© Borgis - New Medicine 1/2009, s. 24-28
Empathy in the therapeutic relationship between the physician, nurse, and patient
Vice Head of The Institute of Nursing and Obstetrics, Faculty of Health Sciences, CMUJ
Katarzyna Wojtas, M.A. Assistant in the Department of Clinical Nursing and Obstetrics, Faculty of Health Sciences, CMUJ
Prof. Antoni Czupryna, PhD, M.D. Head of The Institute of Nursing and Obstetrics, Faculty of Health Sciences, CMUJ
This article discusses theoretical concepts defining empathy and its role as a factor necessary for establishing normal social relations, especially in the context of relations with patients. Being aware of the importance of empathy and its use in everyday life by physicians and nurses is fundamental when therapeutic relations and effective care of other people are concerned. A high level of empathy not only allows effective help to be delivered to patients, but it also becomes a significant element affecting an individual´s professional attitude, i.e. it prevents dissatisfaction, lack of professional fulfilment, and emotional burden. Empathy plays a special and vital role in the process of becoming professionally satisfied for both physicians and nurses taking care of those who suffer.
The objective of this work is to analyze empathy presented by physicians and nurses in their therapeutic relationships established with patients. As a result of this analysis, the meaning of empathy in the effective therapeutic relation is described, which proves empathy to be an essential element of the treatment process as well as ensuring quality of care.
Empathy presented by physicians and nurses in their therapeutic contact with a patient comprises the foundation of the therapeutic relation, which should aim at having a positive influence on the patient´s mind and reinforcement of positive emotions, restoring the patient´s internal balance, and preparing him/her for future functioning in the family and professional environment. Work with a patient is undoubtedly very difficult and it requires from carers adequate personal predispositions. Despite continuous progress in medical sciences, the therapeutic contact with a patient and building a dialogue are still fundamental tools in the treatment process and care. The awareness of the therapeutic contact and communication with the patient, based on empathy, has not lost any of its topicality. This point of view should consider professional work of physicians as well as nurses since the coherence of attitudes presented by members of the therapeutic team guarantees a clear message in the process of treatment and care.
The therapeutic contact is a specific kind of relationship defined by the patient´s life situation related to the fact of becoming ill as well as attitudes of carers combined with the context of the situation in which it takes place. This context includes the patient´s perception of the disease, triggered defence mechanisms, and adaptation skills in the situation changed by one´s illness. Competences and interpersonal skills of physicians and nurses cannot be underestimated since thanks to them caregivers get to know their patient and his/her needs, and become ready to establish the therapeutic contact [1, 2].
The specificity of the therapeutic contact results mainly from an appropriate relationship between the nurse and the physician, their readiness and ability to present empathic attitudes towards each other, as well as their awareness of the responsibility they bear for therapeutic actions taken. Only then would the established relation be called „therapeutic”, „having the potential of understanding the patient, discovering his/her real experiences and expectations, and motivating the patient to become active in the process of treatment” . Indicating the helpful character of this relationship proves that the caregiver´s empathy together with the patient´s feelings affects the quality of the developing therapeutic relationship between the carer and the one taken care of .
Empathy is a trait fundamental for physician and nurse professionals. The empathic attitude, meaning the ability of correct perception of verbal and nonverbal signals sent by the patient as well as the ability to assess the patient´s internal status, is an extremely valuable skill when communicating with other people. Understanding patients leads to a deeper interpersonal relationship between the physician, nurse, and patient, and reflects true, mutual, and effective cooperation of all participants of treatment.
The concept of empathy has its source in philosophy and is related to people´s attitudes toward each other, in which kindness and emotional harmony, initially called „liking”, dominate. However, the content of emotional experiences distinguishes it from empathy. Liking reflects acceptance toward the person with whom a relationship is being set whereas empathy means identification of my own feelings with another´s emotion and feelings or participation in another person´s experiences. Lipss directed the definition of empathy to the sphere of psychology. The term „Einfühlung” was translated as empathy or „feeling together with...” . As far as cognitive psychology is concerned, the sense of the discussed issue means the capability to adopt another´s role and point of view. This capability becomes very important, since understanding another person´s feelings and experiences allows one to predict his/her behaviours .
Empathy may also be defined through three different concepts: emotional, cognitive, and emotional-cognitive. When the emotional aspect is considered, empathy concerns harmony, co-experience, and emotional response to another´s experiences. It is emotional experience of the same affective states in a particular situation as those experienced by another person, to whom empathy is directed. This point of view has been presented by many researchers [6, 7, 8, 9, 10, 11, 12, 13].
Taking into consideration correct prediction of one´s feelings, reflections, and behaviours, the character of empathy is related to the capabilities of perceiving and understanding another´s experiences. These presumptions were applied by researchers presenting a cognitive attitude toward empathy. [14, 15, 16, 17, 18].
Empathy, in the emotional-cognitive concept, becomes an element of cognitive processes which play a mediating role in emotional stimulation, influence correct interpretation of the meaning of a perceived situation, and trigger an emotional reaction determined from the perspective of the other person. Emotional reactions are triggered by the perception of a particular situation or imagining it. Empathy is also described as an emotional-cognitive reaction including an executive component manifesting interpersonal communication [19, 20, 21, 22].
Morse´s concept of empathy seems extremely significant . Empathy is explained on the basis of four components: emotional, moral, cognitive, and behavioural. A fundamental meaning is attributed to the moment of stimulation of emotional empathy as a result of understanding one´s suffering and identifying with this suffering. It motivates the carer to make a conscious decision to recognize suffering and act with empathy or to avoid it and distance oneself from those who suffer.
The moral component or altruistic motivation is triggered by a spontaneous state of emotional excitation, an element of empathy, and results from a conscious decision to participate in another´s suffering. It may also be described as the art of „humanitarian life philosophy” and „deep human wisdom”. The cognitive aspect of empathy assumes that the helping person distances him or herself from emotional mechanisms of empathy and reviews the patient´s situation objectively within the context of social norms and professional knowledge [24, 25]. The behavioural component is understood as the capability of passing and understanding another person´s point of view including numerous communicational programmes (verbal and non-verbal). The authors emphasize the significance of cognitive and behavioural empathy. Also other studies on empathy take into account the behavioural component. Empathy is understood here as an active form, the final phase of an empathic act, where emotional and cognitive factors are transitional phases. The behavioural component, dominating in active empathy, causes the carer to experience not only the emotional status of the other person, but also his/her needs. As a result of this process, the perception of signals about the subject´s status is combined and the needs of the person whose substance is to help others are revised . While analysing the concept of empathy its interpersonal character must be mentioned. This view of the discussed issue allows empathy to be presented as interpersonal communication and activity of prosocial character. However, it does not exclude the value of intrapersonal processes happening in both interacting partners.
When attention is paid to the relationship forming between the physician, nurse, and patient, understanding empathy in all three aspects, i.e. emotional, cognitive, and behavioural, proves to be rational. It is expected to concern the capability of perception and interpretation of the patient´s reactions while being able to modify the caregiver´s own behaviours adequately to the objective needs of the patient.
The therapeutic contact taking empathy under consideration
The therapeutic contact and the relationship evolving between the physician, nurse, and patient comprise the most important elements in care of the patient. They include the creation of emotional bonds necessary for this type of contact . When beginning this therapeutic relationship, physicians and nurses should be aware of the fact that both sides of this specific form of contact must participate in it actively and define the direction of this bond. Creating the relationship becomes a factor motivating the patient to take actions in the process of treatment in order to return to one´s social roles. Therefore, one may say that the ability to start and support the therapeutic relation with the patient is an act of art. Once the therapeutic contact is established, its correctness concerns an adequate attitude toward the patient, the necessity of reinforcing the patient´s dignity and self-esteem .
The roles of the physician and nurse are worth underlining because it is they who ensure patients of their safety through an emphatic contact based on the truth and delicacy, active listening, asking open questions encouraging discussion and eliminating negative emotions. Showing empathy proves that the highest level of understanding mental suffering of the person taken care of was achieved, and that it is possible to abreact negative emotions. „Empathy has the greatest value at the moment of confrontation between the nurse and the patient because it allows understanding of the patient´s perspective, which means rational reactions as well as more internal and emotional attitudes toward the patient” . This is a very valuable and appreciated capability thanks to which nurses may understand their patients. Only then may therapeutic actions begin.
Emphatic comprehension of the patient in an atmosphere favourable for expressing one´s feelings is undoubtedly an element of communication with the person taken care of. As a result, care delivered by the nurse enters another dimension and encourages the patient to make progress and work on oneself . The analysis of empathy in the light of the physician-patient relation points to the characteristic relation created between both sides of the communication line because the physician is expected not only to engage one´s cognitive and instrumental abilities, but most of all, create emotional bonds. The patient needs the caregiver to understand his/her situation and expects concrete help and improvement of his/her mood.
The following words describe it perfectly: „the presence of an empathic physician, who can feel the situation, guarantees the sense of being understood intimately” . The therapeutic contact based on empathy, built by the physician and nurse, and providing effective help to the patient, depends on the following determinants:
– choosing suitable place of work by caregivers,
– the physician´s and nurse´s awareness of the tasks in the process of treatment,
– the necessity of creating an atmosphere of safety and stability for the patient,
– gaining the patient´s trust,
– the patient should not be judged and no consequences should be drawn for the patient´s mistakes resulting from the disease,
– preserving a balance between my own „me” and the patient,
– the awareness of being a member of the therapeutic team.
Empathy comprises the fundamental way of understanding the patient and making him/her feel understood. The physician and nurse taking care of the patient must make a conscious effort to empathize into the internal perceptive construction of the patient and not to lose their own identity as well as objectivity at the same time. Empathy requires the capabilities of careful listening, reacting, and a high level of self-consciousness to be used effectively. Emphatic reactions are connected with reflecting the patient´s emotions, which may be precise or imprecise. Meanwhile, the physician and nurse are expected to share these emotions in order to get some explanations. The formula of empathy is as follows: You experience (emotions) because (explanation); am I right (verification that the patient was understood correctly)?
Physician: „Y ou feel hurt and angry because you spent so much time and effort on this problem.”
Patient: „ Yes, I feel exactly this way.”
Physician: „ You feel hurt and angry because you spent so much time and effort on this problem.”
Patient: „ No, not really. I just feel helpless.”
Physician: „ I see, so this is all about helplessness, not anger.”
Patient: „ Yes, that is correct.”
Empathy encourages the patient to expose his/her feelings and emotions on a deeper level, which teaches him/her how to face personal feelings and emotions. It is a very important part of care of the patient because the therapeutic relationship filled with empathy determines the quality of this care. It is also an element of personal development of the patient as well as the physician´s and nurse´s taking care of him/her. One might risk a statement that effective empathy, characterized by verbal communication, becomes a major therapeutic tool in some situations. This mainly concerns relationships with patients suffering from diseases with a poor prognosis, chronic illness, after surgical interventions, and terminal states. In these cases the physician and nurse are expected to decrease anxiety through emotional company and conversation, which often is started and directed by the patient. On one hand this type of relation must satisfy the patient´s cognitive demands; on the other hand it should become proof of profound understanding of what the disease or approaching death means to him/her. Therefore, teaching physicians and nurses empathy seems rational since a higher level of empathy determines more effective communication.
This attempt to describe the significance of empathy in the aspect of three components (emotional, cognitive, and behavioural) in the process of communication between the nurse and the patient may be illustrated through different model situations which occur in nursing practise from time to time. These situations present empathic behaviours, ambiguous attitudes, some of them inconsistent with empathy, and those expressing only sympathy.
A CASE MODEL 
Mary is a 45-year-old woman during her first 24 hours after mastectomy. Anna, a morning shift nurse, talks to her:
Anna (opening the cabinet): Mary, which nightgown would you like to put on after washing?
Mary (tired): I don´t want to wash today. I feel pain in my chest.
A (facing Mary): How about I give you an analgesic injection. Do you think you can wash then? (The nurse accompanies the patient and listens to her carefully.)
M (sad): I really don´t want to cause any trouble today. I can´t.
A (maintaining visual contact, holding the patient´s arm, standing in front of the patient and recognizing emotions and sadness.)
M (crying): I can´t (sobbing). I´m terrified.
A (sitting on the bed, holding the patient´s hand): Are you afraid of the sight of your wound? (clarification of diagnosed fear)
M (still crying): Yes, I can´t believe this is happening to me.
A: Can´t you believe it? (reflection)
M (sobbing): I don´t know. How are we going to find ourselves, me and my husband?
A: Are you afraid that he is going to find himself another, more attractive woman? (interpretation of feelings)
M: I´ve been taking care of my body and we´ve had a good marriage (expression of emotions).
A: And now you are afraid of his reaction because of the mastectomy (identification and interpretation of hidden feeling; communicating emotions back to the patient).
M: Yes (the nurse is sitting and continuing nonverbal communication – dispelling anxiety and comforting the patient). I´m sorry but I´m worried and I´ve got depression.
A: I can understand you, it´s normal that you´re crying because this situation is extremely traumatic. Maybe I can chase away your fears. We´ll do everything possible to help you handle this problem (expressing understanding).
M: Thank you very much. I feel that it would be better to leave it and put aside negative thoughts (the patient wipes her tears).
The empathized person (Mary) is freed from her emotional stress. This model illustrates the behavioural component of empathy in concordance with the attributes described previously.
The following example does not illustrate all attributes of empathy. It is an ambiguous case (the same characters):
Mary: I´m really scared today. I can´t take it any more.
Anna: Are you afraid of pain?
M: No. I´m terrified (it looks like she is in tears).
A: You shouldn´t feel terrified. I´ll be here with you and give you analgesics. You are going to feel better (goes to get analgesics).
The nurse starts to listen. However, she interprets only the expression of feelings, not hidden emotions. This empathic process is unsuccessful.
The next example illustrates a conflicting case (the same characters):
Mary: I´m really scared today. I can´t take it any more.
A: Very well. I feel much better after refreshment (precedent in order to prepare the patient for washing).
In this example the nurse neglected the feelings and emotions of her patient. The nurse´s attitude cannot be called pre-empathic or empathic.
The next case illustrates the relation to the concept of sympathy (the same characters):
Mary: I´m really scared today. I can´t take it any more.
Anna: Are you afraid of distress?
M: I´m terrified (starts to cry).
A (having tears in her eyes): I can feel how terrifying it is for you.
In this example, the nurse engages emotionally in the patient´s expression but she does not help the patient to manage her feelings and fails to understand her emotions.
Nurses and physicians working with ill people should present a holistic attitude toward their patients and consider the patient´s capability of managing disease. Standing by the patient cannot be simple passive waiting for changes and progress of the treatment process. They are expected to be active in the therapeutic contact, predictive and able to evaluate taken actions for the sake of their patient. Their relationship with the patient should be dominated by awareness of the fact that a correctly built and sustained relation based on empathy is beneficial to both sides. The patient is given help and positive energy, which comprise the motivation for taking actions, support and reinforce the conviction that the effort made in the process of treatment was right. As a result, the patient becomes a perfect reflection of the physician´s and nurse´s work, their attitudes and effective care. This constitutes a source of professional satisfaction and proves that the choice of work place was correct, and most of all, it prevents professional burnout. It proves that the effort and engagement in the therapeutic relationship will be rewarded through the patient´s improvement and his/her satisfaction with the quality of care. „There is no doubt that empathy is a difficult art, requiring constant improvement in the relation with another person, especially that it creates a basis for helping and solving interpersonal conflicts. The discussed emotional availability offered by the physician and nurse results from their sensitivity and awareness of the fact that these are the only guarantees of adequate help given to the patient in the process of treatment and it prevents professional burnout” .
Empathy, as the central factor in the therapeutic relationship, influences the following elements:
? the expectation of professional knowledge from all members of the therapeutic team how to build therapeutic relations, competently accompany the patient in his/her situation changed by disease, express understanding and hope proportionally to the state and possibilities of the patient,
? the physician´s and nurse´s awareness of the fact that once established, sustained, and deepened, the therapeutic relation affects the patient´s mental sphere and has the potential to reduce negative emotional reactions, e.g. frustration, anxiety, anger, and rebellion,
? empathic behaviours of physicians and nurses allowing reinforcement of the patient´s resources of managing his/her situation resulting from disease as well as improvement in the patient´s self-esteem,
? personal and professional development of physicians and nurses including their moral attitudes.
Empathy also allows the physician and nurse to participate in the patient´s world, which aids the process of care and makes it easier for the patient to communicate his/her personal mental status, as well as assuring him/her of mental comfort. The issues related to empathy should be discussed within current educational programmes at medical schools and developed through practical training.
The following conclusions may be drawn as a result of the analysis given above.
– Being aware of the acceptance of disease and its consequences in the patient´s behaviour comprises an indispensable element of the therapeutic relationship.
– The depth of interpersonal relations, affecting the quality of care, depends on the emphatic capabilities of both the physician and the nurse.
– The ability of the physician and nurse to express empathy leads to actual strengthening of patients instead of limited superficial comfort and subjective treatment.
– Empathic physicians and nurses can recognise the feelings and needs of their patients, and through their actions they can cause an improvement in patients´ dignity and self-esteem.
– The development of mature empathic forms in caregivers as well as their skills of controlling the level of empathic engagement in their relationships with patients allows the quality of care to be improved.
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