The Concept of Empathy in Nursing Care


TheConcept of Empathy in Nursing Care


Thesignificance of empathy in care is widely documented in nursingresearch. Empathy is considered as a vital component of the nursingprocess. However, its conceptualization and definition, modes, andinstruments of measurements differ significantly. This paper exploresthe concept of empathy in nursing, examines its components,conceptualization, the models of empathy development, its measures innursing literature, and the role of empathy in nursing care. Theresearch will be organized as follows:


Empathyin nursing is composed of four components: moral, emotive, cognitiveand behavioral empathy

Modelsof Empathy development

Nursingresearch draws its models of empathy development from other fields.The following are the most commonly used models of empathydevelopment: Hoffman’s models of empathy development, Feshbach’sThree-Factor Model, and Buddhist Psychology model

Measurementof empathy

Amyriad of instruments exit on how to measure empathy: the followingare the most commonly used instruments discussed in this research.The Index of Empathy, The Empathy Scale, The Affective Empathy TraitMeasure, Fantasy-Empathy F-E Scale, Empathy Construct Rating Scale

Antecedentsof Emphatic concern

Innursing care, two antecedents of empathic concern often emerge,perceiving the other as in need and valuing the other’s welfare.The two give rise to the aspect of sympathy in empathy and thedistinction that exist between the two.

Roleof Empathy in Nursing

Thereare numerous reasons why nurses should utilize empathy in care.However, the most widely documented use of empathy in nursing is itsdirect role in communication.

Table of Contents

Introduction 4

The components of empathy 5

Emotive Empathy 6

Cognitive Empathy 6

Moral empathy 7

Models of Empathy 7

Hoffman’s models of empathy development 7

Feshbach’s Three-Factor Model 8

Buddhist Psychology model 9

The Index of Empathy 10

The Empathy Scale 10

The Affective Empathy Trait Measure 11

Other Instruments 11

Antecedents of Empathic Concern 12

The Use of Empathy in Nursing 13

Conclusion 16


Thelast four decades have witnessed a mounting interest in investigatingthe concept of empathy and its implication to caring for the ill.Empathy in nursing care has been characterized as emanating from “anatural desire to care about others.” LaRocco (2010) describedempathy when caring for the ill as the physician’s ability toimagine themselves as the patient who comes for help.” However,numerous researchers have criticized this simplistic view of empathy.For instance, there are those who view empathy as a cognitiveattribute that invokes the nurse’s ability to connect andunderstanding the experiences of the patient. This definition,however, is based on descriptions in literature applicable tointerpersonal exchanges between a clinician and her or his patient inthe health care setting. There is consensus in literature thatempathy is a complex and multi-dimensional phenomenon conceptualizedto include natural and intrinsic traits. A literature reviewconducted by Yu &amp Kirk (2009) found out that empathy in nursingresearch has been conceptualized as a personality dimension,behavior, and to some extend an experienced emotion. Several writershave proposed that sine empathy is a complex concept, confusion exitson its meaning and definitions.

Areview of nursing literature points to the fact that there existsmore disagreements than agreements concerning the definition ofempathy. Carl Rogers (1959) proposed the first definition of empathyin relation to caring for the ill. In his work, Rogers describedempathy as an ability “to perceive the internal frame of referenceof another with accuracy as if one were the other person but withouteven losing the as if condition” (p. 259). At his follow up work in1975, Rogers described the empathy as an act of “getting into theprivate perceptual world of another person.” Numerous definitionsexist on the concept of empathy, however, the most commonly used inresearch is rooted in the works of Wispe (1986) whose description ofempathy includes an individual’s non-judgmental comprehension ofthe experience of another person. Baron-Cohen and Wheelwright (2004)extended this definition by describing empathy as “the glue thatholds the social world together”. While numerous definition exitson the concept of empathy, most of the researchers argue that empathyis a critical concept in nursing care. The importance of empathy innursing is based on its centrality in the relationship between thenurse and the patient during care. To delve deep in exploring therole of empathy in nursing care, this paper examines the concept ofempathy, its components, its conceptualization, and the models ofempathy development, its measures in nursing literature, and the roleof empathy in nursing care.

Thecomponents of empathy

Empathyas described in contemporary literature has four main components, themoral, cognitive, emotive, and behavioral aspect (Cunico et al 2012).Similar findings had been established by Nuneset al. (2011)who cited these four aspects as the most recognized components ofempathy in nursing and psychology research. The four components ofempathy were first described by Patterson (1974) who viewed theexperience of empathy to revolved around one or a combination ofthese components.


Emotiveempathy emanates from the emotional response of an individual towardsan empathetic scenario. Researchers in the field of psychologydescribe emotive empathy as the explicit affective response to theexperience of others. The sentimental state at this point has beendescribed as empathic concern or empathic emotion. This means emotiveempathy only exist where an emotional perception is experienced by aperceiving party. The relationship between helping and empathy hasbeen investigated extensively in contemporary nursing research.Findings indicate that emotional empathy is associated with lowlevels of aggression. However, the extent to which emotional empathyresults in helping distressed individuals to problem-solve remainsunsolved. Mehrabian tested the hypothesis that a person who has ahigh level of emotional empathy is lowly situated to act aggressivelyor react by helping the other in pain. Results from the studyindicated that subjects who scored highly on a measure of emotionalempathy had a high probability of engaging in non-aggressivebehaviors than low scorers cited in (McKenna et al. 2012). Helpingbehaviors were defined as sociability, concerns over acceptance andapproval seeking tendency.


Cognitiveempathy as the name suggest has a lot to do with the cognitiveprocesses of the mind. Researchers define cognitive empathy as thatfeeling within one’s self. When experienced in a nursing setting,cognitive empathy entails a nurse’s ability to know experientiallywhat the patient is going through or feeling at any moment of theirexistence within the present condition. Cognitive empathy involvesengagement of perceptual senses, or what many scholars describe asseeing through the other patient’s eyes. Cognitive empathy istherefore viewed an internal experience that moves others to shareand understand the momentary psychological state of another person.References to knowing the mental state of another and accuratelyperceiving current feelings and their meaning are examples ofcognitive functions such as perceiving, imaging, analyzing, judging,and reasoning.


Whetherthere is a moral aspect in empathy is highly controversial inresearch, however, moral empathy is one of the most recognized formof empathy in the religious circles. The concept of moral empathy isrooted in the philosophical view that human beings experience thesame conditions of existence and that they share common needs ashumans. Inherent in this supposition is the conviction that in everyperson is an innate readiness or a persuasive desire to reach out andhelp other when distressed or need assistance. However, severalstudies report a lack of correlation between trait empathy asmeasured on the Hogan empathy scale and measures of cognitivebehavioral empathy. This suggests that cognitive-behavioral empathyis not necessarily depended on trait or moral empathy.

Modelsof Empathy

Variousresearchers have examined the development of empathy in human beings.Empathy according to this researchers is multifaceted: i.e. it is ahuman trait that naturally occurs for all human yet it can equally belearned. Nevertheless, it is widely conceded in nursing research thatthere lacks clear guidance regarding the development of empathy. Mostof the models found in contemporary literature come fromdevelopmental psychologist and Buddhist psychology. Researchers inthese fields have offered extensive models on how empathy developsamong humans. Hoffman (1975) and Fehbach (1975) are two of the mostpopular multidimensional models of empathy development.

Hoffman’sModels of Empathy Development

Arguably,the Hoffman’s models of empathy development is the mostcomprehensive model of empathy development. In his 19752 study,Hoffman defined empathy as an affective emotional responseassociating the importance of the emotions in empathy development.The cognitive role in this model is minimized as it takes a secondaryrole to affective emotional experience. Hoffman recognized six waysthrough which empathic responses to another’s outlook is activated.

Tohelp us understand how emotional factor is aroused in empathicrelationships, Hoffman described the six ways as the channels throughwhich emotions are communicated. According to Hoffman, the firstchannel is the reactive newborn cry. Hoffman described this cry as anemotive response to the sound of another person in distress.Hoffman’s second channel of empathetic development is classicalconditioning. Under this channel, emotional empathy takes place whenan child watches another individual in pain and at the same timeexperiences the emotional pain. Through stimulus detection, theyoungster initiates an emotional reaction that is aroused when he orshe observes others in distress. In the third channel, Hoffman arguedthat the child must have memories of distress for the to expressempathy. Under this mode, memories of distress arouse a child’sempathic reaction based on the association of the current situationwith previous experiences. Hoffman recommended that this mode can beused to explain the way adults connect with the distress of others,signifying that being able to experience one’s own pain isessential for connecting with the pain of others (Duriez, 2004).

Hoffman’sfourth mode is motor mimicry. Through motor mimicry, Hoffman believedthat people are able to relate and connect with the experiences thatothers are going through. When a child imitates the facial signs ofsuffering, this initiates innate kinesthetic cues that activate theability of the child to experience and fill the distress. Hoffmancalled the fifth channel symbolic association. This mode requiresthat one be exposed to symbolic cues of suffering to arouse empathicconnection rather than the actual stimulus person. When explainingthis mode, Hoffman gives the example of a visit to a holocaustmuseum, which would evoke emotional arousal because of the symboliccues associated with museum. The sixth channel is called thecognitive perceptions. Under this mode, an individual takes theperspective of the distressed individual. The experience elicitsassociation with past events and thus encouraging empathic reaction.

Feshbach’sThree-Factor Model

Inresponse to the existing gap in well developed models of empathicreaction, Feshbach 1975 outlined a three-factor model thatconceptualized empathic development. Feshbach’s model includes anaffective factor and two cognitive factors. The first aspect in thismodel is the child’s cognitive ability to distinguish the emotionalsuffering of another. The subsequent factor is the child’s capacityto presume a role taking viewpoint in relation to the person indistress. This entails a cognitive competence to be able tounderstand the other person’s viewpoint. The third constituent ofthis model is emotional responsiveness. For one to be able to sharein other people’s agony, that person must be able to connectemotionally with the other through previous experience of pain.

BuddhistPsychology model

TheBuddhist Psychology model of empathy development is deeply rooted inthe religious philosophy of Buddhism. In this model, empathy isviewed as a cohesive factor that bridges the person to others. Thismodel adopts a view of empathic abilities comparable to the Rogers’first description of empathic relationships. According to this view,empathy is an innate value that is available to all. However, itdevelops out of an individual’s deep understanding of theconnectedness of all beings in this world. Empathy to the Buddhistsis dependent on an individual’s insights and understanding of thefact that suffering is a constant in human existence. Thus, greaterinsight into one’s own suffering plays a critical role in deepeningcompassion and empathy. Based on this view, most Buddhists wouldargue that, only after one looks deep at the self with compassion andacceptance that they can connect with the feelings of the others.Buddhist recommend specific exercises for awareness in order toenhance compassion for the self and others.

Measurementof Empathy

Empathyhas been measured variously in research. The following are thecommonly used instruments for measuring empathy.

TheIndex of Empathy

TheIndex of Empathy was developed by Bryant in 1982. This instrument has22 items that are designed to capture and measure empathy amongadolescents and children. Most researchers have compared this modelto Emotional Empathy Scale developed by Mehrabian and Epstein.Furthermore, the two serve the same purpose. Bryant in hisself-report index of empathy pointed that a comparative result fromthe two models could be of great help when exploring changes inempathy at different ages. On various researches, the internalconsistency reliability coefficients has been reported as 0.54 forfirst graders, 0.79 for seventh graders and 0.68 for fourth graders.

TheEmpathy Scale

Theempathy scale was developed is an empathy trait measure developed byHogan in 1969. The Empathy scale is a 64 item self-report measurebased upon the individual’s capacity to adopt a broad moralperspective that reflects an empathic disposition. Hogan 1969developed this scale by comparing the reaction of 57 high rating menin empathy and 57 low rating men for empathy tests across a combineditem pools of empathy research instruments. The result of thecomparative approach was a compressive model known as the Empathyscale. Researchers examining the validity and reliability of thisinstrument have observed that the results are satisfactory (Hojat etal. 2004).

TheAffective Empathy Trait Measure

Theaffective empathy trait measure is an affective sensitivity scaledeveloped by Campbell, Kagan, &amp Krothwohl, 1971. The instrumentwas developed to determine an individual’s ability to sense anddescribe the instantaneous emotional state of another. The scale isdesigned as a multiple-choice option that a responded should respondto after watching a series of short film excerpts from realcounseling session. The individual whose affective state is beingmeasure views segments of the film and responds to 89 items. Each oneof the 89 items consists of three statements: one statement is thecorrect answer and the other two statements are distracters. Twodifferent kinds of items are included: one to reflect the client’sfeelings about herself or himself, and the other to reflect his orher feelings about the counselor.


Numerousinstruments for measuring empathy exist in contemporary research.While they exist in hundreds, only a few are mentioned in thisreview. The first most popular empathy-measuring instrument is theFantasy-Empathy F-E Scale developed by Scotland et al. (1978). Thisinstrument measures an individual’s propensity to react emotionallyto situations. The instrument has 3 items answered on a 5-pointscale. A review of this scale indicated a correlation of 0.44 betweenthe F-E scale and Emotional Empathy scale.

Consequently,there is the Empathy Test developed by Layton (1979). Laytondescribed the Empathy Test as a two-part 48-item instrumentconstructed with the aim of teaching empathy to nursing students. Theinstrument evaluates whether empathy can be learned. Each piece ofthe instrument has 12 multiple-choice items and 12 true-false items.Layton observed that the reliability coefficient for the gauge werelow and no significant correlation were found between this measureand any of the recognized empathy testing instruments.

Oneother instrument for assessing empathic response is the EmpathyConstruct Rating Scale. This instrument was developed by LaMonica(1981). In this instrument, LaMonica developed 84 items that seeks tocapture the respondent’s outlook on another person in pain. Theitems are answered on a 6-point Likert scale. Recently, a newmeasuring instrument – Empathy Quotient- was developed in Englandby Baron-Cohen, Lawrence, and colleagues (2004). The instrumentcontain 40 empathy items and 20 filter items that are designed tocreate a destruction to the participants from over-focus on empathythat most instruments project. The responses in this instrument arecaptured in 4 point Likert scale. The authors argued that theinstruments is constructed to have clinical implications, mostresearchers have argued that the contents of most of the items do notprop such a claim (Ward et al 2009).

Antecedentsof Empathic Concern

Innursing care, two antecedents of empathic concern often emerge,perceiving the other as in need and valuing the other’s welfare.The two give rise to the aspect of sympathy in empathy and thedistinction that exist between the two. According to Yu &amp Kirk(2009), sympathy is largely construed as a reaction to another’condition while empathy is a reaction with the other. Sympathy isoften taken as unattractive as nurses must focus on the patient andnot their feelings or concerns. Because sympathetic responses arefocused on the other, some researchers have argued that responseslike pity and sympathy may be as soothing for patient as empathy. Inmost researches, nurses are encouraged to be empathetic and notsympathetic.

Thedistinction between empathy and sympathy in nursing research wasinitiated by Wispe (1986) in an analysis that concluded that inempathy, we consider what it would be like if we were the otherperson while in sympathy we automatically known what it would belike to be the other person. When expressing sympathy, we often reachout to the other person, and take action that alleviate theirsuffering. Empathy has been considered as a way of knowling whilesympathy is seen as a way of relating. Despite Wispe’s usefulanalysis, most of the contemporary researchers acknowledge the factthat any attempt to differentiate sympathy and empathy has remainedtroublesome cited in (Yu &amp Kirk 2009).

TheUse of Empathy in Nursing

Theapplication of empathy in nursing practice is widely documented incontemporary care literatures. Researchers coincide on the importanceof empathy in nursing care and its critical role in creating aconnection between the patient and the nurse. The most widelydocumented use of empathy in nursing is in direct communication.Communication as an important processes in nursing utilizes a widerange of concepts that facilitate the experience of the patient.However, empathetic communication is not an easy process. Whencommunicating empathy, it is advised that nurses respond withaccurate and clear statements that captures the patient’sexperiences at that moment. Doing so promotes trust, projectsconfidence and helps create a connection between the patient and thenurse because patients are made to be at ease with nurse making itpossible to reveal when they experience affecting attunement with thenurse. Many researchers consider expression of empathy as a skillthat requires open sharing and an understanding perspective. .Expressing empathy communicates understanding and mutuality thus,converging both acceptance of patient’s reality.

Empathicstatements capture the core of the patient’s experience helpingmove the relationship towards an intimate direction. Thus, empathyexpression particularly in relation to patient’s feeling can beintrusive. Yet empathy expression in nursing is often equated withemotions. For example, Cunico et al (2012) reported recognition andunderstanding of the other’s feeling (in this case the patient) astwo of the most important attributes in empathic communication.Nevertheless, knowing the patient in such a close way may not beappropriate or pleasing.

Anempathic statement from the nurse exposes the patient to theunderlying situation and thus laying the reality in the open. Apatient may not want this exposure, and sensitivity to the patientreaction not an empathic statement is needed. If the patient wants toappear strong or maintain control, the nurse who is sensitive willaccept this and move out of the anticay that empathy can bring. Thismove into intimacy is one reason that there are cautions in thenursing literature against a wholehearted, unquestioning embrace ofempathy. Cunico et al (2012) warns that it may be unrealistic andidealist to expect nurses to be empathic with all patients. Nunes etal (2011) says that empathy may not be always appropriate to thepatient’s situation. They cautions against a danger in nursesprojecting their own perception onto patients in an effort to beempathic. Thus, it is important to consider timing when expressingempathy. Furthermore, a nurse who moves too fast into empathicexpress without considering the timing might lead the patient intofeeling inhibited. The best moment to express empathy for a nurseshould be when the patient demonstrates comfort with discussing hisor her feelings, and the nurse confirms the connection between thepatient’s thoughts and feelings.

Inaddition to helping nurses understand and create a connection withpatients, empathy in nursing is taken as a means of promotingpersonal change and growth as the patient is undergoing treatment.The counseling view of empathy in the nursing literature is basedprimarily on the work of Car Rogers. Rogers, a psychologist who isconsidered as the pioneer of client-centered therapy, describedempathy as an essential characteristic of the therapeuticrelationship. The humanistic philosophy that underpins Rogers’theory of counseling is consistent with patient-centered relationshipas central to that care. Therefore, it is understandable that nurseswho first conceptualized the therapeutic nature of the patient-nurserelationship were influenced by the work of Carl Rogers.

Nevertheless,there is critique in the nursing literature that conceptualization ofempathic nursing that have been based on theory borrowed from anddeveloped for another discipline and therefore is inappropriate. Acounseling view of empathy, which focuses on promoting patient’spersonal growth, may not at all times be suitable in a nursingsituation unless the nurse is also a psychotherapist. It must beacknowledged that while nurses serve people experiencing transitionsin their life, not all patients are in the course of experiencingpersonal growth. In such cases, it is advisable for nurses tounderstand each patient’s personal experience, and develop specialways of empathizing with each patient at a personal level. However,they should not necessarily focus on encouraging psychological growthand personality change.

Thereare times when nurses do promote change in a patient – for example,assisting patient in developing new skills, such as trainingself-injections for Type 1 diabetes. However, care is not necessarilyfocused on bring about change in the patient’s way of being andliving. Nurses often support and assist people as they experiencetransitions in health and illness, acting as partners in the patientjourney and change is inevitable with transition. However, inaddition to guiding the transformational process for the patient,nurses help by standing alongside and comforting the patient in theirrecovery process.


Therole of the concept of empathy in nursing is widely documented incontemporary research. In fact, the professional of nursing has longembraced the process of empathy and integrated it as critical tenetin caring practices. Through empathy, nurses connect and understandpatient’s experiences. Throughout the history of nursing, empathyhas been recognized as an essential factor in promoting rapport. Asestablished in research, rapport is essential to developing andmaintaining a connection with the patient that is based on sharedunderstanding. In addition, it is important that the patient perceivethat nurses do indeed understand their health related circumstances.When used appropriately, empathy facilitates awareness and organizesperception in addition not promoting mutual understanding.


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