellmg with people who are physically ill Methodological difficulties combmed with the results of studies demonstratmg low levels of empathic abihty m nurses have culrmnated m disenchantment v«th this topic A framework is used to show why nurses cannot always demonstrate empathic awareness of every patient's need and an alternative approach for exploring the nature of empathy is suggested
INTRODUCTION
HISTORICAL OVERVIEW
It IS generally accepted that the quality of empathy, the abihty to enter another person's feelmgs and see the world through his or her eyes without losmg objechvity, must be of fundamental importance m nursmg Thus Chapman (1983) descnbes nursmg as an mterpersonal achvity demanding a high level of empathic awareness Tbs view IS shared by authors emphasizmg the need for good communicahon between nurse and patient (see Bumard 1987, Fenton 1987, Mallick 1988) although Aggleton & Chalmers (1986), argumg the need for nursing theory, imply that «npathy belongs to an era when 'Many nurses supposed that professional nursing prachce was best achieved
Most research studies concemed with empathy have been undertaken m the USA and rely heavily on the work of psychotherapists, espeaally Carl Rogers Roger's theory (1961), based on extensive expenence with clients dunng psychotherapy and counselhng, is concemed with faalitatmg the growth and development of human personality towards maximum potenhaL Accordmg to Rogers (1958), the abihty of one individual to help another depends on the creation of a relahonship fostermg warmth, genumeness, sensihvity and empathy His definihon of empathic behaviour, now regarded as classic, is
when based largely upon instind and empathy' The topic generated considerable research throughout Jo sense the client's pnvate world as if it were your own, the 195(te and 1960s, but m recent years mterest has waned without ever losmg the 'as if' quality both among psycholt^ists and nurses, possibly because (Rogers 1957) of the way in which the concq)t of ranpathy ongmally developed, a thane expanded upon below A second difficulty has been We of a dear defenitioa impeding the Throi^hout the 1960s, the research of other psydtodeveloimwnt dF vahd measunng devices therapists and counsellors tended to substanhate Roger's 1167
D Gould views (see Truax 1963, Carkhuff & Berenson 1967, CarkhufF 1969) Nurses m the USA interested m these concepts operated from the premise that all nurses, by choosing to enter the profession and to remam m prachce, care about their patients and hope to understand them (La Monica 1979) Not surpnsmgly, their defmihons of empathy rely heavily upon Rogenan theory, as this literature was most readily available Thus Gagan (1983) asserts that the most commonly used defiruhon of empathy m the nursmg literature is The ability to perceive the meaning and feelings of another person and to communicate that feelmg to the other
Table 1 Methods for quanhfying empathic b^taviour Type of approach
Examples of approach
Self-rating scales
Empathy Construct Rating Scale (ECRS) (La Monica 1981)
Ratings by expert judges or colleagues
Hogan Empathy Scale (Hogan 1969)
Client/patient ratings
Accurate Empathy Scale (AES) (Truax 1961) CarkhufFs Helpee Stimulus Expression (Carkhuff 1969)
Most contemporary nurse researchers would subscnbe to Empathy Subscale of the these views (see Kalisch 1971, Sparling & Jones 1977, Barratt-Lennard Relationship Inventory (BLRI) Stetler 1977, Layton 1979, La Monica 1979) (Ban-att-Lennard 1962) Today the term empathy is frequently employed by authors exhortmg nurses to develop mterpersonal skills, but rather loosely, parhaJarly in the popular nursmg press, where ability to empathize is often equated with ability to Grummon 1972, Conklin & Himt 1975), an idea for which care for the person as an individual Thus Wilson-Bamett there is still some evidence La Monica (1981), subjecting (1988a) implies that empathy is the ability to provide her newly developed Empathy Construct Rating Scale psychological support, while Bumard (1988) relates (ECRS) to factor analysis, concluded that it measures a empathy to commumcahon skills, particularly allowmg single trait, but a factor analysis by I A Rogers (1986) on pahents freedom to express emotion, for example by crymg the same scale indicated that two factors were measured or showing anger This use of the term empathy expressed compassion (generalized empathy) and msensihvity and almost in lay terms, is not helpful when attemphng to mdifference As Deutsch & Mandle (1975) pomt out, unhl operahonalize a definihon for research purposes because it we have firmly identified those constructs compnsmg IS too vague and ignores the vast research endeavour which empathy, research results will remam of doubtful value has stnven to determine the prease nature of the concept The value of this exerase has recently been demonstrated by Teasdale (1989) who has shown that saentific enquiry MEASURING EMPATHY concemmg the nature of the concept 'reassurance' (urgently Reynolds & Presley (1988) explam that lnshximents required because of its over-use among nurses) has been designed to measure empathy fall mto three mam groups hampered through lack of an operahonal definihon (see Table 1), which have been develof>ed independently sometimes by authors from difiFerent academic disaplmes The difiFerent approaches and their methodological flaws DEFINING EMPATHY have been highhghted by Gagan (1983) Only one of As early as 1952, pre-datmg Rogers' concern with the measures currently m use — the ECRS (La Monica onpathy, the psychologists Hastorf & Bender hypoth- 1981)—has been developed by a nurse specifically for esized on the evidence of early ratmg instruments, that use in the nursmg situahon Scales devised by therapiste empathy might conshtute a multi-dimensional concept, for dioits m psychotherapy or counsellmg may be possibly incorporahng objectivity, cogrutive ability and inappropnate m a nursmg context ability to urtderstand how other people think This view is TTie relahonship between client and counsellor is quite shared by Taft (1955) m his review of 81 studies attempt- difiPeroit from the relahonship between pahent and nurse mg to determine how mdividuals judge the fieelmgs and Many patients depotd on the nurse for physical care and behaviour of others Over the years, analysis of difiFerent those m hospital have contact with nurses all day, although scales purporhng to measure empathy has repeatedly not always the same nurse, except m units where prmiary suggested that more tiuut one construct may exist (see nursmg is practised Chents in ccHmsellmg do not depead Buckheimer 1963, RaRwpcwt & Chmsky 1972, Kurtz & on the courtsellor for physical care TTw two are irot m
Empathy
contact once the session has ended, but usually the same counsellor is seen on each occasion Tradihonally, hospital patients seem reluctant to cnticize nursmg care (Nehnng & Geach 1973) This could bias the results of empathy scales designed for pahent or client to judge helper empathy, although with the advent of consumensm m the NHS this situation may change All the scales widely used have been developed m the USA where hospital pahents as well as clients in counseUing accept payment as normal Fundamental differences between people who volunteer for counsellmg or psychotherapy and those who require health care must be considered when the same scales are used for both It is possible that people m counseUing may recognize their own needs more readily, may be more articulate, more affluent or more or less assertive of their needs than the larger hospital populahon Fmally, the aims of nurse educahon and therapist preparation differ nurses are concerned with pahent teaching and information-giving as well as with counselling (see Wilson-Barnett 1988b) The intended outcomes of nursing care and psychotherapy and counselling likewise differ Not surpnsmgly, in view of these problems and the mulhplicity of approaches taken to measure empathy, research findmgs have often been contradictory Layton (1979), for example, d e m o n s ^ e d general agreement between three empathy measures (Carkhuff Scales, the empathy subscale of the Barratt-Lermard Relahonship Inventory (BLRI) and a newly-developed empathy test), but Kalisch (1971) failed to achieve consensus between the Accurate Empathy Scale (AES), BLRI and Carkhuff Scales Lack of agreement is also shown m Forsyth's study (1979) where 50% of the nursing sample (M = 70) completmg the Hogan Empathy Scale considered themselves highly empathic compared to 9S% of the patients rating them on the BLRI Despite inherent difficulhes conceming the precise nature of empathy, and madequate methods of measurement, there have been attempts to determine elements of the 'empathic personahty' Thus Sp>arlmg & Jones (1977) could demonstrate no dififerences m empathic ability according to age, mantal status, level of education or length of nursing expenence using the Carkhuff Helpee Stimulus Expressions (1969) but found that nurses workmg in a psychiatnc sethng were significantly more empathic thai those on general wards (P
Empathy: a review of the literature with suggestions for an alternative research strategy Dmah Goidd BSc MPhil RGN DipN CertEd
Senior Lecturer tn Nursir^, Dejutrtment of Commumty Health and Nurstng Studtes, Sotdth Bank Polytechnic, 103 Borough Road, London SEl OAA, England
Accepted for publicahon 20 February 1990
GOULD D (1990) Jourrtai of Advanced Nurstng 15, 1167-1174 &npathy: a review of the literature with suggestions for an alternative research strategy Although empathy is regarded as a necessary component of good quality nursing care, defining and measunng empathy have both been fraught with problems A histoncal overview helps to explain these difificulties, as nurses have tended to accept the views of psychotherapists uncnhcally, and have used scales developed for clients m counsellmg with people who are physically ill Methodological difficulties combmed with the results of studies demonstratmg low levels of empathic abihty m nurses have culrmnated m disenchantment v«th this topic A framework is used to show why nurses cannot always demonstrate empathic awareness of every patient's need and an alternative approach for exploring the nature of empathy is suggested
INTRODUCTION
HISTORICAL OVERVIEW
It IS generally accepted that the quality of empathy, the abihty to enter another person's feelmgs and see the world through his or her eyes without losmg objechvity, must be of fundamental importance m nursmg Thus Chapman (1983) descnbes nursmg as an mterpersonal achvity demanding a high level of empathic awareness Tbs view IS shared by authors emphasizmg the need for good communicahon between nurse and patient (see Bumard 1987, Fenton 1987, Mallick 1988) although Aggleton & Chalmers (1986), argumg the need for nursing theory, imply that «npathy belongs to an era when 'Many nurses supposed that professional nursing prachce was best achieved
Most research studies concemed with empathy have been undertaken m the USA and rely heavily on the work of psychotherapists, espeaally Carl Rogers Roger's theory (1961), based on extensive expenence with clients dunng psychotherapy and counselhng, is concemed with faalitatmg the growth and development of human personality towards maximum potenhaL Accordmg to Rogers (1958), the abihty of one individual to help another depends on the creation of a relahonship fostermg warmth, genumeness, sensihvity and empathy His definihon of empathic behaviour, now regarded as classic, is
when based largely upon instind and empathy' The topic generated considerable research throughout Jo sense the client's pnvate world as if it were your own, the 195(te and 1960s, but m recent years mterest has waned without ever losmg the 'as if' quality both among psycholt^ists and nurses, possibly because (Rogers 1957) of the way in which the concq)t of ranpathy ongmally developed, a thane expanded upon below A second difficulty has been We of a dear defenitioa impeding the Throi^hout the 1960s, the research of other psydtodeveloimwnt dF vahd measunng devices therapists and counsellors tended to substanhate Roger's 1167
D Gould views (see Truax 1963, Carkhuff & Berenson 1967, CarkhufF 1969) Nurses m the USA interested m these concepts operated from the premise that all nurses, by choosing to enter the profession and to remam m prachce, care about their patients and hope to understand them (La Monica 1979) Not surpnsmgly, their defmihons of empathy rely heavily upon Rogenan theory, as this literature was most readily available Thus Gagan (1983) asserts that the most commonly used defiruhon of empathy m the nursmg literature is The ability to perceive the meaning and feelings of another person and to communicate that feelmg to the other
Table 1 Methods for quanhfying empathic b^taviour Type of approach
Examples of approach
Self-rating scales
Empathy Construct Rating Scale (ECRS) (La Monica 1981)
Ratings by expert judges or colleagues
Hogan Empathy Scale (Hogan 1969)
Client/patient ratings
Accurate Empathy Scale (AES) (Truax 1961) CarkhufFs Helpee Stimulus Expression (Carkhuff 1969)
Most contemporary nurse researchers would subscnbe to Empathy Subscale of the these views (see Kalisch 1971, Sparling & Jones 1977, Barratt-Lennard Relationship Inventory (BLRI) Stetler 1977, Layton 1979, La Monica 1979) (Ban-att-Lennard 1962) Today the term empathy is frequently employed by authors exhortmg nurses to develop mterpersonal skills, but rather loosely, parhaJarly in the popular nursmg press, where ability to empathize is often equated with ability to Grummon 1972, Conklin & Himt 1975), an idea for which care for the person as an individual Thus Wilson-Bamett there is still some evidence La Monica (1981), subjecting (1988a) implies that empathy is the ability to provide her newly developed Empathy Construct Rating Scale psychological support, while Bumard (1988) relates (ECRS) to factor analysis, concluded that it measures a empathy to commumcahon skills, particularly allowmg single trait, but a factor analysis by I A Rogers (1986) on pahents freedom to express emotion, for example by crymg the same scale indicated that two factors were measured or showing anger This use of the term empathy expressed compassion (generalized empathy) and msensihvity and almost in lay terms, is not helpful when attemphng to mdifference As Deutsch & Mandle (1975) pomt out, unhl operahonalize a definihon for research purposes because it we have firmly identified those constructs compnsmg IS too vague and ignores the vast research endeavour which empathy, research results will remam of doubtful value has stnven to determine the prease nature of the concept The value of this exerase has recently been demonstrated by Teasdale (1989) who has shown that saentific enquiry MEASURING EMPATHY concemmg the nature of the concept 'reassurance' (urgently Reynolds & Presley (1988) explam that lnshximents required because of its over-use among nurses) has been designed to measure empathy fall mto three mam groups hampered through lack of an operahonal definihon (see Table 1), which have been develof>ed independently sometimes by authors from difiFerent academic disaplmes The difiFerent approaches and their methodological flaws DEFINING EMPATHY have been highhghted by Gagan (1983) Only one of As early as 1952, pre-datmg Rogers' concern with the measures currently m use — the ECRS (La Monica onpathy, the psychologists Hastorf & Bender hypoth- 1981)—has been developed by a nurse specifically for esized on the evidence of early ratmg instruments, that use in the nursmg situahon Scales devised by therapiste empathy might conshtute a multi-dimensional concept, for dioits m psychotherapy or counsellmg may be possibly incorporahng objectivity, cogrutive ability and inappropnate m a nursmg context ability to urtderstand how other people think This view is TTie relahonship between client and counsellor is quite shared by Taft (1955) m his review of 81 studies attempt- difiPeroit from the relahonship between pahent and nurse mg to determine how mdividuals judge the fieelmgs and Many patients depotd on the nurse for physical care and behaviour of others Over the years, analysis of difiFerent those m hospital have contact with nurses all day, although scales purporhng to measure empathy has repeatedly not always the same nurse, except m units where prmiary suggested that more tiuut one construct may exist (see nursmg is practised Chents in ccHmsellmg do not depead Buckheimer 1963, RaRwpcwt & Chmsky 1972, Kurtz & on the courtsellor for physical care TTw two are irot m
Empathy
contact once the session has ended, but usually the same counsellor is seen on each occasion Tradihonally, hospital patients seem reluctant to cnticize nursmg care (Nehnng & Geach 1973) This could bias the results of empathy scales designed for pahent or client to judge helper empathy, although with the advent of consumensm m the NHS this situation may change All the scales widely used have been developed m the USA where hospital pahents as well as clients in counseUing accept payment as normal Fundamental differences between people who volunteer for counsellmg or psychotherapy and those who require health care must be considered when the same scales are used for both It is possible that people m counseUing may recognize their own needs more readily, may be more articulate, more affluent or more or less assertive of their needs than the larger hospital populahon Fmally, the aims of nurse educahon and therapist preparation differ nurses are concerned with pahent teaching and information-giving as well as with counselling (see Wilson-Barnett 1988b) The intended outcomes of nursing care and psychotherapy and counselling likewise differ Not surpnsmgly, in view of these problems and the mulhplicity of approaches taken to measure empathy, research findmgs have often been contradictory Layton (1979), for example, d e m o n s ^ e d general agreement between three empathy measures (Carkhuff Scales, the empathy subscale of the Barratt-Lermard Relahonship Inventory (BLRI) and a newly-developed empathy test), but Kalisch (1971) failed to achieve consensus between the Accurate Empathy Scale (AES), BLRI and Carkhuff Scales Lack of agreement is also shown m Forsyth's study (1979) where 50% of the nursing sample (M = 70) completmg the Hogan Empathy Scale considered themselves highly empathic compared to 9S% of the patients rating them on the BLRI Despite inherent difficulhes conceming the precise nature of empathy, and madequate methods of measurement, there have been attempts to determine elements of the 'empathic personahty' Thus Sp>arlmg & Jones (1977) could demonstrate no dififerences m empathic ability according to age, mantal status, level of education or length of nursing expenence using the Carkhuff Helpee Stimulus Expressions (1969) but found that nurses workmg in a psychiatnc sethng were significantly more empathic thai those on general wards (P
