The Role of Empathy in Nursing Care within a Positive Ageing Context
By Andrew Gowan © All rights reserved
Empathy is foundational to nursing care and in those over 65 (the older adult), it becomes even more important. Age increases the risk and prevalence of degenerative diseases such as cardiovascular diseases and cancer, (Statistics New Zealand, 2007). The older adult has more likelihood of such health issues, altered cognition, psychosocial impairment, grief and loss, communication difficulties and other physical disabilities. In some respects, to offset these negative issues there has emerged the concept of positive ageing, which focuses on sustained independence, mental agility, social belonging and physical activity (Hill, 2011). Positive ageing is alive and well in New Zealand as attested to by the 93 per cent of older adults’ living independently in private dwellings (Statistics New Zealand, 2007). This has implications for home-carers, nurses and other professional helpers who need to understand and foster maximal independence in this age group. The nurse as carer, communicator and educator can, with an empathetic attitude, encourage autonomy and independence. Empathy is a valuable resource, and both a learned and inborn psychosocial skill having a major role in nursing care of the older adult in order to support positive ageing, to promote independence, wellbeing and positive health outcomes. Search strategies of the literature revealed a number of definitions of empathy relating to nursing contexts. The most useful of these highlighted two sides to empathy: therapeutic empathy and emotional empathy (Norman, 1996). These concepts will be explored in relation to care of the older adult.
Caring for the sick, weak, disadvantaged or disabled is the core task of the helping/healing professions, in nursing, it can be argued that care is the “foundational element” (Daly, Speedy & Jackson, 2010, p.81) This care is uniquely focussed on the patient rather than on the illness or condition they have. Care in the nursing context, whether in the client’s home, in a care facility, a clinic or hospital setting is a therapeutic relationship consisting of elements of courtesy, understanding and empathy. The quality of this relationship has an impact on the health and wellbeing of the client (Norman, 1996; Reynolds and Scott, 2000; Edwards, Peterson & Davies, 2006; Oudshoorn, Ward-Griffin & McWilliam, 2007). Underpinning nursing care is empathy; which has been defined as identifying with another how they are feeling (Taylor, Lillis, LeMone & Lynn, 2011), or understanding the “client’s world from the client’s point of view” (Weiten, 2007, p.629).
Empathy is being intellectually and emotionally aware of the client’s feelings and needs from their perspective (Norman, 1996). Being thus mindful is a starting point for promoting positive ageing for the older adult, and, “a prominent need of older persons succumbing to age related decline and physiological deterioration is not simply to mediate age related decline, but to find wellbeing, purpose in living, and happiness even when physical deterioration is present” (Hill, 2011, p.69); nursing care provides a unique platform to meet these needs. Norman (1996) identified two models of empathy: therapeutic empathy and emotional empathy. Therapeutic empathy is a learned skill used by professionals that is objective, distant and aloof, which evolved from the psychoanalytic school. Emotional empathy, on the other hand is learned from experience and involves an intuitive sense of the “patients plight” (Norman, 1996, p.314), and this is far more useful to a nursing context. Furthermore, empathy may be broken into four component parts: moral, emotive, cognitive and behavioural. The moral and emotive aspects fit within the emotional empathy model, while cognitive and behavioural fit into the therapeutic model. Empathy is considered a therapy in its own right and is practiced as such in psychoanalysis and counselling disciplines (Norman, 1996). In a nursing context this helps to explain how empathetic communication and care positively impacts health outcomes. Emotional empathy, embodies an ‘attitude’ of care that at its core is experiential, identified by words such as “warmth”, “compassion”, “sensitivity” and “understanding” (Norman, 1996, p.315).
Empathy, according to Reynolds and Scott, (2000) involves perceiving the client’s feelings, understanding their state, and communicating that understanding to the client. Thus the client feels understood and not alone, because another (the nurse) shares their emotions and sentiments (Cunico, Sartori, Marognolli and Menghini, 2012). To be empathetic involves mindfulness or the ability to be totally alive and present (Scheick, 2011) coupled with making the nurse- client relationship as positive as possible, ensuring the highest quality nursing care, and outcomes (Reynolds and Scott, 2000). Difficulties arise when the nurse is not self –aware and mindful, and shifts empathy into sympathy. This counter transference, where the nurse “shares personal concerns and feelings and projects these onto the patient” (Taylor, et al., 2011, p.450) damages the therapeutic relationship (Scheick, 2011).
A lack of empathy is a failure to understand the client’s needs. Care suffers, and the client will feel less important, unheard, untrusting; and inappropriate healthcare may result (Reynolds and Scott, 2000). That psychosocial skills such as empathy are a core feature of the therapeutic relationship is widely understood (Edwards, Peterson & Davies, 2006; Taylor, et al., 2011; Cunico, Sartori, Marognolli and Menghini, 2012), and empathy is important to quality nursing care according to nurses (Burhans & Alligood, 2010). However, are psychosocial skills really that important to the elderly client? Van der Elst, Dierckx de Casterle´and Gastmans, (2012) in a mixed method literature review showed that elderly patients and residents put more value on a nurse’s technical skills than psychosocial skills, however the combination of technical aptitude and psychosocial skills (in particular empathy and availability) were most valued. The client felt most helped when the nurse demonstrated both expertise and care attitudes that were harmoniously intertwined.
The New Zealand population is ageing, with over 12 per cent of the population 65 years or older at the 2006 census compared to 8.5 per cent in the early 1970’s. Life expectancy has crept up in recent decades to 78 years for males and 82 for females, but despite longevity gains, quality of life and improvements in overall health have not changed (Statistics New Zealand, 2007). The New Zealand Ministry of Health promotes positive ageing and recently published guidelines for healthy nutrition and physical activity in the elderly. The aim is to help older New Zealanders stay “more active and independent for longer, and to prevent illness” (Ministry of Health, 2013). Positive ageing specifically examines those issues related to old age and grew out of the positive psychology movement, which seeks to recognize the “positive, adaptive creative and fulfilling aspects of human existence” (Weiten, 2007, p.16). A positive ageing framework encourages a culture of continued psychological growth, social interaction, intellectual stimulation and positive roles for the older adult. This can counter the prejudice of ageism still prevalent in society (Onedera & Stickle, 2008; Webster & Bryan, 2009). Stereotypes of the older person as being a burden to society, viewing declining health as unavoidable or other negative characteristics must be replaced with more helpful attitudes by health care professionals as well as society (Taylor, et al., 201, p.415). Negative stereotypes affect coping strategies and optimal living for the older person; producing greater physical and psychological stress (Onedera & Stickle, 2008; Berk, 2010). The point of empathy is to see beyond the condition (old, frail, dysfunctional) to recognize the individual themselves. To empathise with the older client is to put oneself in their shoes; to “comprehend their predicament and…facilitate a better quality of life” as a result of that understanding (Norman, 1996, p.316). For the older person with chronic health issues or decreased mobility and function, the focus of empathetic care must include the person’s (and their family’s where appropriate) goals with the aim of enhancing independence. (Taylor, et al., 2011, p.426)
Empathy is the base upon which other dimensions of care are built (Norman, 1996). Without an empathetic understanding of the person’s needs, sense of self, independence, health status, cognition and goals, the nurse cannot fulfil any further care. Advocacy, partnership, and the technical aspects of care would cease to exist if it were not for empathy first being in place (Cunico, Sartori, Marognolli and Menghini, 2012). Two- way communication is vital to empathy, and critical to the therapeutic relationship (Edwards, Peterson & Davies, 2006). A primary assumption of quality nursing care is that patients are generally” articulate and capable of resolving their own problems” (Norman, 1996, p.315). This is not always the case especially in advancing age and decline. In such cases empathy needs to be modified to best fit the individual’s needs. Communication for example, may involve non – verbal cues such as changes in the person’s demeanour as well as verbal cues. Any factor which limits communication will impact on the quality of the therapeutic relationship, and hence the empathetic dynamic. The older adult may experience any number of communication problems such as hearing loss, aphasia, impaired speech (Taylor, et al., 2011). It is important that the caregiver recognise when the older person is experiencing any difficulties and take measures to improve communication.
The older adult is at risk for psychological issues which may include depression, anxiety, sleep disorders, dementia (Hill, 2011). An empathetic carer can make a difference by being a listener and counsellor, and then an advocate, and interventionist. The nurse is in a valuable position as a trustworthy, skilled professional to support and encourage the older adult experiencing these ‘stage of life’ issues (Caris-Verhallen, Kerkstra & Bensing, 1997). Being valued is most important to the very old who experience declines in physical health, as it helps transcend limitations of their daily life situation (Onedera & Stickle, 2008). Physical touch can also be an important part of empathetic communication, a special way that comfort is shown to patients (Chang, 1999). Placing a hand on the shoulder or on a forearm or hand can make a lot of difference to the patient, and in particular the elderly patient who may be starved of touch due to life circumstances. Illnesses, bereavement, physical incapacity, are lonely times and touch can bridge the gap toward wholeness. Physical touch involves an exchange of positive affection between the caregiver and client, powerfully demonstrating empathetic understanding of the caregiver (Chang, 1999).
Nursing often involves a level of power over the client. This may be intentional or even necessary, but is often detrimental to the relationship as it can make the client feel powerless and uncomfortable (Oudshoorn, Ward-Griffin & McWilliam, 2007). Furthermore, empathetic exchange is hindered with the older person when they are made to feel less in control (Webster & Bryan). This can occur through language: ordering the older person around, demanding they take their medicine or abide by the care plan, “using closed communication and using terms of endearment” (Oudshoorn, Ward-Griffin & McWilliam, 2007, p.1437). These types of negative communication are unhelpful in the therapeutic context. In a critical study of client nurse power relationships in home-based palliative care, Oudshorn (2007) identified factors contributing to positive outcomes. Though this study focussed on power in relationships, it highlights practical areas also important to the empathetic relationship in the care of elderly or terminally ill: “giving clients more liberation, being humble, providing comfort, doing caregiving tasks on request and mutual decision making” (p.1439). Allowing the person to remain in control of their situation and communicating in an empathetic manner that shows care and consideration maintains their sense of dignity, has been shown to be important to the older person (Webster & Bryan, 2009). The coping skills and attitude to life that the older person possesses; their sense of optimism and resilience, will help them overcome challenges they face as age and decline become more manifest (Hill, 2011).
Empathy is critical to nursing care in any context, and there are specific and unique elements where empathy is even more necessary in the care of the older person. Empathy can be divided into therapeutic and emotive empathy; however, in nursing care of the older person, both aspects of empathy have value. The empathetic carer listens attentively and communicates in such a way that the client feels heard, valued and respected, knowing that their needs will be met. The needs of older clients vary greatly depending on the physical and cognitive state, presence or absence of chronic health conditions and the internal resources and resilience of the individual. The nurse as carer having an empathetic attitude can foster those qualities that promote positive ageing and provide the older person with a sense of dignity, independence and effective communication (Webster & Bryan, 2009). Positive aging is widely promoted and is changing the way nursing care of the older person is implemented. The nurse has an important role to play in promoting and developing positive ageing and empathy is a foundational prerequisite to quality nursing care.
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