5
Lonqnan Group UK Ltd 1987 Empathy: we know what we mean, but what do we teach? William J. Reynolds This article resulted from a paper, presented by the author, at the Hildegard Peplau seminar on the interpersonal role of psychiatric nurses, given at the Highland College of Nursing and Midwifery, Inverness. It discusses empathy ~ the ability to see things from another person’s point of view. That ability is held to be the core characteristic of a helping relationship, but a review of the literature reveals that there is little agreement about how empathy should be defined. Consequently, it is argued that there is a need for nurse teachers to define what they mean by empathy. Failure to do so may result in confusion about what is being taught. Furthermore, it is proposed that all teachers should be trained in experiential teaching methods, and that the effects of structured empathy training should be investigated within an experimental research design. THE CENTRALITY OF EMPATHY While a broad range of interpersonal constructs may be applied to the nurse-client relationship, an impressive argument can be found within the literature to support the view that empathy may be the most important facilitator of a therapeutic relationship. Carkhuff (1970) em- phasises that without empathy there is no basis for helping. That view has been repeated by numerous writers: ‘A voluminous amount of the accumulated research and theoretical findings on inter- personal relationships supports the view that empathy is the most critical ingredient of the helping relationship.’ (Kalish 1971, p 202) ‘Empathy has been found to be the primary W J Reynolds MPhil RMN RGN RNT, Senior Tutor, Post Basic Education, Highland College of Nursing and Midwifery, Raigmore Hospital, Inverness Manuscript accepted August 1987 Reprint requests to W.J.R. ingredient in any helping relationship. (La Monica et al 1976, p 447) How empathy is acquired In view of the relationship demonstrated be- tween empathy and therapeutic effectiveness, for example, Mullen et al (197 l), Altmann ( 1973) and Kendall and Wilcox (1980), it is important to know whether empathy is stable or responsive to training or education. Beres et al (1974) seem unconvinced that empathy can be learned. Those writers expressed the view that the literature does not make it clear whether empathy is innate, or whether it re- presents something which can be developed through training. Perhaps this confusion is re- lated in part to the fact that a review of the literature reveals that there is little agreement about how empathy should be defined. Definitions of empathy Almost irrespective of theoretical orientation, 265

Empathy: we know what we mean, but what do we teach?

Embed Size (px)

Citation preview

Page 1: Empathy: we know what we mean, but what do we teach?

Lonqnan Group UK Ltd 1987

Empathy: we know what we mean, but what do we teach?

William J. Reynolds

This article resulted from a paper, presented by the author, at the Hildegard Peplau seminar on the interpersonal role of psychiatric nurses, given at the

Highland College of Nursing and Midwifery, Inverness. It discusses empathy ~ the ability to see things from another person’s point of view. That ability is held to be the core characteristic of a helping relationship, but a review of the literature

reveals that there is little agreement about how empathy should be defined. Consequently, it is argued that there is a need for nurse teachers to define what

they mean by empathy. Failure to do so may result in confusion about what is being taught. Furthermore, it is proposed that all teachers should be trained in experiential teaching methods, and that the effects of structured empathy training should be investigated within an experimental research design.

THE CENTRALITY OF EMPATHY

While a broad range of interpersonal constructs

may be applied to the nurse-client relationship,

an impressive argument can be found within

the literature to support the view that empathy

may be the most important facilitator of a

therapeutic relationship. Carkhuff (1970) em-

phasises that without empathy there is no basis

for helping. That view has been repeated by

numerous writers:

‘A voluminous amount of the accumulated

research and theoretical findings on inter-

personal relationships supports the view that

empathy is the most critical ingredient of the

helping relationship.’ (Kalish 1971, p 202)

‘Empathy has been found to be the primary

W J Reynolds MPhil RMN RGN RNT, Senior Tutor, Post Basic Education, Highland College of Nursing and Midwifery, Raigmore Hospital, Inverness Manuscript accepted August 1987 Reprint requests to W.J.R.

ingredient in any helping relationship. (La

Monica et al 1976, p 447)

How empathy is acquired

In view of the relationship demonstrated be-

tween empathy and therapeutic effectiveness,

for example, Mullen et al (197 l), Altmann

( 1973) and Kendall and Wilcox (1980), it is

important to know whether empathy is stable

or responsive to training or education. Beres et

al (1974) seem unconvinced that empathy can

be learned. Those writers expressed the view

that the literature does not make it clear

whether empathy is innate, or whether it re-

presents something which can be developed

through training. Perhaps this confusion is re-

lated in part to the fact that a review of the

literature reveals that there is little agreement

about how empathy should be defined.

Definitions of empathy

Almost irrespective of theoretical orientation,

265

Page 2: Empathy: we know what we mean, but what do we teach?

266 NURSE EDUCATION TODAY

the concept of empathy, originating from the German word ‘Einfuhlung’ as used by Lipps (1903), (which means literally feeling within), refers to the ability of one person to experien- tially ‘know what another is experiencing at any given moment, through the latter’s eyes’. In other words, nearly all theorists refer to a perceptual rather than a communicating skill. References to empathy as a trait or human quality, indicate that ‘a necessary condition of empathy is that the observer understands in some sense, the affective state of the empathee’ (Smither 1977, p 254).

Kalish (1973) wrote:

‘Empathy is the ability to enter into the life of another person, to accurately perceive his current feelings and their meanings. In em- pathy, the helper borrows his patients’ feel- ings in order to fully understand them, but he is always aware of his own separateness. He realises that the feelings of the patient are not his own. (p 1548)

However, some theorists have conceptualised empathy in a manner which differs from that of clinical theory. Thus, Truax (1961) wrote:

‘Accurate empathy involves more than the ability of the therapist to sense the patient’s “private world” as if it were his own. It also involves more than just the ability of the therapist to know what the patient means. Accurate empathy involves both the sensitiv- ity to current feelings and the verbal facility to communicate this understanding in a lan- guage attuned to the client’s feelings. (p 2)

The Traux definition has shifted the emphasis from a way of perceiving to a way of com- municating, from a trait or human quality to a form of interaction. This shift in definition has resulted in a discussion about how empathy is best taught and measured. Some writers suggest that empathy is an art and that this concept defies rigourous measurement. However, Zoske et al (1983), argue that empathy is now regarded as an interpersonal concept, com- prising a specific set of skills, rather than an instinctual quality possessed by certain persons,

and that these skills are both teachable and measurable.

The teaching and measurement of empathy

Because nursing is essentially a series of nurse- client interactions, and empathy is considered to be an essential prerequisite to the helping relationship, there is a need to establish, once and for all, whether empathy can be acquired through education and training. Experimental, didactic and experiential (student-centred) training programmes in the USA (Carkhuff & Truax 1965; Kalish 197 1; La Monica 1976; Law 1978; Kirk 1979; Layton 1979), indicate that state empathy (interactional gmpathy) can be taught. However, the results of several of these studies have been inconclusive. The Kalish (1971) study, while reporting a significant improvement in empathy, a self-evaluation, and a clinical instructor’s evaluation of empathy, showed no gains on a client evaluation of empathy. Similarly, Layton (1979) reported mixed results when empathy ratings for junior students increased, but not for senior students. La Monica [ 1976) indi- cated that, while intensive empathy training significantly raised nurses’ levels of empathy, more training was needed to enable all subjects to reach at least the minimal level of empathy necessary to successfully help another person. Further confusion arises from the study con- ducted by Disiker & Michiellute (1981) which explored the nature and direction of trait em- pathy (empathic disposition or cognitive em- pathy) in medical students over a period of time. No evidence was found that trait cm- pathy was positively changed by exposure to a course in human communication.

Those studies attempted to measure empathy using a variety of differently constructed instru- ments. In spite of the lack of correlation which has been reported among the different empathy scales used, research has generally indicated that they are all reliable and valid measures of empathy. Barrett-Lennard (1974) has suggested that relating to another person empathically

Page 3: Empathy: we know what we mean, but what do we teach?

NURSE EDUCATION TODAY 267

involved certain distinct phases. It is possible that different scales measure different phases of empathy, for example, therapist traits (empathic disposition), or global therapist qualities such as the therapist’s communicated commitment to the therapy interaction. While some doubt may always exist about what is actually being measured, those studies tend to support the view that state empathy might be a type of behaviour which would respond to training. By contrast, Disiker & Michiellute’s (1981) research suggests that trait empathy may be an extremely stable quality that is resistent to short-term education in adulthood. This view is congruent with Hogan’s (1975) claim that trait empathy is relatively impervi- ous to short-term training, while state empathy should be relatively easy to teach and learn.

EXPERIENTIAL LEARNING

A review of the literature reveals that several teachers and researchers have suggested that experiential (student-centred) learning which included skills analysis, followed by practice, followed by feedback, is the most effective form of interpersonal skills training (see Reynolds 1982; Reynolds & Cormack 1985; Ellis & Watson 1985; McLeod-Clark 1985). Central to that approach is Bandura’s (1977) view that self-efficacy, the degree of 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’s work suggests that a great deal of interpersonal responses are learned vicariously, in other words, established at a distance through the observation of others. It is possible, therefore, that without an initial role model to learn from, the individual might well not acquire behaviours, or the idea that certain behaviours can effectively bring rewards. While past re- search has encouraged teachers to believe that a type of (cognitive-behavioural) empathy can be .taught by experiential teaching- methods, empathy.

Analysis of data confirmed and supported the conclusions drawn from American research. No statistically significant change occurred among measures of trait empathy during a 3- month nursing module, and a close association was shown to exist between stable aspects of personality on Cattell’s 16PF test, and scores on the Hogan Scale. By contrast, state em- pathy, as measured by the Empathy Construct Rating Scale, did significantly change among most measures (self-report, client and charge nurse-ratings) in two out of three colleges of nursing. While this study could not establish whether teaching was effective, it is suggested that state empathy may not be stable, and that it is a promising ‘target’ for nurse educators.

Part of Reynolds’ study involved an examin- ation of the students’ educational programme by means of a semi-structured interview with nurse teachers. Differences existed among three nursing colleges in respect of how teachers defined, taught and assessed empathy. Amongst the sample (n = 15), teachers’ views differed about whether empathy could be taught and learned, and those views were, in part, related to individual teacher’s operational definition of

the absence of an agreed operational definition of empathy, poses a problem for teachers. The problem is, how to know what is being taught and learned.

CURRENT SCOTTISH EMPATHY RESEARCH

Some of the issues discussed here were ad- dressed by Reynolds (1986) who explored the nature and direction of change in student nurses’ empathy, during the progress of the first psychiatric nursing module, in the Scottish Semi-Comprehensive System of nurse training. The measuring instruments were the Hogan Empathy Scale, a self-reporting measure of trait empathy, and the Empathy Construct Rating Scale, a self-reporting, client, and as- sociate measure of state empathy (see Hogan 1969; La Monica 1981).

Page 4: Empathy: we know what we mean, but what do we teach?

268 NURSE EDUCATION TODAY

Operational definitions of empathy

A minority of teachers (n= 5) provided a

cognitive-behavioural definition of empathy,

and clearly viewed empathy as a form of

interaction which could and should be taught.

A good example included:

By contrast, the majority of teachers (?I= 10)

provided a cognitive definition of empathy. For

example:

‘Empathy is an attitude, it refers to the

degree of sensitivity towards anothers

feelings.’

‘An empathic individual can accurately Most subjects who perceived empathy to be

understand another person’s experiences, can a trait, or perceptive quality, were less certain

objectively “view the world” through that that it could be taught than those who viewed

person’s “eyes”, and can respond therapeuti- empathy as a type of interaction. A few

cally to the emotional content of another’s regarded it as being unteachable. Examples

communication.’ included:

It could be assumed that if teachers viewed

empathy as a type of interaction, then their

teaching and evaluation would focus upon

behaviour as well as attitudes. In this case, that

assumption proved to be correct. A variety of

experiential teaching methods, in both the

classroom and clinical areas, were described

which concentrated on the students’ ability to

demonstrate their comprehension of an

individual’s world. An example included:

‘How do you teach empathy?’

and

‘I’m not sure whether empathy can be

taught or whether it is a skill or an attitude.’

‘During clinical practice students complete

and discuss a daily journal with me. I am

asking them to share thoughts and feelings.

To begin with they tend to write what they

think I want to read but, as a rule, they

eventually become more open.’

Unlike subjects who viewed empathy as a form

of interaction, evaluation tended to be some-

thing that had not been seriously considered.

Teachers appeared to be surprised to be asked

whether empathy objectives existed, and any

evaluation that did occur tended to be based

on poorly defined and subjective impressions.

‘I think that it is an overall impression: 1

haven’t really thought about it to tell the

truth.’

and

A variety of assessment approaches were

utilised. Those included the use of global rating

scales and/or a comparison of the teacher’s

experiential knowledge of clients with the

student’s perception. One subject depended on

his memory of a modified version of the Truax

Accurate Empathy Scale. The utilisation of this

scale was emphasised by the following

comments:

‘I don’t really know what I teach students

about empathy. My objectives are vague.’

‘A minority of students display a very low

level of empathy, O-l on the scale, either

ignoring or only partially picking up what

the client means. Some of our students reach

If evaluation is global, or does not exist, one

might wonder which criteria teachers use to

provide students with feedback, and how

teachers evaluate the effectiveness of teaching.

While cause-effect relationships are difficult to

establish, it is possible that failure to evaluate

teaching outcome may result in ineffectual em-

pathy training.

a much higher level on the scale where they

accurately put back their perceptions to the

CONCLUSION

client.’ Research has tended to suggest that empathy is

Page 5: Empathy: we know what we mean, but what do we teach?

NURSE EDUCATION TODAY 269

a

disposition) would appear to be resistent to the influence of short-term education, the inter- actional phase of empathy (state empathy), comprising a specific set of behavioural responses, might be responsive to short-term education.

Recent Scottish research (Reynolds 1986) has that nurse teachers are often unclear about what they mean by empathy and that the confusion of the construct has

for teaching and learning. Teachers who viewed empathy as a trait, or perceptual quality, tended to believe that it could not be taught and measured. By con- trast, teachers who considered empathy to be a form of tended to believe that

learning in both the classroom and clinical areas could facilitate the empathic approach.

While structured teaching methods have been associated with significant changes in learner’s state empathy, further

research is necessary if we are to establish how best we can facilitate that type of

In order to further investigate this problem it may be necessary to train nurse teachers in teaching methods. Finally, it is proposed that a common oper- ational definition of empathy would facilitate

teaching and future empathy research.

References Altmann H 1973 Effects of empathy, warmth and

genuineness in the initial counselling interview.

Counsellor Education and Supervision 12: 225-228

Bandura A 1977 Self efficacy: towards a unifying theory of

behaviour change. Psychological Review 84: 191-215

Barrett-Lennard G 1974 Empathy in human relationships:

significance, nature and measurement. Paper presented

at the Annual Conference of Australian Psychological

Society, Perth

Beres D, Barlow J 1974 Fantasy and identification in

empathy. The Psychoanalytic Quarterly 43: 26-50

Carkhuff R, Traux C 1965 Training in counselling and

psychotherapy: an evaluation of an integrated didactic

and experiential approach. Journal Consulting

Psychology 29: 333-336

Carkhuff R 1970 Helping and human relations: a primer

for lay and professional helpers (Vol 2). Rinehart &

Wintson Inc, New York

Disiker R, Michiellute P 1981 An analysis of empathy in

medical students before and following clinical experience.

Journal Medical Education 56: 1004-1010

Ellis R, Watson C 1985 Learning through the patient. Nursing Times 81: 52-54

Hogan R 1969 Development of an empathy scale. Journal

of Counselling and Clinical Psychology 33: 307-316

Hogan R 1975 Empathy: a conceptual and psychometric

analysis. The Counselling Psychologist 5: 14-18

Kalish, B 1971 An experiment in the development of

empathy in nursing students. Nursing Research 20: 202%

211

Kalish B 1973 What is empathy? American Journal of

Nursing 73: 1548-1552

Kendall P, Wilcox L 1973 Cognitive behavioural treatment

for impulsivity: concrete vs conceptual training in non

self-controlled problem children. Journal Consulting and

Clinical Psychology 48: 8&91

Kirk W 1979 The effect of interuersonal process recall

method training and interpersonal communicating

training on the empathic behaviour of psychiatric

nursing personnel. Thesis, University of Kansas

L .a Monica E, Carew D, Winder A, Haase A, Blanchard K

1976 Empathy training as the major thrust of a staff

development programme. Nursing Research 25: 447~451

L ,a Monica E 1981 Construct validity of an empathy

instrument. Research in Nursing and Health 4: 389400

L ,aw E 1978 Toward the teaching and measurement of

empathy for staff nurses. Thesis, Brigham Young

University, Salt Lake City, Utah

Layton J 1979 The use of modelling to teach empathy to

nursing students. Resfarrh in Nursing and Health 2:

163-176 Lipps T 1903 Einfuhlung. lnnere Nachahmung, Cnd

Organemplindungen. Archives of Gestalt Psychology 20:

135-204

McLeod-Clarke J 1985 The development of research in

interpersonal skills in nursing. In: Kagan C (ed)

Interpersonal skills in nursing, research and applications.

Groom Helm, London

Mullen J, Abcles N 1971 Relationship of liking, empathy

and therapist’s experience to outcome of therapy.

Journal Counselling Psychology 18: 39-43 Reynolds W 1982 Patient-centred teaching: a futur-e role

for the psychiatric nurse teacher? Journal of Adbanred

Nursing 7: 469-475

Reynolds W, Cormack D 1985 Clinical teaching of group

dynamics: An evaluation of a trial clinical teaching

programme. Nurse Education Today 5: 10~108

Reynolds W 1986 A study of empathy in student nurses.

M.Phil Thesis, Dundee College of Technology

Smither S 1977 A reconsideration of the development study

of empathy. Human Development 20: 253--276

Traux C 1961 A scale for the measurement of accurate

empathy. Wisconsin Psychiatric Institute. Discussion

paper 20, Madison, Wisconsin

Zoske J, Pietrocarlo D 1983 Dialysis training exercise for

improved staff awareness. American Association of

Nephrology and Technicians Journal 19-39