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Advances in Nursing Science
Vol. 30, No. 3, pp. E61–E72
Copyright c
2007 Wolters Kluwer Health |Lippincott Williams & Wilkins
Toward a Holistic
Conceptualization of Empathy
for Nursing Practice
Theresa Wiseman, PhD, PGDEd, BSc(Hons)Psych, RGN, RNCT
This article proposes a new holistic conceptualization of empathy for nursing practice that
allows different aspects of the literature to be understood. This study is based on the data of a
doctoral study exploring the nature of empathy on an oncology ward. The findings revealed
that empathy is not a single phenomenon. Four different forms of empathy were identified,
namely, empathy as an incident, empathy as a way of knowing, empathy as a process, and
empathy as a way of being. These different forms of empathy can be understood in terms of a
continuum of empathy development and suggest a new way of conceptualizing empathy that
can be depicted diagrammatically. Key words: concept of empathy,empathy,ethnography,
nurse-patient relationship,theory building
THERE is much written about the impor-
tance of empathy in nursing practice,1–4
yet the body of knowledge is diverse and con-
fusing as empathy has been conceptualized in
different ways.5–7 Empathy theory does not
seem to reflect practice. Sunderland8shows
how empathy has been termed a personality
trait, an ability, an attitude, a feeling, an in-
terpersonal process, a sensitivity, and a per-
ceptiveness. Several writers have suggested
that confusion about the meaning and com-
ponents of empathy is a result of the com-
plexity of the empathic process. There have
been a number of attempts to clarify the na-
ture of empathy through concept analyses.5–9
Yet, all writers advocate more research is
needed to develop a concept of empathy that
Author Affiliation: Florence Nightingale School of
Nursing and Midwifery, Kings College London,
London, UK.
The author thanks Dr Jan Savage and Professor Pam
Smith for their support and critical engagement with
the ideas presented in this article that formed part of
her doctoral thesis. The autthor also thanks the partic-
ipants for their involvement in the study.
Corresponding Author: From the Florence Nightin-
gale School of Nursing and Midwifery, Kings College
London, James Clerk Maxwell Bldg, 57 Waterloo Rd,
London SE1 SWA, UK (theresa.wiseman@kcl.ac.uk).
is useful in nursing practice, research, and
education. The purpose of this article is to
propose a new holistic conceptualization of
empathy for nursing practice that allows dif-
ferent aspects of the literature to be under-
stood. The conceptualization has been devel-
oped from the data of a doctoral study that
explored the nature of empathy on an oncol-
ogy ward.10 To show how theory is devel-
oped from research findings and established
thinking, when describing the components
of the model, I have incorporated the extent
to which areas of the conceptualization con-
firms, contrasts, and further develops current
thinking and established literature.
CURRENT CONCEPTUALIZATIONS
OF EMPATHY
Despite years of interest and numerous
studies on empathy, an agreed conceptualiza-
tion has remained allusive.7,11 The most com-
mon definition of empathy is “the ability to
perceive the meanings and feelings of another
person, and to communicate that feeling to
the other.”
11 Many writers make a distinction
between empathy and sympathy. Sympathy
involves imagining how one would feel if one
were experiencing what is happening to the
E61
E62 ADVANCES IN NURSING SCIENCE/JULY–SEPTEMBER 2007
other, whereas empathy is imagining what it
is like to be that person, experiencing the sit-
uation as she or he does.2However, although
there is general agreement as to the definition
of empathy, there is much variance on the na-
ture of empathy.5
Some researchers believe that empathy has
several attributes, whereas others consider it
in a narrow and particularistic way. Initially,
debate centered on whether empathy was a
state (a condition a person experiences) or
a personality trait (a characteristic or disposi-
tion), though contemporary theorists suggest
empathy has both these components.5,10,12,13
Alligood12 and Morse et al5distinguish 2 sepa-
rate types of empathy; basic empathy, which
is innate, and empathy, which is deliberate
and learned, that is, a skill. Other writers be-
lieve that these 2 perceptions of empathy co-
exist and are linked. For example, Zderad14
and Burnard2propose that people have a gen-
eral disposition to be empathic that may be
developed into a skill. Researchers who con-
ceptualize empathy as a skill15,16 often focus
their research on how to teach empathy, de-
vising different programs, and ways of mea-
suring empathy.
A number of writers identify components
of empathy,5,17–19 whereas others conceptual-
ize empathy in terms of a process composed
of different stages.14,20,21 Morse et al5con-
ducted an extensive concept analysis of em-
pathy and identified empathy as comprising 4
components—moral, emotive, cognitive, and
behavioral. The moral component is the in-
nate ability or the empathic disposition. The
emotive component refers to the ability to
subjectively perceive another person’s feel-
ings. The cognitive component is the intellec-
tual ability to understand another’s perspec-
tive, whereas the behavioral component is
the ability to communicate empathic under-
standing and concern.
An example of a conceptualization of em-
pathy as a process is provided by Barrett-
Lennard20 who describes 3 phases of an em-
pathy cycle. Phase 1 is marked by listening,
reasoning, and understanding. Phase 2 is con-
veying understanding of the patient’s expe-
rience, and phase 3 refers to the patient’s
awareness of the helper’s communication.20
From this very brief overview of different
conceptualizations of empathy, it can be seen
how difficult it is to make sense of these con-
ceptualizations for practice. Morse et al5and
Bennett22 propose that confusion has arisen
because empathy is a multidimensional, mul-
tiphase construct that is often considered in a
narrow way as a unitary construct.
One of the difficulties getting a holistic pic-
ture of empathy has to do with the methodol-
ogy used. Most research concerning empathy
consist of quantitative studies that begin by
the researcher defining the phenomenon
under study and exploring it by means of
questionnaires or observation.15,23–27 As the
researcher may isolate different aspects of
empathy to study, a well as use different
tools to measure it, there is diversity in
findings—making it difficult to apply and
make sense of it in practice. This has led to
knowledge of different aspects of empathy
but a lack of knowledge of empathy holisti-
cally, and how it exists in nursing practice.
The aim of this study from the outset was to
explore the concept of empathy in practice.
The study provides evidence for Morse’s
comment that empathy is multifaceted and
challenges existing conceptualizations. The
findings suggested that empathy was not a
single phenomenon. In addition, the study
contributes to existing literature in that
findings show how different understandings
can coexist because empathy is a multi-
faceted phenomenon. Before explaining the
conceptualization and how it is related to the
literature, the study is described in detail.
STUDY METHODOLOGY
The study used an ethnographic approach
to examine the concept of empathy on an
oncology ward. The research was based in a
14-bed, mixed-sex ward for people with can-
cer in a UK NHS Hospital Trust. Data collec-
tion was carried out over a period of 2 years.
Several methods were employed including
Toward a Holistic Conceptualization of Empathy for Nursing Practice E63
participant and nonparticipant observations,
as well as informal and formal interviews
with staff (nurses, doctors, ward receptionist,
counselor, and domestic staff) and patients on
the ward. Interviews were conducted with 16
patients and 24 staff members.
During participant observation, I worked
with the nurses on the ward in order to ex-
plore empathy in practice. I used a broad def-
inition of empathy when identifying an em-
pathic episode, that is, an episode where it
appeared to me that the nurse was taking or
understanding the patient’s perspective and
where this impression was subsequently con-
firmed by the nurse and the patient. When
asking participants about examples of em-
pathic episodes, I would also ask them to ex-
plain the elements of the episode that made it
empathic. During fieldwork, I carried a note-
book in my pocket in order to detail direct
quotes from participants, which I thought
might be significant and to act as an aide mem-
oir. Data were analyzed using a modified the-
matic analysis from Morse28 and Coffey and
Atkinson.29 Respondent validation further in-
creased validity within interpretation.
The findings fall into 4 main areas. First,
the findings suggest that using empathy en-
abled care to be patient focused and allowed
nurses insight into the ways in which their
patients experienced and coped with illness.
Empathic understanding facilitated problem
Figure 1. New conceptualization of empathy.
solving and care planning in ways that
increased the nurses’ job satisfaction and feel-
ings of making a difference. The experience
of empathy made patients feel valued and
understood, and enhanced the nurse-patient
relationship. Second, the findings suggest that
empathy is not a single phenomenon. Four
different forms of empathy were identified,
namely, empathy as an incident, empathy as
a way of knowing, empathy as a process, and
empathy as a way of being. These different
forms of empathy can be understood in terms
of a continuum of empathy development and
suggest a new way of conceptualizing empa-
thy. Third, the findings indicate that context
is crucial to the expression of empathy. Over
the 2 years of fieldwork, there were many
changes that occurred in the setting. The
extent to which empathy was expressed and
the form of empathy employed were related
to the context in which nurses worked and
the type of knowledge privileged in that con-
text. Empathy was most commonly expressed
when staffing levels were good, nurses prac-
ticed patient-centered care, and recognized
the value of different ways of knowing.
THE HOLISTIC CONCEPTUALIZATION
OF EMPATHY
Figure 1 represents the new conceptual-
ization, showing the location of the different
E64 ADVANCES IN NURSING SCIENCE/JULY–SEPTEMBER 2007
forms of empathy along this continuum, with
empathy as an incident at one pole and em-
pathy as a way of being at the other pole. Dif-
ferent points along the continuum represent
different stages of empathy development and
expression. Along the continuum, the double
helix of socialization and knowledge repre-
sents the ways in which the nurse’s ways of
knowing and knowledge, as well as her or his
socialization, contributes to developing her or
his empathy skills. Engulfing the continuum is
the context of care showing the part played
by the context in the development and ex-
pression of empathy. Although represented as
linear, it must be stressed that a nurse can
move in either direction along the continuum
depending on the context.
This conceptualization differs from the
finding of Walker and Alligood30 in that it
incorporates the dynamic nature of empathy
expression within a changing environment,
which is particularly relevant in today’s
health service. The number of different ways
empathy has been conceptualized in the past
shows it to be a multifaceted phenomenon,
and the different forms of empathy identified
and the influence of ways of knowing and
socialization highlighted in this study show
how previous conceptualizations relate to
each other. I begin by explaining my concep-
tualization in more detail, then proceed to
consider the findings in light of the literature.
Figure 1 shows that one pole of the con-
tinuum is represented by empathy as an inci-
dent. There were many examples of discreet
episodes of empathy. Typically, empathic
episodes occurred when nurses were admit-
ting patients, breaking bad news, when the
patient had asked the nurse to discuss particu-
lar issues and during planning of the patient’s
discharge. Nurses reported that episodes
of empathy helped to develop the nurse-
patient relationship, as well as increased their
job satisfaction and feelings of making a
difference.10,31 Positive feedback gained from
empathic episodes encouraged the nurse to
use empathy. As the nurse’s knowledge of the
patient increased (from using empathy as a
way of knowing, from the developing rela-
tionship, or from increasingly working with
the patient), the more incidences there were
of the nurse being empathic with that patient.
This study shows that as the episodes of
empathy with a particular patient increased,
the nurse slipped into empathic mode with
that patient more freely. In this way empa-
thy became less active and more passive. It
was used more automatically, similar to driv-
ing or ease of use when developing a skill.∗
According to those who experience empathy,
it started to feel “second nature” or very easy
to go into empathy mode. As the nurse con-
tinued to develop her or his empathy skills,
she or he began to use empathy as the pro-
cess in which she or he worked with the pa-
tient. Empathy then became a process. Typ-
ically, nurses developed their empathy skills
initially with particular patients, but as their
skill developed, the number of patients with
whom they were empathic increased. For
some nurses as they continued to develop
their empathy skills, empathy became a way
of being. It came to characterize the nature
of the relationship between the nurse and the
patient. Initially, it may be that the nurse ex-
perienced empathy as a way of being with
that particular patient, but as the nurse’s self
awareness increased and the sense of self
within the empathic episode developed, em-
pathy became the nurses’ way of being with
everyone—with patient, relatives, and col-
leagues. The nurse communicated an open-
ness to be empathic, a readiness to be em-
pathic. The findings suggest that nurses move
across the continuum because of a combina-
tion of factors that include knowing the pa-
tient, positive experiences of being empathic,
increased use of empathy leading to develop-
ing empathy as a skill, and because of her or
his overall professional development. All of
these factors were facilitated by the context
in which the nurses were working.
∗Benner32 explained the nature of skill acquisition
and the development of expertise as did Dreyfus and
Dreyfus.33
Toward a Holistic Conceptualization of Empathy for Nursing Practice E65
INCORPORATING WALKER AND
ALLIGOOD’S THEORY OF EMPATHY
This holistic conceptualization draws to-
gether an understanding of empathy as an
evolving or developmental process,34,35 with
recognition of the crucial part that the con-
text plays both in the development and sus-
tained expression of empathy. My conceptu-
alization incorporates Walker and Alligood’s30
recent ideas of a theory of empathy in nurs-
ing. They state that empathy can organize the
input of information received by the nurse
that allows her or him to form a deeper,
more meaningful knowledge of the patient’s
experience. The findings of this study con-
firm Walker and Alligood’s work in relation
to the development of empathy, especially
with regard to the effect of the micro- and
macrostructures on the development of em-
pathy. However, Walker and Alligood do not
address the dynamic nature of empathy ex-
pression within a changing environment. Fig-
ure 1 depicting conceptualization shows how
it builds on Walker and Alligood’s work in that
the context engulfs empathy, showing its ef-
fects on the development and expression of
empathy. Alligood et al36 stress the need for
empathy to be conceptualized within a nurs-
ing perspective and not using borrowed the-
ory. Nurses can gain from other sources and
disciplines while keeping in mind that contex-
tually, nursing knowledge development needs
to come from nursing.37 This study, in con-
trast to Walker and Alligood, shows the dif-
ferent ways empathy is expressed within the
nurse-patient relationship and how it is af-
fected by the context of care.
EMPATHY AS AN INCIDENT (ALIGNING
THE ANALYSIS OF MORSE ET AL)
The analysis of empathy of Morse et al38 is
based on specific incidents of empathy and
identifies 4 components of empathy (moral,
emotive, cognitive, and behavioral). How-
ever, this conceptualization has limited rele-
vance to nursing because it is situated within
a counseling model. There are elements of the
explanation that are useful but they do not re-
fer to the context of nursing.
The moral component referred to by Morse
et al, where the emphasis is on accepting the
“otherness” of fellow human beings, was ev-
ident in nurses’ reasons why they used em-
pathy. For example, one nurse explained that
she used empathy in assessment “because
there is no other way I will know what the ex-
perience of the patient is.”The moral compo-
nent was also evident in the way the staff were
empathic with each other. The conceptualiza-
tion of Morse et al is limited in that they con-
sider empathy in isolation and the moral com-
ponent refers to the individual nurse, whereas
the findings of this study indicate that the
ward, unit, and trust philosophies, beliefs,
and values have an impact on empathy expres-
sion. The effects of the macrostructures on
the individual are missed in the conceptual-
ization of Morse et al. In this study, the impor-
tance of the nurses’ group beliefs and values
were highlighted in the ways in which at the
beginning of fieldwork staff respected individ-
uals’ ways of knowing that changed over time.
In addition, as the moral component of Morse
et al appears fixed, it does not account for
the decreased amounts of empathic incidents
from the same person. The moral aspects of
empathy are discussed further in the “Empa-
thy as a way of knowing”section.
Morse et al suggest that the emotive com-
ponent is the ability to subjectively perceive
another’s feelings. This component is based
on 2 assumptions, that empathy is an inher-
ent human quality and that a person’s emo-
tional distress is contagious and motivates the
nurse to be empathic or to distance himself
or herself from the distress of another.39 This
may be useful if seen in the context of the
wider structures and coping. This study pro-
vides support for the emotive component in
the way nurses on the left of the continuum
(Fig 1) were empathic with patients of similar
background and experience. However, nurses
were not just concerned with distress but also
empathic with people who were joyful and
with those not in distress.
E66 ADVANCES IN NURSING SCIENCE/JULY–SEPTEMBER 2007
Although Morse et al38 warn about relying
heavily on the behavioral component of em-
pathy, they explain it in terms of how em-
pathy can be observed and evaluated. How-
ever, the findings from this study support
Greiner9in that empathy was not always vis-
ible to the observer and that it was only the
nurse and the patient who know the value of
the interaction. Had I been merely observing
rather than participating and discussing inter-
actions with respondents, some episodes of
empathy would have been missed. In addi-
tion, some incidents of sympathy would have
been wrongly labeled empathy.
Morse et al38 question the appropriateness
of empathy in nursing, and compare nursing
with counseling, stating that counseling ses-
sions are inappropriate for acute care. Other
writers, such as Pike,40 have also raised con-
cerns as to whether empathy is appropriate
in nursing practice. The findings of this study
suggest that empathy in nursing is different
to empathy in counseling. There were no ex-
amples of nurses thinking that they were con-
ducting counseling sessions. The nurses were
clear as to the purpose of using empathy in
nursing as were the patients. Nurses did use
other strategies when caring for patients that
included both “holding”and “avoiding”strate-
gies. Nurses explained that when they were
being truly empathic, they sensed if the pa-
tient needed or wanted to be distracted from
the illness as well as when the patient was
ready or in need of a deeper-level conversa-
tion, which again supports Greiner.9Some of
the strategies the nurses used to maintain the
level of disclosure for the patient including
the use of metaphor, jokes, and communica-
tion at different levels where alternative ex-
planations were possible.
EMPATHY AS A WAY OF KNOWING
It is widely recognized that the na-
ture of nursing knowledge is complex and
varied.41–44 Carper44 identified 4 patterns of
knowing in nursing: empirics (the science of
nursing); aesthetics (the art of nursing); per-
sonal knowledge (self-awareness); and ethics
(moral knowledge). Carper highlights empa-
thy as an important mode for aesthetic know-
ing that “is made visible through the action
taken to provide whatever the patient re-
quires to restore and extend his ability to
cope with the demands of his situation.”
44(p17)
Carper views empathy in terms of outcomes.
However, the findings of this study sug-
gest empathy is multifaceted and transcends
Carper’s taxonomy. Empathy as a way of
knowing may provide a more accurate as-
sessment of the patients needs, but may
also incorporates moral knowledge and self-
awareness.
The findings of this study with regard
to empathy as a way of knowing sup-
port a number of studies reporting that
empathy enhanced assessment and care
provision.4,16,43 Building on earlier work, Tan-
ner and colleague43 report 2 ways nurses de-
scribed knowing the patient. The first is in-
depth knowledge of the patient’s patterns of
responses (physical), for example, the way
the patient responds to treatments, the way
he or she usually eat, drink, and move. The
findings in this study regarding empathy as
a way of knowing build on the second way
of knowing of Tanner et al. That is, know-
ing the patient as a person, which refers to
empathic knowing. Nurses in this study who
used empathy as a way of knowing thought
about the whole experience of illness for the
patient. The patient was central to care so
that responses to treatment and treatment
options were interpreted from the patient’s
perspective.
Data from the first year of fieldwork sug-
gest that, although individual nurses used em-
pathy as a way of knowing, it was also re-
flected in the way in which the ward func-
tioned as a group, demonstrated, for example,
through the information giving in the report.
This supports the finding of Olsen45 who sees
empathy as providing an ethical and philo-
sophical basis for nursing, where the individ-
uality of the patient and the patient’s own ex-
perience of illness is paramount.13 The ex-
periences of empathy are ultimately based
Toward a Holistic Conceptualization of Empathy for Nursing Practice E67
on a common humanity. The recognition of
humanity in another is acknowledgment of
another being equal to the self. Thus, in the
nursing context, empathy has been seen by
a number of authors and researchers to rep-
resent a way of knowing that respects the in-
dividuality, needs, wants, values, and beliefs
of the patient. Similarly, the findings from this
study show that nurses used empathy as a way
of understanding the patient’s values and be-
liefs, needs, and priorities. This sense of em-
pathy as a way of knowing ties in with the
moral component of Morse et al5and Simms46
who showed a positive correlation between
moral development and empathy.
In addition, understanding empa-
thy as a way of knowing links in with
psychoanalytic47 and psychotherapeutic48
approaches to empathy, and may also explain
why it can sometimes be unconscious. How-
ever, caution is needed when “borrowing”
theories from other disciplines,36 as the
client-therapist enterprise is very different
from the nurse-patient enterprise. Neverthe-
less, these approaches may contribute to a
deeper understanding of empathy as a way of
knowing and unconscious empathy, as some
nurse researchers have suggested.14,35,49
The findings regarding empathy as a way of
knowing echo the description given by Buie47
where empathy is a means of assessment in-
volving a form of knowing, comprehending,
or perceiving what the client is experienc-
ing within. Nurses were quick to point out
that they did not have direct knowledge of
the experience of the patient but they could
imagine what it was like to be that patient.
The assessment interview was invariably one
in which empathy was used. Staff spoke of
the importance of knowing the patient’s ex-
perience of cancer and how it affected the
patient’s life. The subsequent layering of
knowledge about the patient sometimes led
to unconscious empathy where the nurse
would be empathic without realizing it.
A number of nurse researchers take this
approach where the ego is seen as the ex-
ecutor of empathy35,38 and empathy is an
expression of ego development.14,35 As ego
functioning is possible at different levels—
conscious, preconscious, and unconscious,
it follows that empathy is also possible on
these different levels. This may explain con-
scious empathy—where the nurse is deliber-
ately empathic, and unconscious empathy—
where the nurse is empathic without realiz-
ing it or when the nurse takes on the mood of
the patient. The theories of empathy as an ex-
pression of ego development incorporate the
importance of self-awareness for empathy. In-
deed, many writers stress how self-awareness
is necessary to develop empathy.37,50–52 The
findings of this study showed that knowl-
edge of self and, indeed, all kinds of know-
ing had an impact on empathy development
and expression, which is discussed later in the
article.
EMPATHY AS A PROCESS
Empathy as a process occurs when the
nurse experiences repeated incidents of em-
pathy with the same patient. As the number
of episodes increase, the nurse’s empathic
knowledge of the patient develop to the point
at which empathy becomes a process and
the nurse is empathic with the patient on a
continual basis. The nurse slips into empathy
without effort and apparently without con-
scious intent. Empathy as a process is syn-
onymous with the findings of Tyner21 and
Raudonis53 who have both conceptualized
empathy as a relationship. My findings seem
relevant to these studies in a number of ways.
They are both concerned with dying patients
and include patient perspectives, although
the difference in the settings need to be con-
sidered. Tyner reports that the unmet needs
of the nurses and their depleted energy lev-
els decrease incidents of empathy as they re-
sult in a lack of concentration and focused at-
tention on the patient. However, the difficulty
with Tyner’s article is that the methods she
used are not clear, making it difficult to eval-
uate her findings. Nevertheless, findings from
this study seem to support Tyner. At the begin-
ning of fieldwork, there were many examples
E68 ADVANCES IN NURSING SCIENCE/JULY–SEPTEMBER 2007
of empathy as a process, whereas toward the
end of data collection, it was evident with par-
ticular staff only. Four of these 5 nurses had
been on the ward for the duration of the study,
but even so empathy as a process was not ob-
served as frequently as at the beginning of the
study. Staff reported feeling tired, frustrated,
and not being allowed to nurse in the ways
they wanted to, they did not seem to have the
energy to be empathic.
Raudonis53 used a naturalistic approach
to study the patient’s perspective of the na-
ture, meaning, and impact of empathic rela-
tionships with hospice nurses. Her findings
include affirmation as a person, friendship,
physical well-being, and emotional well-being
as outcomes of patients experiencing empa-
thy. Patients in this study reported that the
experience of empathy meant being acknowl-
edged as a person of value. There were also
many examples of patients being empathic
with nurses. Current findings echo Raudonis’
emphasis on the reciprocity in the relation-
ship, the patients in her study reported that
it was like a friendship. Likewise, patients in
this study referred to “friends”at times, for ex-
ample, when a patient said to a nurse, “You
have lost your friend.” Developing friend-
ships was possible because of the chronic na-
ture of cancer the patients would have many
readmissions.
EMPATHY AS A WAY OF BEING
In this study, as the incidents of empathy
increased, the nurse increased her skills of
empathy and felt competent. The nurse ex-
perienced the effects of being empathic and
witnessed the positive effect it had on the pa-
tient, which, in turn, seemed to encourage
nurses to use empathy more frequently. With
particular nurses, empathy then became a
matter of course; it became the way in which
they nursed, a way of being: seemingly effort-
less. Empathy as a way of being relates to what
Benner and Wrubel52 describe as embodied
intelligence where the body “takes over” a
skill so that the task becomes easier and ef-
fortless yet gives the nurse increased sensi-
tivity to signs and patterns. When embodied
intelligence works well, it is rapid, noncon-
scious, and nonreflective. This may explain
why nurses had not been aware of being em-
pathic. When describing how they use empa-
thy, nurses in this category said, “It’s just the
way I am.” Benner and Wrubel note that em-
bodied intelligence is usually only brought to
a person’s attention when it is not working
well or when it breaks down.
FACTORS AFFECTING DEVELOPMENT
AND EXPRESSION OF EMPATHY
(INCLUDING KNOWLEDGE,
SOCIALIZATION, AND THE CONTEXT)
Familiarity and similarity
In relation to changes in the environment,
the number of incidents of empathy observed
over the course of the study fluctuated and
then decreased. Factors highlighted in the lit-
erature for enhancing empathy include famil-
iarity, similarity with patients, previous ex-
perience of being a patient, the verbal abil-
ity of the patient, and patients who had
chronic illness.34 The findings of this study
indicated that familiarity may increase the
incidents of empathy, both in terms of the
patient’s personality and the environment.
Patients who were friendly, outgoing, and
possessed good communication skills experi-
enced more empathic episodes with nurses,
which is reminiscent of Stockwell’s45 work on
popular/unpopular patients. Nurses reported
that these patients were easier to know and
more open, making being empathic easier
and less effort for the nurse. For nurses at the
left side of the continuum (Fig 1), there were
more incidents of empathy with familiar pa-
tients. It seemed these patients enabled the
nurse to develop their empathy skills.
The findings of this study regarding the
expression of empathy and similarity be-
tween nurses and patients (eg, in terms of
age, gender, background, disposition) sug-
gest that the relationship found by Malek34
is more intricate than initially reported. Some
Toward a Holistic Conceptualization of Empathy for Nursing Practice E69
nurses thought similarity facilitated empathy,
although others reported that it made it eas-
ier to slip into sympathy. An explanation may
be that if empathy is based on a common
humanity,39,38,54 when the nurse is beginning
to develop her empathy skills, being similar
helps that commonality. A few nurses indi-
cated that familiarity made the experience of
empathy more draining, especially when it
was busy because “you knew what the patient
wanted or needed but you couldn’t give it to
them.”
Experience and knowledge of the nurse
The literature regarding nurses’ age, years
of experience, and education yields mixed
results.23,24,38 The findings from this study
may provide one way of explaining or un-
derstanding this variation. Nurses in this
study who used empathy most frequently
were those who seemed confident in what
they knew and comfortable in what they
did not know, and showed a high degree of
self-awareness. Burnard2and Thompson,37 in
particular, have stressed the importance of
self-awareness in developing empathy. Years
of experience made a difference in that at the
beginning of the study the team was well es-
tablished, most nurses had been on the ward
for a number of years, and had a high degree
of expertise in cancer nursing. This also had
implications for managing uncertainty and
coping.
Self-awareness (knowledge of self)
Carper44 describes self-awareness when
discussing personal knowing: “one does not
know about the self; one strives simply to
know the self.”The way in which nurses view
themselves is of prime concern to the thera-
peutic relationship. Ray50 states that the nurse
must know and understand her or his self be-
fore entering into the “life world”of another.
It has been suggested that the more the nurse
is aware of her or his self, the less defended
she or he is and the more open to putting
herself in another’s position.2,37,48 Moreover,
it has been argued that the more the nurse wit-
nesses empathy, experiences empathy, or ex-
periences an empathic milieu, the more she
or he develops self-awareness and awareness
of self in the empathic enterprise.37,48 Self-
awareness is an important aspect of empathy,
as the nurse’s clarity about the boundary be-
tween self and other is essential to maintain
the “as if” stance.
Study findings suggested a relationship be-
tween self-awareness and the expression of
empathy in that nurses whose empathy skills
were well developed seemed also to be very
aware of their strengths and weaknesses and
appeared to reflect on their interactions with
people and the part they played in these. As
nurses were developing their empathy skills,
reflecting on their experiences (eg, in the
supervision group) and the role they played
in the experience, helped to develop self-
awareness. Thompson37 also stresses the im-
portance of reflection to develop empathy.
She states that reflection is critical for the
nurse to make sense and clarify what the
meaning is of the experience for the patient
and for the nurse.
Tyner21 shows how self-awareness is im-
portant for empathy when she explains the
different phases of empathy. She states that
the first phase is identification where the
nurse contemplates a patient’s experiences.
She then incorporates the patient’s feeling,
and both these phases help to reduce so-
cial distance. During the third phase of the
process, the nurse “reverberates” the feel-
ings from within to elicit something familiar
to self-experience. In “reverberation,” one’s
own self-knowledge is deepened, and from
this self-awareness comes an understanding
of what the other person is feeling. The final
phase of detachment provides for comparison
and objective analysis of the feeling to provide
an equilibrium to the intense aspects of the
process.
King41 states knowledge of self is key to un-
derstanding human behavior, because self is
the way we define ourselves to others. Aware-
ness of self helps one to become a sensitive
human being who is comfortable with self
E70 ADVANCES IN NURSING SCIENCE/JULY–SEPTEMBER 2007
and with relationship with others. Awareness
of self makes it more likely that the nurse will
be empathic. Through empathy, perceiving
others and experiencing an awareness of the
situation of the other in themselves, a wide
range of human sensitivity is developed, in-
creasing the nurse’s use of self. The findings
of this study reflect the idea of developing
a wide range of human sensitivity in what
nurses said about empathy increasing their
knowledge about patients’ experiences. Alli-
good et al36 suggest that empathy is a medium
for intrapersonal development and the level
of development is reflected in interpersonal
processes.
Socialization and the context
The study data revealed other factors as im-
portant for facilitating empathy such as pos-
itive role models, the ward philosophy and
environment, and being cared for. These find-
ings support the works of Anderson55 who
showed the importance of role models for sus-
taining empathy following a teaching program
and Bultema56 who showed that the experi-
ence of being cared for by supervisors and
managers made a difference to the amount of
empathy staff expressed.
BARRIERS TO THE DEVELOPMENT AND
EXPRESSION OF EMPATHY
The findings support a number of stud-
ies about barriers to empathy. The barriers
identified in this study support previous
work. These include time,4,16,53,57 inadequate
staffing levels,4,16 lack of support,16,19 ac-
tivities that distanced the nurse from the
patient,58 stress, and patients who block em-
pathy. As the number of empathic incidents
reduced over the course of the data collec-
tion, these episodes became largely confined
to the practical episodes of admitting, dis-
charging, and breaking bad news. By com-
pletion of data collection, there were ex-
amples of shifts where nurses rarely used
empathy. Nurses reported not having time
as the major barrier to empathy, which
confirms other studies.4,16,34,57 However, al-
though there were periods of inadequate
staffing resulting in nurses having more tasks
to do in order to adhere to trust policies, such
as drug administration, lack of time was not
always the case. Data from participant obser-
vation showed that nurses were distancing
themselves more from the patient, which is
reminiscent of Menzies’59 work as well as of
Omdahl and O’Donnell.19 The importance of
the context is discussed elsewhere.10
CONCLUSION
Previous conceptualizations of empathy
have been located within the counseling rela-
tionship. This article proposes a new way to
conceptualize empathy that is located in nurs-
ing and the nurse-patient relationship. It is
an attempt to view empathy holistically, mak-
ing it easier to apply existing research, which
will be useful for nurses in practice and for
further research into empathy. The concep-
tualization presented enables a deeper under-
standing of empathy and accommodates the
different ways empathy has been conceptual-
ized in the past.
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