I Understand How You Feel: The Language of Empathy in Virtual Clinical Training

Abstract

Effective communication is one of the most fundamental aspects of successful patient care, and it frequently depends on the nurses’ ability to empathize with patients while finding effective ways to translate medical science into personally relevant health information. Skilled nurses are expected to understand the patient’s experiences and feelings and be able to communicate this understanding to the patient, but language strategies used to achieve the goal of empathic communication can vary. In this article, we employed the model of message design logics to evaluate what strategies nursing students (N = 343) used to express empathy during a simulated health history training. The results of this study advance our understanding of what constitutes a high-quality response to the disclosure of personal health history facts. In addition to providing a general framework for understanding empathic responses during health history assessment, the message design logic perspective highlights the differences in linguistic choices in simulated patient–provider conversations.

Full text

Journal of Language and Social Psychology
1 –19
© The Author(s) 2016
DOI: 10.1177/0261927X16663255
jls.sagepub.com
Article
I Understand How You Feel:
The Language of Empathy in
Virtual Clinical Training
Yulia A. Strekalova1, Janice L. Krieger1,
Jordan Neil1, John P. Caughlin2, A. J. Kleinheksel3,
and Aaron Kotranza3
Abstract
Effective communication is one of the most fundamental aspects of successful
patient care, and it frequently depends on the nurses’ ability to empathize with
patients while finding effective ways to translate medical science into personally
relevant health information. Skilled nurses are expected to understand the
patient’s experiences and feelings and be able to communicate this understanding
to the patient, but language strategies used to achieve the goal of empathic
communication can vary. In this article, we employed the model of message design
logics to evaluate what strategies nursing students (N = 343) used to express
empathy during a simulated health history training. The results of this study advance
our understanding of what constitutes a high-quality response to the disclosure
of personal health history facts. In addition to providing a general framework for
understanding empathic responses during health history assessment, the message
design logic perspective highlights the differences in linguistic choices in simulated
patient–provider conversations.
Keywords
empathy, virtual nursing training, message design logics, language strategies,
communication skills
1University of Florida, Gainesville, FL, USA
2University of Illinois, Urbana, IL, USA
3ShadowHealth, Gainesville, FL, USA
Corresponding Author:
Yulia A. Strekalova, College of Journalism and Communications, University of Florida, Gainesville, FL
32610, USA.
Email: yulias@ufl.edu
663255JLSXXX10.1177/0261927X16663255Journal of Language and Social PsychologyStrekalova et al.
research-article2016
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2 Journal of Language and Social Psychology
There is a compelling body of evidence that suggests effective communication is one
of the most fundamental aspects to the successful delivery of patient care (Cooper
et al., 2003). The manner in which patients and health care providers linguistically
coordinate to accomplish this goal can be fraught with challenges. A primary chal-
lenge is what Mishler (1984) describes as a clash between the voice of medicine and
the voice of the lifeworld. The speech of health care providers is characterized as the
“voice of medicine,” because talk is commonly geared toward efficiently and effec-
tively delivering science-based medicine. Conversely, patient speech is referred to as
the voice of the lifeworld, because of the emphasis on contextualizing the experience
of health and illness in everyday life.
Nurses represent a unique type of health care provider in that they are expected to
bridge the gap between the voices of medicine and the lifeworld. In so doing, they
assume the role of knowledge brokers who enable the effective translation between the
medical science language used by clinicians and lay language preferred by patients
(Bourhis, Roth, & MacQueen, 1989). To ensure that patients are comfortable sharing
their health information despite the biomedical exigencies of provider–patient interac-
tions, skilled nurses are expected to understand the patient’s situation, feel as if they
were the patient themselves, and be able to communicate this understanding and feel-
ing to the patient (Brunero, Lamont, & Coates, 2010; Rogers, 1975). The latter require-
ment, therefore, suggests that the acceptance and identification with the role of
knowledge broker in these interactions should be observable through the choices of
language strategies, such as expression of empathy. Although empathy comprises cog-
nitive, affective, and behavioral elements (Sulzer, Feinstein, & Wendland, 2016), the
focus in the current study is on the behavioral domain, specifically, the language
nurses use to convey empathy during interactions with patients.
Knowledge Brokering in Medicine and Health
Unlike technological advancements that promote medical science, health provision
relies on patient–provider communication and the successful translation of medical
knowledge into health recommendations through interpersonal exchange of informa-
tion between its primary stakeholders (Ong, de Haes, Hoos, & Lammes, 1995). This
dynamic has the potential to be challenging. Given the complexities involved in dis-
cussing biomedical information and questions with patients, providers may be unmo-
tivated or unable to show empathy. A lack of empathy fails to accommodate to the
emotional and intellectual needs of the patient. Street, Makoul, Arora, and Epstein
(2009) noted that ineffective patient–provider interaction, such as that characterized
by a lack of empathy, can result in negative proximal outcomes, including reduced
patient comprehension, lower trust in providers, and a failure to come to an agreement
on a course of treatment. In turn, these can affect intermediate outcomes, such as
reduced compliance to a treatment regimen, worse self-care skills, and a lack of patient
agency in their own health (Haskard Zolnierek & DiMatteo, 2009). This dynamic per-
petuates a cycle that eventually leads to worse overall health outcomes. Thus, even
though the ostensive purpose of interviews with patients is to exchange medical
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Strekalova et al. 3
information, demonstrating empathy is important for the success of such encounters
and for preventing negative cycles in health outcomes (Bellet & Maloney, 1991; Kim,
Kaplowitz, & Johnston, 2004).
Empathy as a Core Goal in Knowledge Brokering
Empathy, which is “the ability to perceive the meaning and feelings of another and to
communicate those feelings to the other person” (Brunero et al., 2010, p. 65), is recog-
nized as a core communication skill for nurses (Sulzer et al., 2016). Empathy fosters
trust between patients and health providers (Bellet & Maloney, 1991) and is associated
with patient satisfaction and positive clinical outcomes (Street et al., 2009). Empathy
is different from sympathy in that the former includes a strong cognitive component
and presents a state when an individual feels and perceives a situation as if someone
else (Rogers, 1975). Feeling sympathy, however, involves an emotional state that is
associated with entanglement in the feelings of another person (Neumann et al., 2009).
Similarly, empathy is different from compassion in that empathy is congruent with,
but not necessarily identical to, the emotion of another.
Kim et al. (2004) outline how the cognitive and affective components of empathy
converge with the behavioral in communication between nurses and patients. The cog-
nitive aspect is defined as the health provider’s ability to accurately identify the
patient’s mental state or point of view, and then effectively communicate information
back to the patient in a manner that is congruent with that point of view. The affective
aspect of provider empathy relates to the provider’s ability to correctly recognize his
or her patients’ emotional state, match the style of communication to that state, and be
effective at improving on it. Similarly, in translating medical knowledge, skilled
nurses are expected to account both for patients’ health literacy and specifics of the
communication context (Parnell, 2015).
Although expressing empathy is a common goal for nurses, they may employ dif-
ferent message strategies to convey empathy in their communication with patients.
This article aims to explore what language nurses use to express empathy. Specifically,
this article examines communication between nursing students and a standardized vir-
tual patient, and employs the model of message design logics to evaluate what strate-
gies students used to express empathy.
Message Design Logics and Empathy
The Model of Message Design Logics
The model of message design logics (O’Keefe, 1988) identifies assumptions about lan-
guage and proposes that the same communication goals can be pursued using three
different logics: expressive, conventional, and rhetorical. Message design logics explain
why in a similar situation, different people can generate different kinds of messages.
The model also describes a hierarchical relationship among those types of design logics
predicting that rhetorical messages are generally the most sophisticated, followed by
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4 Journal of Language and Social Psychology
conventional and expressive. The characteristics of these logics can be identified
through message elements and used as a general approach for message analysis.
Messages with expressive design logic are aimed at expressing how the speaker
feels, without taking into account how messages will be perceived and what effect
they might have on others. Because expressive messages focus on the speaker’s own
thoughts and feelings instead of the exigencies of the social situation, expressive mes-
sages often can be characterized by inappropriately delivered, although potentially
well meaning, remarks. Speakers using this logic are frequently unsure about the goals
conventionally understood to be relevant to a situation; thus, their messages can be
vague, lack clear direction, or become the repetitions of the same message that has
already been delivered before.
In contrast, conventional messages are more competent than expressive ones
because they are designed to allow individuals to act appropriately in a particular situ-
ation. Speakers using this message logic strive to follow the social rules of a situation
rather than focusing on expressing their own thoughts and feelings. Conventional mes-
sages show concern for the social effects of communication, and thus tend to entail
what is conventionally expected, whether that involves apologies, compliments,
hedges, excuses, and so forth. Speakers who produce conventional messages are
focused on making sure they fulfill their conversational obligations and expectations
in a particular context. From this perspective, communication that is generally expected
in a particular situation becomes the framework for evaluating whether speakers are
effective in delivering relevant and appropriate messages.
Finally, rhetorical message design logic is characterized by the negotiation of social
selves and situations. Rather than taking the social circumstances as given (as is the
case with conventional logic), rhetorical messages seek to negotiate or renegotiate
social circumstances that are advantageous. Rather than seeing problematic situations
as fixed, rhetorical messages attempt to redefine them; for example, rhetorical
responses to patients may suggest ways for the patients to accomplish their own goals
while remaining sensitive to the relevant identity concerns (Caughlin et al., 2008).
These messages are not merely polite, but convey the importance of message receivers
and their beliefs, values, and desires, and they tend to be future-oriented, focusing on
possible outcomes that can be (re)create through communication. These messages aim
to achieve outcomes set forth by the speakers, rather than convey the speaker’s reac-
tion to a particular situation; they express an effort to change or take charge of a par-
ticular situation, clarify intentions of speakers, and provide perspective to message
recipients.
Language Strategies and Empathic Communication in Nursing
Education
A common communication goal in nursing is the expression of empathy in response to
information shared by a patient. Medical exams require health professionals to obtain a
lot of patient information during a brief visit; consequently, medical education for
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Strekalova et al. 5
nurses focuses on the communication and interview skills needed for obtaining as much
of medical information as possible. There is growing recognition, however, that medi-
cal information alone is insufficient for a comprehensive medical exam. Increasingly,
nursing professionals are urged to learn about the patient as a person and establish the
rapport through effective conversation (Levinson & Pizzo, 2011), and this new empha-
sis is reflected in the nursing education curriculum (Brunero et al., 2010).
Training in empathic communication skills is challenged by the fact that interper-
sonal communication during the provision of health care is contextual, and communi-
cative behaviors can be interpreted differently by different people (Gleichgerrcht &
Decety, 2013). However, nurses encounter certain kinds of situations regularly, and
therefore nursing and medical education strive to identify common circumstances and
best practices that would work best for most patients in such situations (Brunero et al.,
2010; Sulzer et al., 2016). Increasingly, nurses are trained to identify the situations
when the expression of empathy is most needed (Kelley, 2015), as health history
assessment interactions may present nurses with numerous opportunities to be
empathic to and understanding of their patients’ medical and personal situations.
Although expression of empathy is widely recognized as a communication goal, little
is known about the various kinds of empathy messages that nursing students use in
attempting to show empathy. The current study relies on theoretical conceptualization
of message design logics to examine the language strategies that nursing students use
when trying to convey empathy in a patient–provider training context. Specifically,
this study asks the following research question:
Research Question 1: What message design logics do nursing students use to
express empathy?
Assuming the message design logics are useful at describing variations in attempts
at expressing empathy, they should be related to other known linguistic markers of
empathy. A number of linguistic features, such as the use of pronouns, have been
shown to shape the extent to which messages are viewed as empathic. The use of
“I-pronouns,” for example, may signify the distance between a speaker and message
recipient (Toma & D’Angelo, 2015). At the same time, “I-pronouns” are associated
with self-disclosure, whereas the use of “you-pronouns” has been linked to negative
communication outcomes, such as worse perceived communication outcomes and
feelings of worry (Biesen, Schooler, & Smith, 2015).
Past research has not explored whether pronoun use is related to message design
logics, and the connections between pronouns and perceived quality of conversations
suggest that there are likely some systematic associations between pronoun usage and
message design logics. Thus, although there is not enough previous work to specify
the exact association, this study asks the following research question:
Research Question 2: What, if any, differences are there in the use of pronouns
across the different message design logics?
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6 Journal of Language and Social Psychology
Method
Data Source
An IRB review was obtained for the research protocol and plan for data analysis. The
current study examined nurses’ empathic abilities during a simulated health history
exam as recorded in training transcripts from an undergraduate nursing course deliv-
ered through virtual simulation. Similar simulated trainings have shown that clinicians
and trainees suspend their disbelief and effectively immerse themselves in the flow of
virtual communication (Bova et al., 2013). As such, simulated training provides the
benefits of training using standardized patients, while fully controlling for similarity
of patient responses and behaviors. From a communication perspective, the simulated
training ensures commonality in certain demands of the encounters; for instance, all
participants encountered contexts that can be conventionally understood as calling for
empathy. Indeed, during the development of the training script, nursing faculty identi-
fied several patient disclosure situations that they viewed as opportunities in which
skilled nurses could express empathy. The final script of the health history simulation
contained as many as nine patient disclosures that would conventionally warrant an
empathic response.
Participants
The data set included dialogs between a virtual patient, Tina Jones, and 343 under-
graduate nursing students attending a health assessment course at nursing schools
from eight states (California, Colorado, Florida, Illinois, Kansas, New York,
Pennsylvania, and Wisconsin). The students were in the first semester of their program
and used a simulation program for health history exam training. Complete demo-
graphic information is not available because the students were not required to provide
it and few did. Although the virtual patient script was the same for each student, the
actual number of encountered disclosures depended on the questions that students
asked during the exam and their ability to find all relevant information about the
patient’s health history.
Procedure
Throughout the simulated patient exam, students typed questions to obtain health history
information from a virtual patient, whose preprogrammed responses were enabled by a
natural language processing solution. Depending on the questions asked during the
exam, nursing students could encounter up to nine health history disclosure opportuni-
ties that warranted the expression of empathy expected of nurses competent in commu-
nication with patients. See Table 1 for brief descriptions of each opportunity. Responding
to the information shared by the patient, students typed statements and labeled ones they
thought showed empathy. The data, therefore, included unambiguous indications of the
students’ intent to be empathic as recorded by the students themselves.
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Strekalova et al. 7
Nursing students encountered 1,625 (52.7%) of 3,087 potential empathic opportu-
nities and followed up with statements intended to be empathic in 545 of those oppor-
tunities (M = 2.33, SD = 1.81). Table 2 provides additional details about the frequency
with which specific opportunities were encountered and followed up.
Approach to the Analysis
Statements submitted by a student in response to an encountered health history disclo-
sure and self-identified as empathic constituted the unit of analysis. If a student pro-
vided more than one empathic statement per opportunity, all statements were
considered together and coded as one response. Three authors, YS, JK, and JN, evalu-
ated a sample of empathic statements, developed coding rules, and continuously dis-
cussed a codebook. The following three rules were accepted as final. First, if in
response to a health history disclosure no conventionally expected statements were
used or statements were inappropriate for the situation, the response was coded as
expressive. Second, if a conventionally expected statement was used but was not fol-
lowed by a potential solution to the issue brought up with the virtual patient, the
response was coded as conventional. Third, if a response included a conventional
statement and an indication of a potential solution or forward-looking perspective, it
was coded as rhetorical.
Table 1. Descriptions of Health History Disclosure Situations.
Situation
number Short name Description
1 Expression of pain Tina expresses frustration about her level of
pain.
2 Impact of injury on daily life Tina brings up her pain and frustration at how
being unable to bear weight on her foot
affects her life.
3 Gaps in health literacy around
diabetic diet
Tina describes controlling her diabetes by
avoiding “sweets.”
4 Lack of treatment with
diabetes medication
Tina reveals that she does not treat her
diabetes with medication.
5 Lack of blood glucose
monitoring
Tina reveals that she does not check her blood
sugar.
6 Gaps in health literacy around
asthma control
Tina describes increased inhaler use and
decreased effectiveness, indicating that her
asthma is uncontrolled.
7 Discomfort in discussing body
image
Tina acts defensive when discussing her body.
8 Loss of a family member Tina shares information about her father dying.
9 Counseling around past drug
use
Tina discusses her past history of marijuana
smoking.
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8 Journal of Language and Social Psychology
Subsequently, three coders who were blind to research questions were trained using
the final coding rules. After initial training, each coder coded the data set in full. The
coders achieved an overall acceptable reliability level across nine opportunities,
Krippendorf’s alpha = .829, with intercoder reliability for individual opportunities
ranging between .7 and .96.
Results
Message Design Logics and Expression of Empathy
Expressive Design Logic. Due to their focus on the speaker’s agenda rather than the
demands of the conversational circumstances, messages created with an expressive
design logic are often characterized by inappropriateness. This feature of expressive
messages was observed in a number of conversations between nursing students and the
virtual patient. In some situations, students provided—and marked as empathic—state-
ments that fail to show cognitive or affective understanding of the information shared
by the patient. In the example below, the student fails to recognize that the patient may
have gaps in health literacy and the effort she takes to overcome them (see Example 1).
Table 2. Frequency of Health History Disclosure Situations by Message Design Logic.
Situation
Message design logics
TotalMissed Expressive Conventional Rhetorical
1. Expression of pain 159 (46.4%) 18 (5.2%) 107 (31.2%) 59 (17.2%) 343
2. Impact of injury on
daily life
75 (60.0%) 11 (8.8%) 26 (20.8%) 13 (10.4%) 125
3. Gaps in health
literacy around
diabetic diet
163 (92.6%) 8 (4.5%) 4 (2.3%) 1 (0.6%) 176
4. Lack of treatment
with diabetes
medication
182 (81.3%) 10 (4.5%) 28 (12.5%) 4 (1.8%) 224
5. Lack of blood
glucose monitoring
140 (83.8%) 13 (7.8%) 11 (6.6%) 3 (1.8%) 167
6. Gaps in health
literacy around
asthma control
179 (92.3%) 9 (4.6%) 6 (3.1%) 0 (0%) 194
7. Discomfort in
discussing body
image
19 (63.3%) 4 (13.3%) 0 (0%) 7 (23.3%) 30
8. Loss of a family
member
60 (25.1%) 11 (4.6%) 158 (66.1%) 10 (4.2%) 239
9. Counseling around
past drug use
102 (80.3%) 15 (11.8%) 3 (2.4%) 7 (5.5%) 127
Total 1,079 (66.4%) 99 (6.1%) 343 (21.1%) 104 (6.4%) 1,625
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Strekalova et al. 9
Example 11
[Student]: do you know about diabetes
Tina Jones: Well, I took a class after I first got diagnosed. I really didn’t know any-
thing about it, and it really helped me. Now I know to avoid sugar to keep my
diabetes under control, and I think it’s working pretty well.
[Student]: ok you do know
Another manifestation of expressive design logic was the acknowledgement of the
information that was shared by the patient without the recognition of past or present
affect the situation might have on the patient’s well-being. Empathy is valued as a skill
among medical professionals because it allows them to recognize the complexity of
patients’ health histories and the interrelation among medical and personal facts. Some
expressive messages showed recognition of the medical value of provided information
without acknowledging any nonmedical information it carried. In Example 2, even
though the student recognized the opportunity to provide empathic support in response
to complaints about pain, the communicated message focused only on the medical
value of the shared information with no acknowledgment of the patient’s experience
or affect.
Example 2
[Student]: what kind of pain is it? sharp pain?
Tina Jones: It’s throbbing and like, sharp if I try to put weight on it.
[Student]: What relieves the pain?
Tina Jones: The Advil helps for a little while.
[Student]: Thank you so much Ms. Jones for the helpful information
Transcripts of conversations between nursing students and the virtual patient have
also revealed another form of expressive message design logic that has been described
theoretically previously (O’Keefe, 1988). Example 3 presents a situation when a stu-
dent was caught up in a loop of expressing words of sympathy and being sorry for the
patient’s foot pain. However, the same ostensibly supportive words were repeated sev-
eral times without attempts to seek additional information or offer a perspective beyond
patient’s information disclosure. In such conversations, the student prompted the patient
to share the same information over and over, which resulted in repeated empathic mes-
sages that neither promoted the patient’s well-being nor elicited new information.
Example 3
[Student]: What is causing your pain?
Tina Jones: My scrape isn’t healing up at all. It’s infected and it’s just getting worse,
not better.
[Student]: I’m sorry to hear that.
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10 Journal of Language and Social Psychology
[Student]: On a scale of 1 to 10 how severe is your pain?
Tina Jones: Ugh . . . I’d say an 8. I mean, it hurts so much.
[Student]: I’m sorry to hear that.
Tina Jones: Thanks.
[Student]: Can you put weight on the injured foot?
Tina Jones: No, I can’t. I can’t put any weight on it without like, shooting pain.
[Student]: Sorry to hear that.
Conventional Design Logic. Messages using conventional design logics typically con-
veyed the expression of empathy through the use of phrases that are commonly expected
in health history disclosure situations. Examples 4 and 5 below provide two common
conversation scenarios. In contrast with the Example 3, “sorry” was used frequently but
never repetitively in this message design logic. Its use was prominent in situations when
the patient talked about pain, either physical, from her hurting foot, or emotional, from
losing her parents. Another frequently used linguistic choice was the expression of
understanding of a patient’s situation and discomfort she might be experiencing.
Example 4
[Student]: Do you ever feel depressed or anxious?
Tina Jones: The closest I ever came to depression was after Dad died. . . . I just felt
sad all the time.
[Student]: I’m so sorry to hear that
Example 5
[Student]: What is preventing you from taking your diabetes medication?
Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was
overwhelming, remembering to take pills and check my sugar. I feel a lot better
now that I’m just eating healthier than I did when I was taking the pills.
[Student]: I can understand how overwhelming that must have been.
Tina Jones: Thanks.
Conventional empathic statements also acknowledged the full scope of the shared
information, beyond the face value of the shared facts (Example 6). Contrary to
expressive messages, in addition to attending to medical information, conventional
messages evinced a general understanding of the patient’s experiences or affect in the
situation. Yet such messages lacked the specificity and suggestions for a course of
action that would be characteristic of a rhetorical message.
Example 6
[Student]: can you tell me if you have done any illicit drugs?
Tina Jones: Well, I used to smoke pot . . . but I don’t do that anymore.
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Strekalova et al. 11
[Student]: how old were you when you smoked weed?
Tina Jones: I started when I was about fifteen, and I stopped when I was twenty or
twenty-one.
[Student]: thank you for sharing that with me I know it can be hard.
Rhetorical Design Logic. Rhetorical messages were marked by the presence of two com-
ponents, the expression of empathy and an attempt to identify actions that could
enhance the patient’s well-being. The student in Example 7 showed efforts to comfort
the patient in response to her complaints about foot pain and described the future steps
that would be taken to resolve it.
Example 7
[Student]: can you rate your pain on a scale of 1-10
Tina Jones: Ugh . . . I’d say an 8. I mean, it hurts so much.
[Student]: I’m really sorry you are in so much pain, we are going to work on getting
that under control for you.
In another situation (Example 8), asking about any prior drug use, a student
expressed appreciation that patient trusted the student with disclosing this sensitive
information and explained the need to ask the questions. The latter could be viewed as
a step to negotiate the circumstances of the encounter and frame it within the primary
goal of health care provision. Although this situation is different from communal cop-
ing in response to an upsetting situation (Caughlin et al., 2008), it still moves to rede-
fine the flow of the health history assessment as a joint project (O’Keefe, 1988) shared
by the nurse and the patient.
Example 8
[Student]: Have you ever used illicit drugs?
Tina Jones: Well, I used to smoke pot . . . but I don’t do that anymore.
[Student]: When was the last time you used marijuana?
Tina Jones: I haven’t smoked pot since I was twenty or twenty-one.
[Student]: Thank you for sharing that information. It’s good to hear that you’ve quit
smoking marijuana; it will help your asthma and your overall health.
Differences in Linguistic Strategies Among Message Design Logics
To answer Research Question 2, the data were auto-coded for the presence of
“I-pronouns” (I, me, my), “you-pronouns” (you, your), or both. After Excel text for-
mulas were used for coding, a sample of results (n = 50) was reviewed for reliability.
No corrections were necessary and automated coding was accepted as final. Table 3
shows a cross-tabulation of message design logics and pronoun use for the empathic
statements.
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12 Journal of Language and Social Psychology
Table 3. Cross-Tabulation of Pronoun Use and Message Design Logics in Empathic
Statements.
Message design logics
Pronoun use
TotalNeither I You Both
Expressive
Obs count 29.0 12.0 25.0 33.0 99.0
Exp count 12.3 22.1 12.9 51.7 99.0
Column percentage 42.6 9.8 35.2 11.6 18.1
Std res 4.7 −2.2 3.4 −2.6
Adj res 5.6 −2.7 4.0 −4.2
Conventional
Obs count 38.0 105.0 39.0 161.0 343.0
Exp count 42.7 76.6 44.6 179.0 343.0
Column percentage 55.9 86.1 54.9 56.5 62.8
Std res −0.7 3.2 −0.8 −1.3
Adj res −1.3 6.0 −1.5 −3.2
Rhetorical
Obs count 1.0 5.0 7.0 91.0 104.0
Exp count 13.0 23.2 13.5 54.3 104.0
Column percentage 1.5 4.1 9.9 31.9 19.0
Std res −3.3 −3.8 −1.8 5.0
Adj res −3.9 −4.8 −2.1 8.0
Total
Count 68.0 122.0 71.0 285.0 546.0
Percentage 12.5 22.3 13.0 52.2 100.0
Note. Obs = observed; Exp = expected; Adj res = adjusted residual; Std res = standardized residual.
Adj res values in bold present variables of interest that contrinute to the significance of the omnibus test.
The use of pronouns varied significantly among empathic statements with different
message design logics, χ2(6, N = 545) = 112.20, p < .01. For subsequent pairwise com-
parisons, the values of adjusted standardized residuals over three were considered a
proxy (Sharpe, 2015). Compared with the other design logics, expressive empathic
statements were more likely to employ “you-pronouns.” Conventional statements
were more likely to use “I-pronouns” than messages with other message design logics.
Finally, rhetorical statements most frequently featured the combined use of both
“I-pronouns” and “you-pronouns.” Illustrations of these differences in the design log-
ics are presented next.
Expressive Design Logic. Empathy can be defined as the understanding and sharing
another person’s experiences and emotions (Batt-Rawden, Chisolm, Anton, & Flick-
inger, 2013). Although expressive statements were characterized by the prevalence of
“you-pronouns,” they failed to provide evidence of students’ reaction to the information
that was disclosed. In Example 9, for instance, a nursing student restates what the
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Strekalova et al. 13
patient has said. However, this undivided focus on the patient fails to signal any sense
that the student empathizes with or is affected by the information personally.
Example 9
[Student]: How often do you use your inhaler?
Tina Jones: Not often. Maybe two or three times a week.
[Student]: What type of inhaler do you have?
Tina Jones: It’s just a regular Proventil inhaler.
[Student]: Does your asthma wake you up at night?
Tina Jones: No, I don’t have a problem with that.
[Student]: Thank you for letting me know about your asthma and your preventative
measures.
Conventional Design Logic. Quantitative analysis of statements that use conventional
message logics showed the prevalence of “I-pronouns.” Students who used this mes-
sage design logic recognized the situational demand of sharing their personal feelings
(e.g., empathy) in response to the information disclosed by the patient. Earlier research
identified the use of “I-pronouns” as an indicator for distancing (Toma & D’Angelo,
2015). However, in situations when students were reacting to patient-shared informa-
tion, combined with the use of situationally appropriate statements, could be viewed
as a departure from the immediate health care provision situation and focus on patient-
centered perspective. The second empathic statement in Example 10 shows how the
student internalizes patient’s feelings to provide a personal assessment of the conver-
sation topic.
Example 10
[Student]: how old was your father when he passed away?
Tina Jones: Last year when Dad passed, he was only 58.
[Student]: how did your father pass away?
Tina Jones: He died in a car accident.
[Student]: i am sorry to hear that
Tina Jones: Thanks.
[Student]: do you have depression?
Tina Jones: The closest I ever came to depression was after Dad died. . . . I just felt
sad all the time.
[Student]: i am sure that was a difficult time.
Rhetorical Design Logic. Finally, statements using a rhetorical message logic were char-
acterized by the use of both “I-pronouns” and “you-pronouns.” Example 11 shows that
the student recognized the opportunity to show empathy in response to the patient’s
disclosure of poor blood sugar monitoring. Using mostly “I-pronouns” to express
words of understanding, the student focused on the implications of this disclosure for
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14 Journal of Language and Social Psychology
patient’s health. Characteristic of this message design logic, statements below also
included “you-pronouns” as part of encouragement for the patient to take charge of her
health despite the difficulties of daily monitoring.
Example 11
Tina Jones: I just have a lot going on in my life, and I only have space in my mind
for so much, you know? It’s a lot easier to stay away from sweets than it is to
remember to test my sugar and be pricking my finger all the time and all of that.
Anyway, the numbers were always so all over the place, and I wasn’t sure what
they meant.
[Student]: I can understand that it difficult to take daily medications but it is impor-
tant to keep up your blood sugar.
Tina Jones: Thanks.
[Student]: Tell me about your blood sugar monitoring?
Tina Jones: I don’t check it very often, honestly . . . I think the last time was about
a month ago.
[Student]: I understand how it can feel like a frustrating chore to check your blood
sugar all the time. But it is important to keep your blood sugar under control.
Discussion
The results of this study advance our understanding of what constitutes a high-quality
empathic response to the disclosure of personal health history facts. Using data from a
simulated health history assessment, this study assessed the variability in providers’
empathic statements while controlling for the variability in patient responses. This
study was unique in that nursing students indicated which statements they intended to
use to express empathy, allowing for an assessment of the quality of such statements
that would be challenging if intent had to be inferred (e.g., showing empathy poorly
may not be recognized as an attempt at being empathic). The message design logics
perspective highlighted a number of differences in linguistic choices in conversations
during health history assessment training. Consistent with the model of message
design logics (O’Keefe, 1988), empathic statements showed noticeable linguistic vari-
ability. These findings confirm that differences in message design logics are a useful
way to categorize empathic responses, allowing for targeted feedback to health care
professionals in training.
In addition to furthering our understanding of the expression of empathy, the cur-
rent study also has important implications for the study of message design logics. Prior
research on message design logics generally has focused on face-to-face communica-
tion (e.g., Peterson & Albrecht, 1996) and the study of responses to particular stimuli,
such as important health disclosures (e.g., Caughlin et al., 2009). The current research
demonstrated that the theory can be applied successfully and reliably to virtual train-
ing systems. Moreover, the fact that the study used broad array of topics that are com-
mon to patient–provider communication and health history situations (e.g., complaints
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Strekalova et al. 15
about pain, conversations about sexual health, and discussions of medication adher-
ence) suggests that the message design logics model may be broadly useful for assess-
ing and improving the quality of student medical providers during training.
The importance of having a basis for targeted training of empathy is clear. Despite
the great amount of research focusing on the positive impact of patient outcomes asso-
ciated with empathic communication (Batt-Rawden et al., 2013; Bellet & Maloney,
1991; Kim et al., 2004; Pedersen, 2009), how to be optimally empathic for effective
knowledge translation is not self-evident. Moreover, the emotional labor of clinical
care can be taxing on providers (Gleichgerrcht & Decety, 2013). One of the most
prominent reasons for physician dissatisfaction is the quality of interpersonal interac-
tions (Pololi, Conrad, Knight, & Carr, 2009). The reciprocal nature of successful
patient–provider communication involves an emotional investment on the part of the
provider. As Hojat et al. (2002) describe, “empathic providers share their understand-
ing, while sympathetic physicians share their emotions with patients. The concepts,
however, do not function independently” (p. 1563). Therefore, it is paramount to
implement an effective, empathic communication model as a requirement within med-
ical and nursing schools so that providers are prepared to enact empathy in ways that
better serve both their patients and themselves.
It is also important to understand what constitutes effective and appropriate
responses to personal health disclosures. Disclosing private, upsetting, or embarrass-
ing information can be difficult for patients, but this information may be key to suc-
cessful health evaluation, diagnosis, subsequent treatment planning, and numerous
other issues related to the provision of patient-centered health care. Inadequate pro-
vider response to shared information can lead to information withholding, poor rap-
port, and patient withdrawal from active shared decision making. Moreover,
inappropriate responses from care providers can lead to stigmatization (Brashers et al.,
1999) and reduced trust in medical professionals (Street et al., 2009). Empathy is not
something providers can impart on patients; instead, it is a transactional communica-
tion process in which both stakeholders mutually influence each other. This interaction
needs to be flexible, and is heavily affected by the medical context, as well as whether
caregivers or family members are in the room, the past history a patient has with their
provider, and the type of empathic response a patient may need.
Limitations
Although theory and past research provide solid reasons for our conceptualization of
how empathy messages vary, the current study does not directly examine whether the
most sophisticated messages are actually viewed as more empathic by actual patients.
Assessing the impact of different message logics on patient care outcomes is beyond
the scope of this article, and future studies could evaluate whether using more advanced
logics result in fuller disclosure of health information by patients and improved health
information discovery by clinicians. Additionally, the current study demonstrates that
there is natural variation among nursing students in the quality of their empathic
responses, even in a standardized simulated context. The study does not show
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16 Journal of Language and Social Psychology
precisely how empathic communication during medical health encounters can be
improved. Doing so would be an important next step in this line of work.
Conclusion
Knowledge translation is a critical component to well-being because it facilitates
knowledge amassed by medical science to be present in the practice of health manage-
ment. Nurses serve as knowledge brokers between patients and the scientifically ori-
ented biomedical community. Some recognition of the need to translate technical
information is implicit in early nursing training, which focuses on the efficient deliv-
ery of medical knowledge. However, successful communication of medical science
information to patients is more complex than simply conveying a diagnosis. Patients’
experiences and feelings shape their understanding of medical information; thus,
efforts to explain medical information that do not attend to the lifeworld of patients are
unlikely to be successful. For nurses to translate biomedical knowledge and informa-
tion into the practice of health care, it is necessary to elicit and consider patients’ views
and experiences. Training for nurses needs to recognize that knowledge translation is
an important part of the professional identity, and that it can only be achieved with
focused attention on language that effectively empathizes with patients’ experiences.
Such recognition implies a need to develop ways of providing feedback to nurses in
training that goes beyond seeking and conveying information and also teaches nurses
to translate the voice of medicine into the voice of the lifeworld. Although empathy is
widely recognized as a core skill in nursing, the role that empathy plays in medical
interviews with patients is not well understood. Scholars of language and social psy-
chology should contribute to the development of such training by continuing to exam-
ine how nurses and nursing students attempt to show empathy and by developing a
fuller understanding of the most effective language for doing so.
Acknowledgments
The authors would like to thank Maxwell Sanders, Thuyvi Luong, and Crismerly Santebanez, the
undergraduate researchers who coded the data reported in this article, and the two anonymous
referees and Cindy Gallois for their insight, encouragement, and valuable comments on this work.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of
this article.
Note
1. Empathic statements are shown in italics. Original spelling and grammar maintained
throughout example transcripts.
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Strekalova et al. 17
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Author Biographies
Yulia A. Strekalova is a PhD candidate at the University of Florida, College of Journalism
and Communications. Her research examines how lay consumers and experts communicate
about health, science, and technology. She is particularly interested in how information is
disseminated and accessed through technology-mediated channels and how uncertainty about
scientific evidence influences decision making and behaviors. Her research has appeared in
journals such as Science Communication, Qualitative Health Research, and Journal of Cancer
Education.
Janice L. Krieger is an associate professor at the University of Florida, College of Journalism
and Communications and director of the STEM Translational Communication Center. Her
research program focuses on translational communication in health and risk decision-making
contexts. Her research is funded through the National Cancer Institute as well as the National
Institute on Drug Abuse and appears in a number of peer-reviewed journals including Human
Communication Research, Journal of Health Communication, Health Communication,
Prevention Science, and the Journal of Community Psychology.
Jordan Neil is a PhD student at the University of Florida, College of Journalism and
Communications. His research program focuses on the development of innovative strategic mes-
sage design to increase evidence-based health prevention behaviors among at-risk populations.
John P. Caughlin is a professor of communication at the University of Illinois at Urbana-
Champaign. His research, which revolves around human relationships, health, and communication
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Strekalova et al. 19
technologies, has appeared in journals such as Communication Research, Communication
Monographs, Journal of Communication, and Human Communication Research.
A. J. Kleinheksel is director of Instructional Design at Shadow Health Inc., an educational
software company specializing in virtual patient simulations for health professions education.
She develops virtual, asynchronous, responsive clinical environments in which students can
practice diagnostic reasoning, communication, and procedural skills, through an agile develop-
ment process.
Aaron Kotranza is chief technology officer and coinventor of the Shadow Health technology
at Shadow Health Inc. His areas of expertize are virtual humans, 3D user interfaces, and applica-
tions of mixed and augmented reality for education and training. His research has been funded
by several NIH and NSF awards prior to joining the company.
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