Running head: EMPATHY
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A Concept Analysis of Empathy
Heather A. Surcouf
Southeastern Louisiana University
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Abstract
The purpose of this analysis is to clarify the concept of empathy. Through a thorough review of
the literature, empathy will be examined as it relates to nursing, noting it’s practical, theoretical,
and research applications. It will be defined, both operationally and in theory. Attributes
consistent with empathy will be explored and case studies will be presented, to include a model
case, borderline case, and contrary case. Antecedents and consequences will also be discussed.
By clarifying the concept of empathy, and applying it to practice, nurses have a unique role in
the continuum of care in the patient’s path to wellness.
Keywords: empathy, concept analysis, understanding, shared feeling, self-awareness
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A Concept Analysis of Empathy
Empathy is an overused concept in the profession of nursing. It is used in multiple
contexts to mean many things and is the subject of many research articles and nursing models.
Although not a fully understood concept, it remains a foundation to nursing practice. On a
doctoral level, through careful analysis of what empathy is, we can attain a unified idea of this
concept; and with further research, expand upon the true meaning of empathy in nursing. Nurses
must be acutely aware of the patient, mind, body and spirit, and relate this to the patient’s
condition and situation. They must “connect” with the patient on some level to experience the
patient’s situation and “walk in their shoes”. Through this connection, they can move the patient
to a state of wellness. In other words, nurses must have “empathy”.
Applications in Practice, Theory, and Research
Empathy in Practice
Empathy, as described by Carl Rogers, is a direct application of practice. He believed it
was a core approach to person centered counseling (Brunero, Lamont, & Coates, 2010). Rogers
described empathy as “the state of perceiving the internal frame of reference of another person,
with accuracy and with emotional components and meanings that pertain to it, as if one were
with the other person, but without the loss of the as-if condition” (as cited in Brunero, et. al,
2010, p. 64). This application holds true in nursing practice. Through empathy, the patient is
able to communicate their realities to the nurse, thereby increasing the ability of the nurse to
respond to the patient’s unique needs (Kirk, 2007).
Halpern suggested that empathy enhances
practice by giving personal meaning to a patient’s words, helping to hold the patient’s attention
or focus on their condition, and facilitating trust and disclosure. He noted that there is evidence
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linking empathy to enhanced therapeutic efficacy (2003). Applied to practice, empathy is a
means to assist in the communication process, which lends itself to effective diagnosing and
treatment. Empathy in nursing practice is often defined as a desired and needed trait or learned
behavior required to communicate effectively and relate to the patient’s experience.
Empathy in Theory
The philosopher, Edith Stein, wrote the dissertation, “On the Problem of Empathy” in
1916. She described empathy encompassing three levels: the other person experienced as an
object; the clarification of the other’s emotion; and the shared feelings ending (Alligood, 2005).
Stein suggested that empathy encompasses a “parallel experience between empathizer and
subject. The empathizer can feel the same feelings of the subject without having the same
feelings” (Määttä 2006, p. 4). Stein’s ideas on empathy are echoed in nursing theory.
Imogene King included the concept of empathy in her general systems framework theory.
King’s model includes three open, interacting systems: the personal (the individual),
interpersonal (two or more persons), and social systems (large systems such as religion, work, or
education) (Alligood, 2000). According to King, empathy organizes perceptions; facilitates
awareness of self and others; increases sensitivity; promotes shared respect, mutual goals, and
social awareness of self; facilitates understanding of individuals from a social context; increases
the understanding of individuals from a historical context; and effects learning and organizes
perceptions” (Alligood, 2000). King asserted that empathy guides the “conceptualization of the
role of the nurse”. It “contributes to the achievement of standards” and “enhances the valuing of
authority”, which facilitates nursing empowerment and professionalism (Alligood, 2000, p. 245).
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Joyce Travelbee also utilizes the concept of empathy in nursing theory in her human-tohuman relationship model. Although her model is associated with caring, empathy is noted as a
component of the stages of caring (Parker & Smith, 2010). According to Travelbee, nurses use
the empathy phase to “see the individual beyond outward behavior and sense their inner
experience at a given point in time”. She asserted that empathy required intellect and
comprehension of emotion and that it was integral to caring (Parker & Smith, 2010, p. 77).
Empathy in Research
There are multiple articles regarding empathy research. Most of these pertain to whether
or not empathy can be measured and how it can be measured. Others attempt to measure the
effects of empathy on patient outcomes. Also apparent in the literature is research regarding
whether empathy can be learned, should be taught, or is an innate characteristic.
The most common type of tool used to measure empathy is a subjective questionnaire
with a related numbered grading scale. This tool is used to measure empathy in nurses and other
healthcare professionals, and measure the patient’s perception as to whether the latter were
empathetic. One example is the Jefferson Scale of Physician Empathy, a twenty item
questionnaire given to patients. It has been subjected to multiple tests for validity, reliability,
and consistency (Berg, Berg, Veloski, & Hojat, 2011). Similar tools include the Jefferson Scale
of Patient Perception of Physician Empathy, the Empathy Assessment Index, Nursing Student
Empathic Communication Questionnaire, the Empathy Construct Rating Scales, the Reynolds
Empathy Scale, the Empathy Quotient, and others (Yu & Kirk, 2009). The literature suggests
that nursing tends to “borrow” tools to measure empathy from other disciplines, rather than
develop their own.
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Definitions of Empathy
Theoretical
A thorough review of the literature indicates that as a concept in nursing theory, empathy
is difficult to define. Kunyk and Olsen (2001) reviewed existing nursing research regarding
empathy. They concluded that existing definitions of empathy can divided as follows: empathy
as a human trait; empathy as a professional state; empathy as a communication process; empathy
as caring; and finally, empathy as a special relationship. As a human trait, Kunyk and Olsen
(2001) conclude that empathy is defined as a natural ability that cannot be taught, but is
instinctive, emotional and involuntary (p.319). As a professional state, empathy is seen as a
learned communication skill which assists in understanding a patient’s reality. Empathy, viewed
as a communication process, is seen as a way to assist in understanding the patient’s feelings and
situation and relaying that understanding back to the patient in a verbal or nonverbal manner.
Empathy defined as caring was not a common finding for Kunyk and Olsen (2000). In this view,
empathy is seen as an ability to perceive the patient’s feelings and situation as it relates to
alleviating client suffering. When defined in the context of a special relationship, empathy is
seen as a reciprocal relationship that has to be developed over time, such as seen in palliative
care or other long term care situations (Kunyk & Olsen, 2001).
Operational
According to Mercer & Reynolds (2002), the word empathy originates from the German
word “ Einfulung”, meaning “feeling within”, and is derived from Tichener from the Greek
roots, “em” and “pathos” or “feeling into” (Mercer & Reynolds 2002). Merriam-Webster’s
online dictionary defines empathy as “the imaginative projection of a subjective state into an
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object so that the object appears to be infused with it. The action of understanding, being aware
of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of
another of either the past or present without having the feelings, thoughts, and experience fully
communicated in an objectively explicit manner” (empathy). In the literature, there are multiple
similar operational definitions. Yegdich (1999) performed a literature review of common
definitions of empathy. He noted that Ballie, described empathy as “putting oneself in the other's
position, `to imagine and try to understand'” (as cited in Yegdich, 1999, p. 84). Zderard and
Gagan viewed empathy as “self-abandonment” and “ openness to the others”. Burnard,
Reynolds, Kalisch, and Zderad viewed empathy as the ability to appreciate others' perspectives,
in contrast to one's own” (as cited in Yegdich, 1999, p.3 ). Operationally, empathy can be
summarized as the ability to share a person’s situation and emotions, understand them without
self-bias or self-involvement, and use that understanding to communicate effectively. It is a tool,
whether learned or innate, that can assist in care of the patient in the continuum of illness to
health.
Defining Attributes
The defining attributes of empathy include a deep understanding and connectedness; an
awareness of self and a shared, perceived feeling; and the ability to understand or deeply relate to
another’s experience without experiencing it. Empathy occurs in the moment, in the perceived
shared experience. Empathy transcends physical and bonds the nurse to patient through a deeper
understanding of the patient’s individual situation. Empathy requires the ability to relate to a
person, understand their situation and how it affects that person without personal effect. To be
connected with someone implies a shared feeling, shared in an attempt to relate to a situation or
experience. Table 1 lists defining attributes for the concept of empathy with their justification.
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Case Examples
Model Case
Jan Smith, DNP, is working in a busy HIV clinic in downtown New Orleans. Ms. Kirby
arrives at her appointment for HIV testing. Dr. Smith discusses the test results with Ms. Kirby.
The results are positive. Ms. Kirby begins to cry quietly. Dr. Smith asks Ms. Kirby, “ What are
you most worried about?” Ms. Kirby states that she is afraid of what the illness will mean to her
as a single mom of two children. Dr. Smith takes Ms. Kirby’s hand, and says, “I understand how
you must be feeling. Being diagnosed with HIV can be scary, especially with all of the
uncertainty you are experiencing in your life right now. HIV is not what it used to be. Many
people live long, active healthy lives with HIV. We will take this one day at a time, monitoring
your levels and following your progress. ” Ms. Kirby wipes her eyes, and says, “Thank you Dr.
Smith, you have made me feel better.”
In this scenario, Dr. Smith uses empathy to “feel” what Ms. Kirby is feeling after
receiving the diagnosis. This is shown by Dr. Smith’s statement relating to Ms. Kirby by saying,
“being diagnosed with HIV is scary.” By saying this, she is validating Ms. Kirby’s fears and
expressing a parallel relationship, at least for the moment, to Ms. Kirby’s situation. She is using
this shared experience to assist Ms. Kirby in moving forward in the continuum of care to a state
of wellness, by stating “We will take this one day at a time.”
Borderline Case
Jan Smith, DNP is meeting with Ms. Kirby for results of her HIV test. Dr. Smith gives
Ms. Kirby the results, which are positive for HIV. Ms. Kirby begins to cry. Dr. Smith asks Ms.
Kirby, “ What are you most worried about?” Ms. Kirby states that she is afraid of what the
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illness will mean to her as a single mom of two children. Dr. Smith says, “You poor dear, I hope
things work out for you, I wish I could make it better.”
In this case, Dr. Smith attempts to form an emotional connection with Ms. Kirby by
asking, “what are you most worried about?” However, rather than making a mutual a connection
and showing a shared experience, Dr. Smith instead shows sympathy by stating, “you poor dear,
I hope things work out for you, I wish I could make it better.”
Contrary Case
Jan Smith, DNP is meeting with Ms. Kirby for results of her HIV test. Dr. Smith gives
Ms. Kirby the results. The results are positive for HIV. Ms. Kirby begins to cry. Dr. Smith tells
Ms. Kirby that she will be fine and schedules an appointment for next month.
This example clearly shows no empathy. Dr. Smith is making no attempt to relate to or
to experience Ms. Kirby’s situation. By lacking empathy in this situation, Dr. Smith misses an
opportunity to assist Ms. Kirby in the journey to wellness.
Antecedents and Consequences
Antecedents
Since empathy is a concept of relationship, two willing parties are required. An
antecedent, thus for empathy, is a willing, open patient, who is able to express him or herself and
their feelings and situation. A receiver, or “empathizer” is also needed. One who is acutely
aware of any personally held bias for the patient; who is objective and self- aware; a keen
observer, who is open to receiving the patient’s feelings. Morse, Bottorff, Anderson, O'Brien, &
Solberg (2006), suggested the mere observation of suffering as an antecedent for empathy.
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“Observing a patient suffering causes distress in the nurse and, consequently, awareness of
his/her own body. Thus, the nurse is engaged with the patient’s experience of suffering, and the
patient’s suffering is embodied by the nurse, and suffering becomes a shared experience” (p.
206).
Consequences
Consequences of empathy include enhanced patient- nurse relationship, a positive patient
outcome, and personal provider fulfillment. Numerous studies have shown a correlation
between empathy and objective and subjective outcomes, such as lowered cholesterol levels,
A1C levels, and increased patient satisfaction.
Other outcomes include improved diagnostic
accuracy, reduced negative symptoms from patients, and greater patient compliance. Increase
provider fulfillment in that through an empathetic relationship, communication is enhanced and a
mutual goal of wellness can be achieved. Caregiver fatigue as a negative consequence of
empathy has been noted in the literature. Empathy can in fact be emotionally exhausting for the
nurse, despite the fact that empathy should be “in the moment” and not carried through to a
personal involvement.
Conclusion
In conclusion, empathy, is an integral part of nursing practice, nursing theory and nursing
advancement. It is through empathy, that nurses exhibits not just an understanding of patients,
but a mutual relationship of shared experience. By nursing’s innate ability to relate to patients
empathetically, with consideration for the nurses own bias and feelings, and for the patient’s
given situation and extrinsic factors, nursing establishes a unique role in patient care. Many
professions “care” for patients, have sympathy, and are compassionate; however, through
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examination of existing theories, conceptual models, practice doctrines, it is nursing who can
play a central role in the patient’s continuum of care form sickness through wellness by utilizing
empathy.
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References
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view. Annual Review of Nursing Education, 3, 299-309.
Alligood, M. R., & May, B. A. (2000). A nursing theory of personal system empathy:
interpreting a conceptualizing of empathy in King's interacting systems. Nursing Science
Quarterly, 13(3), 243-247.
Berg, K., Majdan, J. F., Berg, D., Veloski, J., & Hojat, M. (2011). A comparison of medical
students" self-reported empathy with simulated patients" assessments of the students"
empathy. Medical Teacher, 33(5), 388-391. doi: 10.3109/0142159X.2010.530319
Brunero, S., Lamont, S., & Coates, M. (2010). A review of empathy education in nursing.
Nursing Inquiry, 17(1), 64-73. doi: 10.1111/j.1440-1800.2009.00482.x
Empathy. 2012. In Merriam-Webster.com. Retrieved September 20, 2012, from
http://www.merriam-webster.com/dictionary/empathy.
Halpern, J. (2003). What is clinical empathy? Journal of General Internal Medicine, 18, 670674.
Kirk, T. W. (2007). Beyond empathy: clinical intimacy in nursing practice. Nursing Philosophy,
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Kunyk, D., & Olson, J. K. (2001). Clarification of conceptualizations of empathy. Journal of
Advanced Nursing, 35(3), 317-325. doi: 10.1046/j.1365-2648.2001.01848.x
Määttä, S. M. (2006). Closeness and distance in the nurse-patient relation. The relevance of
Edith Stein's concept of empathy. Nursing Philosophy, 7(1), 3-10.
Mercer, S.W., Reynolds, W.J. (2002). Empathy and Quality Care. British Journal of Quality
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Care. 52, s9-s13.
Morse, J. M., Bottorff, J., Anderson, G., O'Brien, B., & Solberg, S. (2006). Beyond empathy:
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Table 1
Defining Attributes of Empathy With Justification
Defining Attribute
Understanding
Adequate or Relevant
Relative
Justification
Necessary to interpret shared
situation
Connectedness
Relative
Required to formulate
relationship for empathy
Self-awareness
Adequate
Needed to increase awareness of
bias, judgment, and prevent
emotional involvement
Shared feeling
Relative
Both parties must be on the
same level in understanding the
perceived situation