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A concept analysis of empathy 

 ARTICLE  in  JOURNAL OF ADVANCED NURSING · MAY 1996

Impact Factor: 1.69 · DOI: 10.1046/j.1365-2648.1996.12213.x

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Joumal of Advanced Nursmg,  1996,23,1162-1167

A concept analysis of empathy

T h e re s a W i s e m a n RGN BSc(Hons)(Psy) RCNT RNT PGDE

Nurse Tutor, Bloomsbury and Islington College of Nursing and Midw ifery, Lond on,

England

Accepted for pubhcation 2 August 1995

WISEMAN

 T

  (1996)  Journal of Advanced Nursing  23,1162-1167

A concept ana lysis of empathy

The concept of emp athy lies amid m uch confusion This analysis addresse s t

confusion using Walker and A vant's model of concept a nalysis, and looks

 at

what empathy is

  is it

 trait

 or

 state,

 is it

 dynamic

 or

 static, and ho w is

 it

recognized and measured' Implications of these findings are discussed,

limitations ofthe study are acknowledged and areas

 for

 further w ork suggest

INTRODUCTION

Empathy is a tenn widely used and written about m nurs-

mg and, as such, its meaning and apphcation has become

blurred When this happens, one way to clanfy  a term is

to conduct  a concept analysis When embarking  on con-

cept analysis. Walker

 

Avant (1983) advocate choosing

 a

concept

  in

  which

  you are

  akeady interested, either

 one

associated with

  the

 work

 or one

 that

 has

 always been

 of

concern

 to you

  Eighteen years' expenence

 of

 nursmg

 led

to

 the

 author, long ago, forming

 a

 tentative opinion that

 it

IS

 the abihty

 to

 empathize which distinguishes

 an

 average

nurse from

  an

  excellent nurse

 in the

 eyes

 of

  the patient,

regardless

 of

 how care

 is

 delivered Accomp anying this

 is

the fact that durmg

 a

 3-year breeik

 m

  service

 to do a

  full-

time degree in psychology, the author n oted an increased

interest m the subject  of empathy m the nursing press m

relation  to  management, education  and the  process  of

nursing

The hterature highlights the need for analysis Tsh uldm

(1989) asserts that no area of nursm g de man ds m ore empa-

thy than  any other  The more empathic nurses  are the

more likely they are

 to

 give total care Sharkey (1985) sug-

gests that those nurses who seemed to be trusted by their

patients  and approved  of by  colleagues were those with

the ability to imagine how each of their patients felt, from

each patient's perspective, takmg mto account their v ane d

backgroimds cuid different reactions

 to

 illness

 and

 hospi-

talization Reynolds (1987) reveals that although em pathy

IS

 the

  most cntical ingredient

 of

  the helping relationship

(Kalisch 1973), there

 is

  little agreement

 as to how it is to

be defined

  His 1986

  research

  m

  Scotland demonstrated

Correspondence Theresa Wiseman, 26 Wanstead Park Avenue, Wanstead,

London E12 5EN England

that nurse teachers are often un clear about w hat they me

by empathy and that confusion of the construct has im

cations  for  teaching  and  learning Hom blow  and  ot

(1977) point out that research on empathy is com phc

by   the  absence  of an  agreed theoretical framework  a

operational definition

PURPOSE OF N LYSIS

The purposes

  of

 concept analysis mclude clarificatio

terms which have become catch-phrases

  and

  have

their meaning,

  a

  means

  of

  developing operational d

nitions for use Ul theory and research and an intellec

exercise (Walker

 

Avant 1983)  In this analysis, the m

purposes were to  mcrease knowledge of  the concept a

to answer some questions Namely, what  is empathy, i

IS so  important,  how is it  recognized, nurtured  and s

tained, under what conditions does it  fiounsh and dim

ish,  and IS it  static  or  dynamic' Walker  and  Avs

framework is used because, edthough sympathizing w

Rodger's (1989) comments  on  entity  and  dispositi

views, this

 IS

 a first attem pt at concep t analys is and W a

and Avant's

  1988

 book p rovid es full information

  a

simplifies  the process

In order

 to

 gain

 an

 idea

 of

 working definitions

 of

 em

thy used

  by

  'ordinary' nurses,

  a

  group

  of

  nurses

  at t

Royal College

 of

 Nursmg, London, was asked 'What c

to

 mmd

 when

  the

  term empathy

  was

 u s e d ' '

  It

 could

 

argued that this was

 not a

 representative group

 of

 nu

as they were

 on a

 course

 of

 study

 so may

 differ

  m

 te

of better access

  to

  reading matenal, t ime,

  and

  o

resources They may also have higher than average mot

ation To address this, comments were also added

 bom

group of nurses of vanous ages and experience sittmg 

a hospital refectory

  The

  'brainstorm' produced

  t

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  concept analysis of empathy

following Listening, Canng , Un der sta ndu ^,

Feelmg, Empathy, Non-)uc^emental, See how others see.

Permission

In this paper I will consider the ongins of the word

'empathy' and the dictionary defimtions, examme the

broad quahtie s of empathy as descnb ed by Kalisch (1973)

and Bumard (1988), address the debate about whether

empathy is ' trait' or 'state', consider how researchers

define empathy emd finally, examme empathy from the

patients' point of view

DICTIONARY D EFINITIONS

The Fontana (1988)  Dictionary of Modem Thought  high-

lights the ong ms of the word em pathy It was comed by

Vemon Lee m 1904 and then employed by

 E B

  Titchener,

a psychologist, in 1909 as a translation of the German

'Emfdhlmg' which means 'feelmg into' This notion had

been developed by Lotze (1908), provoking the Alienation

Theory of Brechtm However, this is not the forum to

develop this discussion further (see Fontana (1988)

Dictionary of Modem Thought)  The following is the most

abstract definition of empathy

Projection (not necessarily voluntary) of the self mto the feehngs

of others, mto the 'being' of objects or sets of objects, it miplies

psychological involvement, at once Keat's pain and joy

This suggests that empathy can occur subconsciously as

well as consciously, with m am ma te objects as well as ani-

mate, that It mvolves the mind or psyche, and that it can

cause pam as well as joy Another definition w hich m en-

tions inanimate objects is m   Chambers 20th Century

Dictionary

  (1983 p 325)

the power of entenng into ano ther's personality and lmagmat-

lvely experiencing his expenences, the power of entenng mto the

feelmg or spirit of somethmg (especially a work of art) and so

appreciate it fully

Here one gets the no tion of a strength rather than a weak-

ness, and the idea of valuing from 'appreciate it fully'  The

Longman D ictionary of Psychology and Psychiatry

  (1984)

emphasizes the objectivity and interpretation Eispect

the objective awareness of another person's thoughts and fee l-

mgs and their possible meanings One who empathizes sustains

his objectivity and separate feehngs even when confronted with

disturbu^ psychological matenal

Two nursmg d ictionanes were then consulted Saimders

(1989) Encyclopedia and D ictionary of Medicine, Nursing

and Apphed Health  pomts to the understanding compo-

nent and compares empathy with sympathy

Intellectual and emotional awareness and imderstandmg of

another person's thoughts,

 feelmgs and behaviour

even those that

are distressing and disturbing Empathy emphasises understand-

ing, sympathy emphasises sharing of another's feelings and

expenences

Mosby s Medical and Nursmg Dictionary (1986)

 highlights

the understandmg and significance of the person and the

importance of empathy for psychotherapy

The ability to recognise and to some extent share the emotions

and states of

 mmd

 of another and to understand the meaning and

significance of that person 's behaviour It is an essential quabty

for effecbve psychotherapy Compare with sympathy, which

 is

 an

expressed mterest or concem regarding the problems, emotions

or states of mmd of another

LITERATURE REVIEW

The literature concerning empathy shows a wide range of

use ofthe word, from broad to specific Apart from diction-

ary defimtions, five of which were selected, a literature

search gave 53 references All these references w ere exam-

ined but consensus led to 33 bemg used in this article

The five dictionary definitions are im portant to begin the

analysis as each contains differing elements which come

out in the hterature

Early theonsts and wnters saw empathy as a trait or

characten stic which w as stable and could he measured but

not taught Among these are Cronhach (1955), Hogan

(1969), Smither (1977) and more recently, Astrom et   al

(1991) Cronbach and Hogan devised persona hty tests to

test for empathy These authors define em pathy as a per-

sonality attnbute mvolvmg the capacity to respond

emotionally, cognitively and communicatively to other

perso ns with out the loss of objectivity From this defi-

nition, it can be seen that the quahties of empathy mirror

the other theonsts but the denv ation is different Latterly,

theonsts see empathy as havmg both 'trait' and 'state'

components

Williams (1989) maintains that people have a tendency

to expenence empathy that may or may not be actualized

in any specific situation Her research investigated th e

relationship between empathy and burnout, tentatively

suggesting that they may represent opposite poles of the

same underlying construct However, no support for a

polar relationship w as foimd Sharkey (1985) asks why so

few nurses with the abihty to empathize actually use it

She suggests that nurse traimng damages the innate ability

of the tramee to empathize

Confusion

As noted earlier, some wnt ers seem very specific and clear,

about what empathy is whilst others (the minonty) are

imclear, and the concept can easily be confused with other

terms, such as sjmipathy or com mu mcation Among the

latter are Smith (1985), Assimacopoulos (1987) and

W ilson-Bam ett (1988) Sm ith (1985, p 5) says em pathy is

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 1996 Blackwell Science Ltd, Joumal o f  dvanced Nursing

23,

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T Wiseman

'knowing what the other person is suffenng because you

can imagine yourself in similar circumstances or because

you have had similar expene nce' The reader could easily

be forgiven for confusing this with sympathy

Assimacopoulos (1987) also confuses empathy with sym-

pathy and Wilson-Bamett asserts that nurses w ho talk less

are perceived as bemg more empathic

Bumard (1988) defines empathy as the ability to see the

world as another person sees it or to enter mto another's

frame of reference One attempts to set aside one's ow n

perception of thmgs in order to think the way the other

person thinks or feel the way they feel Bum ard distingu-

ishes empathy from sympathy S5rmpathy involves 'feeling

sorry' for the other person or imagining how we would

feel if we were expenencmg what is happening to them

Empathy differs m that we try to imagine what it is like

being that person and experiencing things as they do, not

as we would

Bumard (1988) sees empathy as the key to understand-

ing and, as such , a vital skill for nur ses to leam He

explains that the skill of empathy involves two related

processes One is attempting to view the world as the

patient does and the other is attemptmg to identify the

personal theory that guides patients m their everyday

expe nenc e Because Bum ard sees empa thy as a skill,

he concentrates on methods of developing empathy for

climcal and educational staff

Kalisch (1973) asserts that empathy mu st involve current

feelings of a person, not the feelmgs of yesterday or the

day before She states that it is the ability to enter mto th e

life of another person, stressing the importance of the per-

ception of feelmgs bemg accurate Kalisch also compa res

empathy to sympathy, explaining that m empathy helpers

borrow their clients' feelmgs m order to understand them,

but are alway s aware of their sepa rateness In her defi-

nition of empathy, Kalisch (1973) does not include

the communication of understanding, but does not state

that when empathy is communication, it forms the basis

for a helping relationship She views empathetic per-

ception and communication as a state m terms of levels or

categones rather than an 'all or nothmg' charactenstic

Three components

Rogers (1957) descnbed empathy as having three com-

ponents affective (sensitivity), cognitive (observation

and mental processing), and communicative (helper's

response) LaMonica (1981) highlights the co mm umcation

aspect of em pathy She defines empa thy as sigmfymg a

central focus and feehng, with and m the chent's world

It mvolves accurate perception of the ch ent's w orld by the

helper, commumcation of his/her understandmg to the

chent, and the chent's perception of the helper's under-

standing LaMonica and others (1976) showed that nurses

initially scored low m empathy hut this level mcreased

followmg a staff development progreimme Truax

 

M

(1971) asserted that nurses are generally low m empa

com pared to other professional groups Situa tional fac

have been found to eiffect the level of empathy expres

(Olsen

 

Iwasiw 1989)

Carkhuff (1969) was one of the first theonsts to ass

that if emp athy w as a state, it was dynam ic and theref

cou ld be me asure d on different leve ls He suggested t

empathy is employed when one mdividual hears a

unde rstands another It mvolves 'crawhng inside anot

person's skin' and seeing the world through his/her ey

It mvolves expenencmg the world as if you were t

perso n Carkhuff (1969) stressed the comm imica tion

empa thy and devised a scale to measure em pathy on f

levels based on the response, whether the feehng w

acknowledged or not, surface feehngs refiected and

interpretation of underlying feeling comm unicated Ot

theonsts who have also devised scales include Gaz

(1973) and LaMomca (1981)

TEACHING EMPATHY

As the consensus is that emp athy is a skill which is cruc

to the helping relationship, many authors discuss m etho

of teaching empathy most effectively (Layton 19

Bum ard 1987, Cox 1989, Morath 1989 and Tshu ldm 19

Bum ard (1987) suggests that before nurses can u ndersta

and explore a patient's perspective, they must expl

their own persp ective Self-awareness, therefore, is a pre

quisite to empathy Bum ard identifies other skills nec

sary for empathy including the ability to listen, to of

free attention and to suspe nd judgement Tshu ldm (19

highhghts self-awareness, communication skills, espe

ally listening, perception of feelings withm self and oth

and hidden feelmgs, emd not judgmg others

The literature makes very little mention of the clien

views on emp athy Rogers (1957) states that bemg und

stood

 IS

 the most basic hum an nee d, and it is only by b

understood and accepted that individuals are able

change and grow Although there is literature to show t

empathy affects the helping relationship, there is a lack

reference to the clien t's pom t of view Engledow (1987

nurse, identifies empathy as being vital to her if she w

a patient Many studies do not even use patient assessm

of em pathy This is clearly a deficit ui the literature w hi

needs to be addressed

DEFINING ATTRIBUTES

Having examined the literature, the next step according

the Walker Avant (1988) mo del is to identify 'defini

attnb utes ' A defining attnbu te is something which has

be present for the concept to occur Each characten s

evident from the hterature is discussed and either accept

or rejected as a defijiing attnbute

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A concept analysis of empathy

Trait or state

This was rejected as a defining attnbute because empathy

occurs regardless of wh ether it is a state or trait The htera-

ture points to empath y being both People have a dispo-

sition to be em pathic, but wh ether they are or not dep ends

on situational factors

See

  the world as others see it

All 53 references without excepbon mcluded this as a

charactenstic of em pathy Two of the dictionary defi-

mtions proposed that 'others' could mean an object rather

than a person This was accepted as a definmg attnh ute,

without this empathy cannot occur

Understand another s current feehngs

All references included understanding another's feehngs,

which was accepted as an attnbute Some wnters, among

them Kalisch (1973), stress the im portance of current feel-

mgs because perceptio ns had to be accurate This part of

the characten stic w as rejected hecause if a person is relat-

mg an instance about how they felt m the past, it is still

possible to be empathic and acknowledge the feelings of

the past even though they do not feel that way at present

Non-judgemental

Most references (40) highlight ohjectivity as a component

of em path y Rogers (1957) redefines this m to non-

judgemental Although It could be argued that, if the other

attnbutes were present (that is, seeing the world as others

see it and understa nding the feelmgs of others), this w ould

automatically be present also The author consulted many

colleagues as to this attnbute because some argued that

one could under stand bu t still be judgemental This was

accepted because of its importance, but is more tentative

than the other attributes

Comm unicate the understanding

Commumcation of understanding seems vital if empathy

IS to be felt Although early works do not in clude this, it

does seem implicit All tools for measu ring em pathy

mclude communication of imderstandmg, so this was

regarded as an attnbute

Summ ary of definmg attributes

1

  See the world as others see it

2 Non-judgemental

3 Understandmg emother's feelmgs

4 Commumcate the understandmg

ten ze archetypes and deviations This will help the reader

to clanfy the concept

Model case

Ann, wh o is 35 years old, has two ch ildren an d is suffenng

from ca ncer of the ovary, we nt to see a coun sellor The

counsellor, a 50-year-old man, listened to Ann as she

described her background and how she had been taku^

her anger about her illness out on the children By what

he said and how he acted, Ann knew that he understood

how sh e felt, and did not hlame her for being angry This

IS a model case because it contains all the attnbutes Even

though A nn and the coimsellor have very different 'terms

of reference', he listens to what she says, sees the situation

from her point of view, is not judgemental and is able to

communicate that imderstandmg to her

Borderline case

It was Joe's first day back at school since his father had

died At break-time, he was in the classroom crymg His

teacher came m, listened to how he felt but said nothing

He thought she understood, but she did not say anythmg,

he wished his father was there

This IS a borderline case because the teacher listens to

Joe and he thinks she understands that he is upset about

his father and is a 'cry baby' But he is not sure, as she did

not say anjrthmg It leaves him feelmg uncertsun about the

mteraction and wishmg for secunty

Related case

Beth was upset, she had been forbidden to go out as she

had been con sistently late home She was gomg to miss a

dance wh ich everyone was gomg to attend Kathrjrn said,

'Poor Beth,

 I

 know h ow you feel

  I

 had to miss an important

dance when I was your age because I'd npped my dress

and had nothing to wear'

This IS a related case of sympa thy Katluyn sees Beth is

upset over missing the dance, and thinks she would feel

the same In fact, she remembers a time whe n exactly that

happ ened an d she was upset Katluyn is getting the lmtial

feehng Beth is express ing But she is mte rpretm g it from

her own background and expenence so she misses com-

pletely what it means to Beth Although Beth senses the

warm th of the mteraction, she does not get any feehngs of

understanding, though there does not appear to be any

judging

M O D E L A N D B O R D E R L I N E C A S E S

At this stage. Walker and A vant (1988) advise demo nstrat-

ing a model case and several borderlme cases to charac-

Contrary case

Mrs Jones felt desperate and told the nurse she could not

go on with life 'Oh, don 't be silly,' the nurse replied

'You've got a lot to live for'

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T   Wiseman

This IS a contrary case as there is no acknowledgement

of how M rs Jones is feeling The nurs e does not attem pt

to see the world throu gh M rs Jones' eyes She is judge-

mental and does not communicate any understandmg Mrs

Jones IS left feelmg rem ons trated It took a lot for her

to voice her desperation, she knew nobody would

understand and that she was not worth bothermg about

Once the mod el cases have been identified, the next step

IS to specify the characte nstics prese nt wheneve r the event

occurs These are the anteceden ts (the required charac-

tenstics needed before the concept occurs) and the

consequences (the product of the concept o ccum ng)

Antecedents

This area was quite difficult to identify as there was con-

fusion as to whether antecedents apphed to an mcidence

of emp athy or the skill of empathy It was d ecided to

address both Before em pathy o ccurs there has to be (a) an

interaction mvolvmg communication of a feeling, and

(b) hstem ng on both sides , one to the feelings a nd though ts

of the 'empathee' and the other to empathy being

conveyed

There was consideration of whether a conscious desire

to empathize was an antecedent, but this was rejected as

It could not account for mstances where empathy is sub-

conscious and not desired Self-awareness was also con-

sidered as an antecedent as many programmes teachmg

emp athy begin with self-awareness This was rejected

because some people are naturally empathic (the trait

aspect) without bemg necessanly self-aware

Consequences

The consequences of an empathic interaction is that

'empathees' have a hasic need to be understood satisfied,

they feel valued and m ore ready to und erstan d themselves

and change The person bemg emp athic feels satisfied

because he /she senses they have been of help and fulfilled

the need to be useful to others

The last stage of the model is to identify what phen-

omena dem onstrate the occurrence of the concept The

empmcal referents determine when the concept has

occurred, so can be used as a mea sure They may be similar

or identical to the defining attnhu tes Indee d, m this

analysis they are the same

Empincal referents

Em pin cal referents are (a) the abilify to listen, (b) the

ability to take on an othe r's term of reference, (c) the ability

to understand and not judge, and (d) the ability to

communicate that understanding

DISCUSSION

Reading through the hterature, confusion has occur

because of the trait/state argument and the absence o

working definition of emp athy However, there does n

appear to be consensus that a person may have a disp

sition to be emp athic (trait) but wh ether s he/h e is depen

on a numb er of factors (state) The research q uestion det

mines w hich element of empathy is examined, whethe

be the subject's disposition or the mcidence of empat

how often em pathy oc curs or the qualify ofthe interacti

It IS the latter aspect which caused the author so

difficulfy Most resea rch is qua ntitative an d the exist

tools which measure empathy (mcluduig Carkhuff 196

and LaMonica 1981) begin w ith level one wh ich is 'igno

feehngs exp ressed' ev en though it is specified that a mm

mum level of empathy is level three which fulfils the de

nition This should be addres sed, as it could be t

dichotomy which is causing confusion

Research also needs to measure empathy more global

mc luding subject self-report, c lient report and observatio

both participan t and non-participant This may addre

verbeJ and non-verbal communication of empathy and t

feet that attitudes do not always reflect behaviour and th

what people say they do and actually do are not alwa

the same

CONCLUSION

The aim of this analysis was to clarify the meanmg

empathy and address some questions The questions

wh at em pathy is, is it trait or state, dynam ic or static, a

how it IS recognized ha ve been co nsidered and clea

identified usm g the Walker Avant (1988) mo del

concept analysis

However, the questions how is empathy nurtured an

sustained, and under w hich cond itions does i t f iounsh a

diminish have not been fully examined and have maj

implications for nursmg m recruitment, education (bo

methods and process) and man^ement ( the environme

and the delivery of care)

There is clearly a need for future research in these area

Concept analysis m ay clear the way for that wo rk to beg

References

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Nursing 25(11), 26-29

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Bum ard P (1988) Empathy the key to unde rstanding   T

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Bum ard P (1988) The heart of the counse llmg relationship

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