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Abstract

The concept of empathy lies amid much confusion This analysis addresses that confusion using Walker and Avant's model of concept analysis, and looks at what empathy is is it trait or state, is it dynamic or static, and how is it recognized and measured' Implications of these findings are discussed, limitations of the study are acknowledged and areas for further work suggested
Joumal of Advanced Nursmg, 1996,23,1162-1167
A concept analysis of empathy
Theresa Wiseman RGN BSc(Hons)(Psy) RCNT RNT PGDE
Nurse Tutor, Bloomsbury and Islington
College
of Nursing and Midwifery, London,
England
Accepted
for
pubhcation 2 August 1995
WISEMAN
T
(1996) Journal of Advanced Nursing 23,1162-1167
A concept analysis of empathy
The concept of empathy lies amid much confusion This analysis addresses that
confusion using Walker and Avant's model of concept analysis, and looks
at
what empathy is
is it
trait
or
state,
is it
dynamic
or
static, and how is
it
recognized and measured' Implications of these findings are discussed,
limitations ofthe study are acknowledged and areas
for
further work suggested
INTRODUCTION
Empathy
is a
tenn widely used and written about
m
nurs-
mg and,
as
such,
its
meaning
and
apphcation has become
blurred When this happens,
one way to
clanfy
a
term
is
to conduct
a
concept analysis When embarking
on con-
cept analysis. Walker
&
Avant (1983) advocate choosing
a
concept
in
which
you are
akeady interested, either
one
associated with
the
work
or one
that
has
always been
of
concern
to you
Eighteen years' expenence
of
nursmg
led
to
the
author, long ago, forming
a
tentative opinion that
it
IS
the abihty
to
empathize which distinguishes
an
average
nurse from
an
excellent nurse
in the
eyes
of
the patient,
regardless
of
how care
is
delivered Accompanying this
is
the fact that durmg
a
3-year breeik
m
service
to do a
full-
time degree
in
psychology,
the
author noted
an
increased
interest
m the
subject
of
empathy
m the
nursing press
m
relation
to
management, education
and the
process
of
nursing
The hterature highlights the need
for
analysis Tshuldm
(1989) asserts that no area of nursmg demands more empa-
thy than
any
other
The
more empathic nurses
are, the
more likely they are
to
give total care Sharkey (1985) sug-
gests that those nurses who seemed
to be
trusted
by
their
patients
and
approved
of by
colleagues were those with
the ability to imagine how each
of
their patients felt, from
each patient's perspective, takmg mto account their vaned
backgroimds cuid different reactions
to
illness
and
hospi-
talization Reynolds (1987) reveals that although empathy
IS
the
most cntical ingredient
of
the helping relationship
(Kalisch 1973), there
is
little agreement
as to how it is to
be defined
His 1986
research
m
Scotland demonstrated
Correspondence Theresa Wiseman, 26
Wanstead
Park Avenue, Wanstead,
London E12 5EN England
that nurse teachers are often unclear about what they mean
by empathy and that confusion
of
the construct has impli-
cations
for
teaching
and
learning Homblow
and
others
(1977) point
out
that research
on
empathy
is
comphcated
by
the
absence
of an
agreed theoretical framework
and
operational definition
PURPOSE OF ANALYSIS
The purposes
of
concept analysis mclude clarification
of
terms which have become catch-phrases
and
have lost
their meaning,
a
means
of
developing operational defi-
nitions
for use
Ul theory
and
research
and an
intellectual
exercise (Walker
&
Avant 1983)
In
this analysis, the mam
purposes were
to
mcrease knowledge
of
the concept
and
to answer some questions Namely, what
is
empathy,
if it
IS
so
important,
how is it
recognized, nurtured
and sus-
tained, under what conditions does
it
fiounsh
and
dimm-
ish,
and IS it
static
or
dynamic' Walker
and
Avsmt's
framework is used because, edthough sympathizing with
Rodger's (1989) comments
on
entity
and
dispositional
views,
this
IS
a
first attempt at concept analysis and Walker
and Avant's
1988
book provides full information
and
simplifies
the
process
In order
to
gain
an
idea
of
working definitions
of
empa-
thy used
by
'ordinary' nurses,
a
group
of
nurses
at the
Royal College
of
Nursmg, London, was asked 'What came
to
mmd
when
the
term empathy
was
used''
It
could
be
argued that this was
not a
representative group
of
nurses
as they were
on a
course
of
study
so may
differ
m
terms
of better access
to
reading matenal, time,
and
other
resources They may also have higher than average motiv-
ation To address this, comments were also added
bom a
group
of
nurses
of
vanous ages
and
experience sittmg
in
a hospital refectory
The
'brainstorm' produced
the
1162© 1996 BlackweU Science Ltd
A concept analysis of empathy
following Listening, Canng, Understandu^,
Feelmg, Empathy, Non-)uc^emental, See how others see.
Permission
In this paper I will consider the ongins of the word
'empathy' and the dictionary defimtions, examme the
broad quahties of empathy as descnbed by Kalisch (1973)
and Bumard (1988), address the debate about whether
empathy is 'trait' or 'state', consider how researchers
define empathy emd finally, examme empathy from the
patients' point of view
DICTIONARY DEFINITIONS
The Fontana (1988) Dictionary of Modem Thought high-
lights the ongms of the word empathy It was comed by
Vemon Lee m 1904 and then employed by
E B
Titchener,
a psychologist, in 1909 as a translation of the German
'Emfdhlmg' which means 'feelmg into' This notion had
been developed by Lotze (1908), provoking the Alienation
Theory of Brechtm However, this is not the forum to
develop this discussion further (see Fontana (1988)
Dictionary of Modem Thought) The following is the most
abstract definition of empathy
Projection (not necessarily voluntary) of the self mto the feehngs
of others, mto the 'being' of objects or sets of objects, it miplies
psychological involvement, at once Keat's pain and joy
This suggests that empathy can occur subconsciously as
well as consciously, with mammate objects as well as ani-
mate, that It mvolves the mind or psyche, and that it can
cause pam as well as joy Another definition which men-
tions inanimate objects is m Chambers 20th Century
Dictionary (1983 p 325)
the power of entenng into another's personality and lmagmat-
lvely experiencing his expenences, the power of entenng mto the
feelmg or spirit of somethmg (especially a work of art) and so
appreciate it fully
Here one gets the notion of a strength rather than a weak-
ness,
and the idea of valuing from 'appreciate it fully' The
Longman Dictionary of Psychology and Psychiatry (1984)
emphasizes the objectivity and interpretation Eispect
the objective awareness of another person's thoughts and feel-
mgs and their possible meanings One who empathizes sustains
his objectivity and separate feehngs even when confronted with
disturbu^ psychological matenal
Two nursmg dictionanes were then consulted Saimders
(1989) Encyclopedia and Dictionary of Medicine, Nursing
and Apphed Health pomts to the understanding compo-
nent and compares empathy with sympathy
Intellectual and emotional awareness and imderstandmg of
another person's
thoughts,
feelmgs
and
behaviour,
even those that
are distressing and disturbing Empathy emphasises understand-
ing, sympathy emphasises sharing of another's feelings and
expenences
Mosby's Medical and Nursmg Dictionary
(1986)
highlights
the understandmg and significance of the person and the
importance of empathy for psychotherapy
The ability to recognise and to some extent share the emotions
and states of
mmd
of another and to understand the meaning and
significance of that person's behaviour It is an essential quabty
for effecbve psychotherapy Compare with sympathy, which
is
an
expressed mterest or concem regarding the problems, emotions
or states of mmd of another
LITERATURE REVIEW
The literature concerning empathy shows a wide range of
use ofthe word, from broad to specific Apart from diction-
ary defimtions, five of which were selected, a literature
search gave 53 references All these references were exam-
ined but consensus led to 33 bemg used in this article
The five dictionary definitions are important to begin the
analysis as each contains differing elements which come
out in the hterature
Early theonsts and wnters saw empathy as a trait or
charactenstic which was stable and could he measured but
not taught Among these are Cronhach (1955), Hogan
(1969),
Smither (1977) and more recently, Astrom et al
(1991) Cronbach and Hogan devised personahty tests to
test for empathy These authors define empathy as a per-
sonality attnbute mvolvmg the capacity to respond
emotionally, cognitively and communicatively to other
persons without the loss of objectivity From this defi-
nition, it can be seen that the quahties of empathy mirror
the other theonsts but the denvation is different Latterly,
theonsts see empathy as havmg both 'trait' and 'state'
components
Williams (1989) maintains that people have a tendency
to expenence empathy that may or may not be actualized
in any specific situation Her research investigated the
relationship between empathy and burnout, tentatively
suggesting that they may represent opposite poles of the
same underlying construct However, no support for a
polar relationship was foimd Sharkey (1985) asks why so
few nurses with the abihty to empathize actually use it
She suggests that nurse traimng damages the innate ability
of the tramee to empathize
Confusion
As noted earlier, some wnters seem very specific and clear,
about what empathy is whilst others (the minonty) are
imclear, and the concept can easily be confused with other
terms,
such as sjmipathy or commumcation Among the
latter are Smith (1985), Assimacopoulos (1987) and
Wilson-Bamett (1988) Smith (1985, p 5) says empathy is
©
1996 Blackwell Science Ltd,
Joumal
of
Advanced
Nursing,
23,
1162-11671163
T Wiseman
'knowing what the other person is suffenng because you
can imagine yourself in similar circumstances or because
you have had similar expenence' The reader could easily
be forgiven for confusing this with sympathy
Assimacopoulos (1987) also confuses empathy with sym-
pathy and Wilson-Bamett asserts that nurses who talk less
are perceived as bemg more empathic
Bumard (1988) defines empathy as the ability to see the
world as another person sees it or to enter mto another's
frame of reference One attempts to set aside one's own
perception of thmgs in order to think the way the other
person thinks or feel the way they feel Bumard distingu-
ishes empathy from sympathy S5rmpathy involves 'feeling
sorry' for the other person or imagining how we would
feel if we were expenencmg what is happening to them
Empathy differs m that we try to imagine what it is like
being that person and experiencing things as they do, not
as we would
Bumard (1988) sees empathy as the key to understand-
ing and, as such, a vital skill for nurses to leam He
explains that the skill of empathy involves two related
processes One is attempting to view the world as the
patient does and the other is attemptmg to identify the
personal theory that guides patients m their everyday
expenence Because Bumard sees empathy as a skill,
he concentrates on methods of developing empathy for
climcal and educational staff
Kalisch (1973) asserts that empathy must involve current
feelings of a person, not the feelmgs of yesterday or the
day before She states that it is the ability to enter mto the
life of another person, stressing the importance of the per-
ception of feelmgs bemg accurate Kalisch also compares
empathy to sympathy, explaining that m empathy helpers
borrow their clients' feelmgs m order to understand them,
but are always aware of their separateness In her defi-
nition of empathy, Kalisch (1973) does not include
the communication of understanding, but does not state
that when empathy is communication, it forms the basis
for a helping relationship She views empathetic per-
ception and communication as a state m terms of levels or
categones rather than an 'all or nothmg' charactenstic
Three components
Rogers (1957) descnbed empathy as having three com-
ponents affective (sensitivity), cognitive (observation
and mental processing), and communicative (helper's
response) LaMonica (1981) highlights the commumcation
aspect of empathy She defines empathy as sigmfymg a
central focus and feehng, with and m the chent's world
It mvolves accurate perception of the chent's world by the
helper, commumcation of his/her understandmg to the
chent, and the chent's perception of the helper's under-
standing LaMonica and others (1976) showed that nurses
initially scored low m empathy hut this level mcreased
followmg a staff development progreimme Truax
&
Milhs
(1971) asserted that nurses are generally low m empathy
compared to other professional groups Situational factors
have been found to eiffect the level of empathy expressed
(Olsen
&
Iwasiw 1989)
Carkhuff (1969) was one of the first theonsts to assert
that if empathy was a state, it was dynamic and therefore
could be measured on different levels He suggested that
empathy is employed when one mdividual hears and
understands another It mvolves 'crawhng inside another
person's skin' and seeing the world through his/her eyes
It mvolves expenencmg the world as if you were that
person Carkhuff (1969) stressed the commimication of
empathy and devised a scale to measure empathy on five
levels based on the response, whether the feehng was
acknowledged or not, surface feehngs refiected and the
interpretation of underlying feeling communicated Other
theonsts who have also devised scales include Gazda
(1973) and LaMomca (1981)
TEACHING EMPATHY
As the consensus is that empathy is a skill which is crucial
to the helping relationship, many authors discuss methods
of teaching empathy most effectively (Layton 1979,
Bumard 1987, Cox 1989, Morath 1989 and Tshuldm 1989)
Bumard (1987) suggests that before nurses can understand
and explore a patient's perspective, they must explore
their own perspective Self-awareness, therefore, is a prere-
quisite to empathy Bumard identifies other skills neces-
sary for empathy including the ability to listen, to offer
free attention and to suspend judgement Tshuldm (1989)
highhghts self-awareness, communication skills, especi-
ally listening, perception of feelings withm self and others
and hidden feelmgs, emd not judgmg others
The literature makes very little mention of the client's
views on empathy Rogers (1957) states that bemg under-
stood
IS
the most basic human need, and it is only by bemg
understood and accepted that individuals are able to
change and grow Although there is literature to show that
empathy affects the helping relationship, there is a lack of
reference to the client's pomt of view Engledow (1987), a
nurse, identifies empathy as being vital to her if she were
a patient Many studies do not even use patient assessment
of empathy This is clearly a deficit ui the literature which
needs to be addressed
DEFINING ATTRIBUTES
Having examined the literature, the next step according to
the Walker & Avant (1988) model is to identify 'defining
attnbutes' A defining attnbute is something which has to
be present for the concept to occur Each charactenstic
evident from the hterature is discussed and either accepted
or rejected as a defijiing attnbute
1164© 1996 Blackwell Science Ltd, Joumal of Advanced Nursing, 23, 1162-1167
A concept analysis of empathy
Trait
or state
This was rejected as a defining attnbute because empathy
occurs regardless of whether it is a state or trait The htera-
ture points to empathy being both People have a dispo-
sition to be empathic, but whether they are or not depends
on situational factors
See the world as others see it
All 53 references without excepbon mcluded this as a
charactenstic of empathy Two of the dictionary defi-
mtions proposed that 'others' could mean an object rather
than a person This was accepted as a definmg attnhute,
without this empathy cannot occur
Understand another's current feehngs
All references included understanding another's feehngs,
which was accepted as an attnbute Some wnters, among
them Kalisch (1973), stress the importance of current feel-
mgs because perceptions had to be accurate This part of
the charactenstic was rejected hecause if a person is relat-
mg an instance about how they felt m the past, it is still
possible to be empathic and acknowledge the feelings of
the past even though they do not feel that way at present
Non-judgemental
Most references (40) highlight ohjectivity as a component
of empathy Rogers (1957) redefines this mto non-
judgemental Although It could be argued that, if the other
attnbutes were present (that is, seeing the world as others
see it and understanding the feelmgs of
others),
this would
automatically be present also The author consulted many
colleagues as to this attnbute because some argued that
one could understand but still be judgemental This was
accepted because of its importance, but is more tentative
than the other attributes
Communicate the understanding
Commumcation of understanding seems vital if empathy
IS to be felt Although early works do not include this, it
does seem implicit All tools for measuring empathy
mclude communication of imderstandmg, so this was
regarded as an attnbute
Summary of definmg attributes
1 See the world as others see it
2 Non-judgemental
3 Understandmg emother's feelmgs
4 Commumcate the understandmg
tenze archetypes and deviations This will help the reader
to clanfy the concept
Model case
Ann, who is 35 years old, has two children and is suffenng
from cancer of the ovary, went to see a counsellor The
counsellor, a 50-year-old man, listened to Ann as she
described her background and how she had been taku^
her anger about her illness out on the children By what
he said and how he acted, Ann knew that he understood
how she felt, and did not hlame her for being angry This
IS a model case because it contains all the attnbutes Even
though Ann and the coimsellor have very different 'terms
of reference', he listens to what she says, sees the situation
from her point of view, is not judgemental and is able to
communicate that imderstandmg to her
Borderline case
It was Joe's first day back at school since his father had
died At break-time, he was in the classroom crymg His
teacher came m, listened to how he felt but said nothing
He thought she understood, but she did not say anythmg,
he wished his father was there
This IS a borderline case because the teacher listens to
Joe and he thinks she understands that he is upset about
his father and is a 'cry baby' But he is not sure, as she did
not say anjrthmg It leaves him feelmg uncertsun about the
mteraction and wishmg for secunty
Related case
Beth was upset, she had been forbidden to go out as she
had been consistently late home She was gomg to miss a
dance which everyone was gomg to attend Kathrjrn said,
'Poor Beth,
I
know how you feel
I
had to miss an important
dance when I was your age because I'd npped my dress
and had nothing to wear'
This IS a related case of sympathy Katluyn sees Beth is
upset over missing the dance, and thinks she would feel
the same In fact, she remembers a time when exactly that
happened and she was upset Katluyn is getting the lmtial
feehng Beth is expressing But she is mterpretmg it from
her own background and expenence so she misses com-
pletely what it means to Beth Although Beth senses the
warmth of the mteraction, she does not get any feehngs of
understanding, though there does not appear to be any
judging
MODEL AND BORDERLINE CASES
At this stage. Walker and Avant (1988) advise demonstrat-
ing a model case and several borderlme cases to charac-
Contrary case
Mrs Jones felt desperate and told the nurse she could not
go on with life 'Oh, don't be silly,' the nurse replied
'You've got a lot to live for'
©
1996 Blackwell Science Ltd,
Joumal
of
Advanced
Nursmg,
23,
1162-11671165
T Wiseman
This IS a contrary case as there is no acknowledgement
of how Mrs Jones is feeling The nurse does not attempt
to see the world through Mrs Jones' eyes She is judge-
mental and does not communicate any understandmg Mrs
Jones IS left feelmg remonstrated It took a lot for her
to voice her desperation, she knew nobody would
understand and that she was not worth bothermg about
Once the model cases have been identified, the next step
IS
to specify the charactenstics present whenever the event
occurs These are the antecedents (the required charac-
tenstics needed before the concept occurs) and the
consequences (the product of the concept occumng)
Antecedents
This area was quite difficult to identify as there was con-
fusion as to whether antecedents apphed to an mcidence
of empathy or the skill of empathy It was decided to
address both Before empathy occurs there has to be (a) an
interaction mvolvmg communication of a feeling, and
(b) hstemng on both sides, one to the feelings and thoughts
of the 'empathee' and the other to empathy being
conveyed
There was consideration of whether a conscious desire
to empathize was an antecedent, but this was rejected as
It could not account for mstances where empathy is sub-
conscious and not desired Self-awareness was also con-
sidered as an antecedent as many programmes teachmg
empathy begin with self-awareness This was rejected
because some people are naturally empathic (the trait
aspect) without bemg necessanly self-aware
Consequences
The consequences of an empathic interaction is that
'empathees' have a hasic need to be understood satisfied,
they feel valued and more ready to understand themselves
and change The person bemg empathic feels satisfied
because he/she senses they have been of help and fulfilled
the need to be useful to others
The last stage of the model is to identify what phen-
omena demonstrate the occurrence of the concept The
empmcal referents determine when the concept has
occurred, so can be used as a measure They may be similar
or identical to the defining attnhutes Indeed, m this
analysis they are the same
Empincal referents
Empincal referents are (a) the abilify to listen, (b) the
ability to take on another's term of reference, (c) the ability
to understand and not judge, and (d) the ability to
communicate that understanding
DISCUSSION
Reading through the hterature, confusion has occurred
because of the trait/state argument and the absence of a
working definition of empathy However, there does now
appear to be consensus that a person may have a dispo-
sition to be empathic (trait) but whether she/he is depends
on a number of factors (state) The research question deter-
mines which element of empathy is examined, whether it
be the subject's disposition or the mcidence of empathy,
how often empathy occurs or the qualify ofthe interaction
It IS the latter aspect which caused the author some
difficulfy Most research is quantitative and the existing
tools which measure empathy (mcluduig Carkhuff 1969,
and LaMonica 1981) begin with level one which is 'ignores
feehngs expressed' even though it is specified that a mmi-
mum level of empathy is level three which fulfils the defi-
nition This should be addressed, as it could be this
dichotomy which is causing confusion
Research also needs to measure empathy more globally,
mcluding subject self-report, client report and observation,
both participant and non-participant This may address
verbeJ and non-verbal communication of empathy and the
feet that attitudes do not always reflect behaviour and that
what people say they do and actually do are not always
the same
CONCLUSION
The aim of this analysis was to clarify the meanmg of
empathy and address some questions The questions of
what empathy is, is it trait or state, dynamic or static, and
how it IS recognized have been considered and clearly
identified usmg the Walker & Avant (1988) model of
concept analysis
However, the questions how is empathy nurtured and
sustained, and under which conditions does it fiounsh and
diminish have not been fully examined and have major
implications for nursmg m recruitment, education (both
methods and process) and man^ement (the environment
and the delivery of care)
There is clearly a need for future research in these areas
Concept analysis may clear the way for that work to begm
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... These relational strategies are hypothesized to contribute to positive affective responses, perceived value-add, predictability, and a safe and secure learning environment, which will promote trusting relationships among team members. A common set of skills for employing all five relational strategies include the ability to actively listen, to offer free attention, and to suspend judgement (63). ...
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