SURVEY ON EMPATHY : FUNDAMENTAL ISSUES REGARDING ITS NATURE AND TEACHING

To be able to "demonstrate empathy" is one of the stated objectives of the South African Nursing Council (S.A.N.C.). In their teaching guide for the subject "Nursing Dynamics", it is the compulsory subject for all post-basic clinical programmes (S.A.N.C. 84/M89 dated 1989-02-17). The prominence accorded to empathy in the curriculum would lead one to expect clarity among nurse educators and pro­ fessional nurses regarding what it is and how it may be taught. Yet this does not appear to be the case in practice. Empathy as a phe­ nomenon remains elusive. Much ambiguity surrounds it and the term is used in different ways by different people. At times empathy and sympathy appear to be used interchange­ ably, and many factors no doubt contribute to this confusion. Educational programmes of the majority of practising nurses and nurse educators did not include training in the devel­ opment of empathy skills. Nursing textbooks in general present only brief references to em­ pathy and do not address rigorously the ques­ tion of its nature and whether and how it may be taught and evaluated. Publications of sch­ olars and researchers which address these is­ sues are not readily and freely available in nursing colleges and clinical areas, and in es­ sence, if empathy is to be demonstrated in nursing and if research in this area is to ad­ vance, issues relating to empathy need clarifi­ cation. It is the purpose of this paper to analyse theory and identify fundamental is­ sues regarding the nature and teaching of em­ pathy and its place in clinical nursing practice.

To be able to "demonstrate empathy" is one of the stated objectives of the South African Nursing Council (S.A.N.C.).In their teaching guide for the subject "Nursing Dynamics", it is the compulsory subject for all post-basic clinical programmes (S.A. N.C. 84/M89 dated 1989-02-17).The prominence accorded to empathy in the curriculum would lead one to expect clarity among nurse educators and pro fessional nurses regarding what it is and how it may be taught.Yet this does not appear to be the case in practice.Empathy as a phe nomenon remains elusive.Much ambiguity surrounds it and the term is used in different ways by different people.At times empathy and sympathy appear to be used interchange ably, and many factors no doubt contribute to this confusion.Educational programmes of the majority of practising nurses and nurse educators did not include training in the devel opment of empathy skills.Nursing textbooks in general present only brief references to em pathy and do not address rigorously the ques tion of its nature and whether and how it may be taught and evaluated.Publications of sch olars and researchers which address these is sues are not readily and freely available in nursing colleges and clinical areas, and in es sence, if empathy is to be demonstrated in nursing and if research in this area is to ad vance, issues relating to empathy need clarifi cation.It is the purpose of this paper to analyse theory and identify fundamental is sues regarding the nature and teaching of em pathy and its place in clinical nursing practice.

Origin and development
The historical roots of the word empathy date back to the early part of this century when Ed ward Titchener, an English psychologist at Cornell University introduced the word in the English language as an equivalent of the Ger man word "Einfiihlung".The latter term was coined about 1885 by Theodor Lipps, a Ger man psychologist (Mackay et al 1990: 29).Einfiihlung literally means "feeling into" and was used for describing a person who is very understanding (Universal Readers Digest Dic tionary 1987: 505).Evidently "empatheia" was an early Greek word meaning affection and passion with a quality of suffering.Bar- In nursing empathy is generally re garded as an essential component o f nurse-patient interaction, but there ap pears to be a lack o f clarity among nurse educators and professional nurses regardingits nature and how it may be taught and measured.This paper fo cuses on an analysis o f selected theoreti cal works related to the nature and teaching o f empathy, and an attempt is made to identify fundamental issues re garding thephenomenon "empathy'' and its place in clinical nursing practice.

ABSTRAK
In verpleegkunde word empatie in die algemeen as 'n wesenlike /component van verpleeg-pasiënt interaksie beskou.D it blyk egter o f daar heelwat onduidelikheid onder verpleegdosente en praktisyns bestaan met betrekking tot die aard en onderrig van empatie.In hierdie studie w ord'n analise van geselekteerde teoretiese werkeoor empatie gemaak en '« poging word aangewend om fundamentele vraagstukke ten opsigte van empatie en dieplek daarvanin klimese verpleegpraktyk te identifiseer.rett-Lennard (1981: 91) points out that the "era" means in or into, and there is the idea at least of going into a strong feeling or connec tion with another.The Latin equivalent large ly borrowed from the Greek, was pathos which can mean feeling/perception.
In ensuing decades the meaning of empathy evolved further to include perceptual and in teractional events as well.Its importance in helping relationships increasingly was recog nised.Psychoanalysts and therapists de veloped the skill "to understand the client", to see with his eyes and listen with his ears" -to put themselves in his shoes and to obtain in this way an inside knowledge, that is almost firsthand (Freud 1957: 40;Katz 1963;13;Barrett-Lennard 1981: 92).Carl Rogers (1957) a psychotherapist well-known for his work in defining the characteristics of a help ing relationship identified empathy, warmth and genuineness as the three qualities of a therapist that provide the necessary and suffi cient conditions for therapeutic growth to occur.
By the 1950's empathy began to have some influence in nursing.In the nursing literature Peplau, an interaction nurse theorist speaks in-( directly about empathy in her comments about nursing care.Understanding of the meaning of the experience to the patient is re quired in order to function as an educative therapeutic maturing force (Peplau 1952;41).Speroff published an article in 1956 entitled "Empathy is important in nursing".Hender son (1964) wrote of the nurse's requirements to know and understand the patient, to get in side his skin.In subsequent years many more nurses put forth empathy as a critical compo nent of helping relationships and an essential part of nurse-patient interaction (Travelbee 1964(Travelbee ,1971;;Ludeman 1968;Zderad 1969;Ehmann 1971;Kalisch 1973;Leininger 1978;Watson 1979;La Monica 1981;Dageneis & Meleis 1982).Most of these writings reflected the influence of Carl Rogers.

CONCEPTUALISATION AND DEFINITIONS
An analysis of conceptualisations and defini tions of empathy in contemporary publica tions of scholars and researchers reveals a wide divergence of thought with regard to the nature of empathy.Empathy has been identi fied as an innate ability or personality predis position or trait; a learned skill; an emotional phenomena in which one person experiences the feelings of another person; a cognitive un derstanding of the situation of another person, a state and a process.(Rogers 1957;Travel bee 1966;Ludemann 1968;Kalisch 1971;Forsyth 1979;Watson 1979;La Monica 1981;Dageneis & Meleis 1982;Janzen 1984).
These variations are reflected in the defini tions of the writers.For Rogers (1957: 99) empathy means "to sense the client's world as if it were your own, without ever losing the 'as i f quality.This is empathy and this seems essential to therapy".Travelbee (1966: 137) sees it as the ability to share in the other per son's experience.Ludemann (1968: 277) de scribes it "as entering into the spirit of another and becoming aware of being nearly identical with him or her".Kalisch (1971: 203) de scribes it as "the ability to enter into the life of another person and to accurately perceive his or her current feelings and understand their meanings.To Watson (1979: 28-30) em pathy is the ability to experience and thereby understand the person's perceptions and feel ings and to communicate these under standings . La Monica (1981: 398) considered empathy to be a sequence of per ceptual and interactional events (state em pathy) which involves both verbal and non-verbal behaviour on the part of the hel per.She provides the following definition: "Empathy signifies a central focus and feeling with and in the client's world.It involves ac curate perception of the client's world by the helper, communication of this understanding to the client and the client's perception of the helper's understanding".Forsyth (1979: 55) > describes empathic individuals as "those who possess keen insight, imaginative perceptive ness and social acuity about other persons".Dageneis and Meleis (1982: 415) identify a personality dimension they entitle empathy which has as subdimensions adaptability, so ciability, consideration and sensitivity.Janzen (1984: 3) defines empathy as "a psychological process of a nurse feeling into a client's thinking; sensing, comprehending and sharing his/her internal frame of reference.

THE EMPATHIC PROCESS
The trend to examine empathy as a process oc curring in stages or phases has been spelt out by several writers.Zderad (1969) describes a psychological process of empathy comprised of three phases.First the nurse vicariously ex periences another's private world by construct ing "a mental image of him/her including his physical appearance, affects, life experiences, modes of behaviour, attitudes, defences, values and fantasies".The nurse's ego then splits into an observing and observed part, with the observed part remaining in sympath etic resonance with the other person.The third phase of the process involves the nurse's detachment, her ejection of the other's ego and her examination of the internalised con tent.Layton (1979) describes a psychological pro cess of empathy made up of three compo nents; the empathic state of the nurse, the communication of empathy from nurse to client, and the perception of a nurse's empa thic state by the client.Empathy therefore in volves a personality predisposition (sensitivity), an experienced emotion (sensing and feeling the client's predicament) and a cognitive and behavioural aspect (under standing the client and communicating this un derstanding in a language attuned to a client's current feelings, and the client's perception of this feeling).
In 1981 Barrett-Lennard, a psychologist deli neated "a sequence of distinct stages involved in empathic interaction".This sequence en compassed a five-step empathy cycle as fol lows: (1) A actively attends B who hopes A is receptive (empathic act).
(2) A resounds to B so that the latter's experience becomes known to A (empathic resonation).
(3) A shows felt awareness of B's experience (expressed empathy).
(4) B has a sense of A 's understanding (received empathy).
(5) B continues expression which provides A with information to confirm perception of B's experience and to confirm B 's per ception of A as understanding.The cycle then reverts to step two (Barrett-Lennard 1981: 91-94).Schwartz et al (1983) presented a three dimen sional model on empathy for nurses which in cludes three discrete approaches to empathy.

DIMENSIONS OF EMPATHY
1 The predictive approach Here the nurse possesses the ability to predict accurately the thoughts and feel ings of others, that is take on their role, even if their attitudes are different from her own.In other words, to be empathic, the nurse takes on the role of the patient and accurately knows how he/she thinks and feels, even if he/she is very different from her.
2 The achieved approach This is an interactive client-centered ap proach.Here the thoughts and feelings of the other, while not becoming the nurse's, need to be perceived by the other as being understood.Instead of focusing on accurate understanding (as in the pre dictive approach) the focus in this ap proach is on whether the other person feels understood.In other words the nurse is empathic if the patient thinks she understands him/her.The nurse has achieved empathy because the patient be lieves that she understands.
3 The behavioural approach Behaviours which promote under standing characterise this approach and not the perceived understanding by the other.In other words the nurse is empa thic if she can make appropriate state ments in response to the patient.
These divergent views expressed by wri ters on the nature of empathy, the empa thic process and dimensions of empathy naturally hold grave implications for nurse educators.The assessments of whether the students are able to demon strate empathy necessarily will differ ac cording to the conceptualisation of empathy in nursing schools and dmical practice.La Monica (1981) in her research on empathy solicited descriptions of a highly empathic person from female psychology graduate students, nurses and university pro fessors and found that perceptiveness and compassion showed the highest loadings in a factor analysis of descriptions she gathered.These findings raise further questions for the nurse educator.Is there a critical point in a scale, which could be developed to assess characteristics stated to be essential in empa thic relations, below which a person cannot be properly trained to offer genuine empathy?

EM PATHY VERSUS SYMPATHY
Even though it is generally accepted that em pathy is different from sympathy, there ap pears to be considerable ambiguity in the use of these terms in the literature and the distinc tion maintained by some writers is not necess arily accepted by others.Bradley and Edinberg's summary of the differences be tween these terms probably represents the ma jority view.According to them the sympathetic nurse is subjective, as opposed to the empathic nurse who maintains a sense of objectivity.The sympathetic nurse offers con dolence and pity, whereas the empathic nurse offers support and understanding.The sym pathetic nurse "takes on" client's feelings whereas the empathic nurse "borrows client's feelings".The sympathetic nurse loses selfidentity, whereas the empathic nurse main tains self-identity" (Bradley & Edinberg, 1986: 89).
Empirical evidence of a distinction between empathy and sympathy is offered by Gruen and Mendelsohn (1986) who found empathy to be a stable personality factor, whereas sym pathy depended on an interaction between the personality of the observer and the plight of the individual in the observed situation.

THE GOALS OF EMPATHY
Differences in opinion exist, too, with regard to the goals or the desired endpoints of empathic relationships.In the nursing literature two main ideas regarding the goals of empathic relationships emerge.Some writers hold that the goal is to analyse objectively an other's experience and thereby effect thera peutic change (Zderad 1969;Kalish 1971;Mansfield 1973).Others maintain that the goal of empathy is to share another person's pain or distress in order to relieve him or her carrying it alone.(Travelbee 1964;Tyner 1985).
The difference in these ideas is significant and again raises questions about the nature and place of empathy in nursing.

EMPATHY AND CARING
Despite the divergencies regarding the nature of empathy there appears to be agreement among the nurse writers referred to so far, that empathy is a necessary or core condition in helping relationships and an essential part of the nurse-patient interaction.It has in fact been postulated that through empathy nurses reach the essence of care but this view is not supported unanimously within the literature.
A number of contributors to the literature have called it into question.In 1965 Eysenck published results of his research of the effec tiveness of psychotherapy and found the im portance of empathy on the part of the therapist small or nonexistent.In 1983 Gladstein on the basis of his research, maintained that despite claims for the positive effect of empathy on client outcomes, the evidence in this regard was equivocal.He stated: "It ap pears as though empathy in counselling/psy chotherapy can be helpful in certain stages with certain clients and for certain goals.However, at other times it can interfere with positive outcomes (Gladstein 1983: 467).
In nursing, La Monica (1979) pointed to the need to investigate whether nurses being empathic make a difference to what she terms 'nursing care outcomes'.This need still ap pears applicable today.
Griffin does not see a place for empathy in her philosophical analysis of caring in nurs ing.She maintains that empathy is wholesale immersion in the feeling of another and that the intensity of this involvement is not feas ible in nursing practice.Instead of empathy Griffin uses the notions of attunement and per spective to conceptualise caring practices (1985: 289-295).Benner (1984) performed extraordinary exam inations of the actual caring practices of nur ses, using clinical episodes, critical incidents and examplars from practice as a data base.Empathy is however, not a term Benner chooses to describe caring behaviour.She uses "compassion", "presencing", "inspiring hope", "comforting", "touch", "support" and "mediating" among her descriptions of caring.In Benner's accounts of actual prac tice, there are no descriptions of nurses sens ing a patient's experience as if it were their own, or of vicariously experiencing a pa tient's world.Rather, expert nurses have a storehouse of experiences that allows them to understand a patient's lived experience with out necessarily experiencing it themselves.
There are no examples of a nurse being the ob server and the observed simultaneously, or of objectively analysing a vicarious experience.
In addition Benner offers no examples of nur ses consciously and deliberately using expert caring to achieve a specific planned goal.
From the work of Benner, previous notions about the role empathy plays in successful nurse-patient interaction and the way nurses "use" empathy to effect therapeutic change seems called into question.

TEACHING OF EMPATHY
There is considerable agreement in the lit erature that empathy is a human potential, which must be developed and not left to chance.Aspy, (1975)  Upon mastery of attending skills, group mem bers are ready to develop the ability to give fa cilitative responses.A facilitative response is one that perceives accurately the speakers feel ings and conveys that understanding to the speaker.These responses can be measured for their empathic content on Gazda's em pathy scale.
Several other empathy training models exist of which those of Carkhuff and Truax are probably the first ones to have been designed.Truax and Carkhuff (1967) translated em pathy into an observable and measurable beha viour and developed scales to measure this behaviour.These two scales were developed later into human relations training models.
Several interpersonal skill development pro grammes conducted with nurses in which em pathy is a dominant focus have been de scribed in the literature (Kalish 1971;Farrell Haley and Magnaso 1977;La Monica, 1983;Anderson and Gerard 1984;Bradley and Edinberg 1986;La Monica, Madea and Oberst 1987;Mackay et al 1990).Most of these are based on the training models already de scribed.These programmes range in length from six to forty-five hours and include the common features of didactic instruction, ex periential learning, modelling behaviour, re hearsal and feedback.Teaching strategies include role-playing, video-taped vignettes, work-books and small group discussions.Bradley and Edinburg (1986: 90-103) advo cate four verbal and four non-verbal skills which nurses should learn in order to increase the likelihood of developing an atmosphere of trust and empathy through the therapeutic use of self.The four verbal skills are the use of "I" statements, reflection, sharing feeling and verbal reassurance while the four non-verbal skills are non-verbal reassurance, attending to the client, active listening and the use of silence.
There seems ample evidence to show that par ticipants in the Empathy Training pro grammes increased their abilities to offer empathic responses at a helpful level, but, the application of empathic skills in the practice fields remains a problem which has yet to be solved.

THE MEASUREMENT OF EMPATHY
Numerous instruments purporting to measure empathy have been developed, but there is little agreement among researchers on exactly what should be measured and how it should be measured.Each of the measurement ap proaches stem from a different view of em pathy as a concept.Instruments are categorised as self-report, client observer measures, peer judgment or independent ob server judgment.
The Truax Accurate Empathy Scale (1961,1963), CarkhufPs Empathic Understanding in Interpersonal Processes Scale (1969) and Gazda's Empathy Scale (1984) probably are the most frequently used observer empathy rating scales.According to these scales, an empathic response is determined by how well we communicate understanding of a speaker's feelings and the meaning attached to those feelings.Truax developed an 8 point em pathy scale, while Carkhuff developed a 5 point scale.Carkhuff's Scale is a simplifica tion of the Truax Scale.Gazda's Empathy Scale is a seven-point scale with 3.0 being a fadlitative response.A 1.0 to 2.5 response does not convey understanding and respect for an individual.These responses range from a hurtful to a neutral response, whereas a 3.0, 3.5 or 4.0 response is empathic, conveys re spect and forms a fadlitative relationship.
Defined on the empathy scale, a 3.0 response is one which communicates the primary feel ings made by the client and includes the meaning the client attaches to these feelings.In essence, a 3.0 response conveys under standing of how the client feels (affect) and the meaning (content) attached to those feel ings.On all these scales empathy is rated by judges (independent observers) and several in vestigators have found that inter-judge relia bility is a problem with these measurements (Layton 1979;Janzen 1984).
A Several problems have been noted with regard to client perception measuring instruments.Gagan (1983) summarises these problems as follows: (1) Patients perceive nurses as empathic whether they are or not, evidenced by high correlations with patient satisfaction and low correlation with empathy train ing.
(2) The B.L.R.I. assumes the professionalclient relationship to be sustained over time, whereas in nursing, especially in hospital nursing, relationships are often of short duration so that the patient does not know the nurse well enough to re spond to the questions asked on the B.L.R.I.
(3) Patients are a captive group and may be deterred from offering candid responses through concerns for their subsequent care.
A self-rating scale using a personality perspec tive which has been employed in nursing studies (Forsyth 1979;Brunt 1985) is Hogan's Empathy Scale.This scale consists of 64 statements which respondents claim to be true or false relative to their self-appraisals.Hogan (1975) developed this scale to distin guish the person who is socially perceptive and aware of impressions made on others, from the one who relates to everyone in the same way in socially desirable or convential terms.
The major criticism of self-report scales is that most depend on an intellectual self-apprai sal of ability which may not be borne out behaviourally.To substantiate this criticism Kunst-Wilson and Associates (1981) can be cited.They found no agreement between selfreports of empathic ability and observer ratings of actual ability in their study on empa thic ability and observer ratings of actual ability in their study on empathic perceptions of student nurses.

CONCLUSION
The exploration of empathy as discussed in this paper has revealed several issues which stand out as particularly important.Firstly, there is no doubt that conceptual agreement concerning empathy as a phenomena is lack ing.There is a lack of consensus on the na ture of empathy, how it may be defined and how it can be measured.
Secondly, there are unanswered questions con cerning the validity of a number of measures published which purport to assess empathy, which restricts opportunities for investigators to build upon the work of others.
Thirdly, it seems that nurses have problems in operationalising empathy as it has been de scribed in the nursing relationship and there is a lack of consensus whether empathy is a valid concept for practice.
These issues have clear implications for nurse educators.As there is still much uncertainty with regard to various aspects relating to em pathy, and as it is currently unknown whether helper empathy, in fact makes a difference in positive patient outcomes, the question arises whether there is justification for educators to include empathy skill attainment in pro grammes for the preparation of nurses.
Should not the emphasis rather be on the de velopment of caring relationships of which empathy is but one component?The close as sociation between the various caring compo nents suggest that it is somewhat artificial to separate them and focus only on empathy, par ticularly when conceptual agreement on the phenomenon is lacking.Furthermore since the application of empathy in practice appears to be problematic, should attention not first be given to supportive environments and clini cal role models?If there is no reinforcement for using facilitative empathy from role mod els or other practitioners, is it cost-effective to teach it in the classroom?
It will be important for our future under standing of nursing to answer all the questions raised.The need for further research is indi cated.Research evidence needs to include both quantitative and qualitative documenta tion of results and to include multicultural im plications of the findings.
It is dear that the accurate and valid measurement of empathy is a formidable re search goal not yet fully achieved and this has grave implications for nurse educators who have to measure empathy.Without a depend able measure they will not be sure of the relia bility or validity of their assessment.Lack of consensus on the means of measuring em pathy blocks the progress of research into the effect of the care-givers use of empathy in nurse-patient interactions on the subsequent well-being of the patient.