Rehearsing empathy: exploring the role of poetry in supporting learning

ABSTRACT

Empathy is an important aspect of therapeutic relationships in health and social care settings. Health educators can foster empathy development in learners through creative writing activities. Drawing on the humanities, specifically poetry, this paper offers strategies for educators to support empathy development in learners, with a focus on service user poetry and associated creative writing activities. We discuss how poetry can enable alternative perspectives about care to emerge thereby challenging previously held assumptions about mental and physical states. Using poetry can enable a rehearsal of empathy by bringing experiences to the learner in a safe and facilitated environment. Through creative writing activities, we believe that students can learn to better understand and empathise with others, as well as explore their own feelings and experiences related to caregiving, to support self-care.

KEYWORDS:

• Poetry
• empathy
• self-care
• healthcare

Background

In health and social care settings, empathy is an important aspect of therapeutic relationships, offering several benefits for people receiving care (Ozcan et al., 2011; Sheehan et al., 2013). Empathic relationships lead to increased patient satisfaction, improved adherence to treatment regimens and better health outcomes (Batt-Rawden et al., 2013; Kelm et al., 2014; Yuguero et al., 2018). When people receiving care sense practitioners understand them, they feel increased control over their treatment and have a raised perception of their health status (Trzeciak et al., 2017). In recent years, interest in empathy has grown, for example, a review of the nursing education literature identified that out of 83 papers, over one third had been published on this subject between 2016 and 2018 (Levett-Jones et al., 2019). One reason for this interest in empathy might be that several high-profile healthcare reports from across the world have described poor relational care practices, which lead to patients feeling misunderstood and even neglected (Francis, 2013; Jones, 2018). The ability to assess others’ perspectives and recognise individual choice is an international regulatory expectation in health and social care practice (General Medical Council, 2019; Health and Care Professions Council, 2016; Nursing and Midwifery Council, 2018). However, there have been suggestions that learner empathy decreases during the higher education experiences of health and social care practitioners, with reasons ranging from negative role modelling from senior staff, to fear of making mistakes, and time pressures (Ferri et al., 2015; Ward et al., 2012).

Showing empathy to others is important in health and social care practice although less is known about how learners show empathy to themselves. Self-empathy could be important for health and social care learners, when considering self-care and positive mental health. Sherman (2014, p. 230) suggests self-empathy enables a “fairer self-assessment”, which then requires a shift in perspective about a situation, which might have occurred. Sherman (2014) draws on the work of Goldie (2011, p. 87) which explores the existence of two selves and the ability to see “ … oneself as another”. For Sherman (2014), viewing self-empathy in this way enables a self-reintegration, enabling access to past emotions surrounding an event, but in a less judgemental way. Sherman (2014) describes self-empathy as involving elements of compassion and self-friendship, which could be important for learners, and Chiu et al. (2020) suggest an element of self-compassion could be associated with flexible perspective shifting, which is important when feeling emotions empathically. Self-compassion is a concept that comprises three elements; self-kindness, common humanity, and mindfulness (Neff, 2003). Self-compassion can alleviate mental health problems as it supports the development of resilience and reduces self-criticism and shame (Trompetter et al., 2017). By developing self-compassion, health and social care students across a range of disciplines can reduce not only their mental health problems but the shame they might feel as a result (Kotera et al., 2020, 2020). Supporting positive mental wellbeing in health and social care students is important, as these learners are not only exposed to academic pressures, but to the reality of clinical practice and the associated stress, which can lead to burnout and poor-quality care provision (Román-Calderón et al., 2022; Zhao et al., 2015).

Definitions of empathy

There are various definitions of empathy available in the literature, involving both cognitive and affective states, and in healthcare practice it is seen as an important marker of quality care (Hojat et al., 2013). The term “empathy” is believed to be a translation of the German word Einfuhlung, described as “feeling into” (Caplan & Goldie, 2011). In the late 19^th Century this term was used in an aesthetic sense, to describe the projection of emotion into art, rather than people (Matravers, 2017).

The psychologist and philosopher Theodor Lipps developed the first scientific theory of empathy, explaining it not solely as the way people experience objects, but also as the way they understand the mental states of others (Montag et al., 2008). In contemporary health and social care practice, viewing empathy in this way might be problematic, not least because it shifts the responsibility for empathy provision onto the caregiver, to know what another person is thinking and feeling (Van Dijke et al., 2020). Perceiving empathy as a one-sided act on the part of the empathiser reduces opportunities for relational caring and runs the risk of empathy becoming intrusive, patronising or overwhelming for people (Reynolds & Scott, 2000). The phenomenologist Edith Stein developed Lipps’ ideas further, suggesting that empathy is more than an understanding but a feeling-based experience of another person’s feeling (Svenaeus, 2018). Stein’s thesis, Zum Problem der Einfuhlung, (On the Problem of Empathy) published in 1917, explored the idea that empathy is a way to feel “oneself into the experiences of the other person” (Svenaeus, 2018, p. 742). Her philosophy of empathy promotes an “other directedness” with a focus on the empathee, and because of this, practitioners can learn not only about others, but also about themselves (Van Dijke et al., 2020).

The aim of this paper is to explore how reading poetry and engaging in associated creative writing opportunities can support the development of empathy in health and social care students. We will provide practical examples related to different aspects of practice, including practitioner self-care. We will use the philosophy of empathy developed by Edith Stein in her thesis Zum Problem der Einfuhlung as it supports not only empathy towards others, but also learner self-growth. Our aim is not to provide a solution to the enhancement of empathy in others. However, using the arts and humanities in this way supports Rolfe’s (2014, p. 1183) assertion of the need to develop a “philosophical scholarship”, which offers a point of view, and engages readers in an ongoing discussion.

Steinian empathy

Stein believed others are available to us to be understood and through the empathic process we can experience their experience (Stein, 1989). The empathiser begins by gaining an initial assessment of the empathee’s emotional state. There is an intentional attempt to self-transpose, that is, transfer into the empathee’s place (Davis, 1990). In the second stage, the empathiser experiences a similar emotion to the empathee. The empathiser cannot experience the same emotion, as the empathee, but can identify with it, based on past experiences. This stage enables a strong emotional connection, to the extent that the two individuals share the same feeling, albeit for the empathiser, in a non-original way. This is helpful in the caring context because it enables the empathiser to stay connected with their own experiences and sense of self (Hamington, 2004).

In stage three, the empathiser has a more complete understanding of the empathee’s experience and can now return from the connection in stage two. Maataa (2006, p. 8) suggests that in stage three, “the feeling of affinity ceases, and we become ourselves once more.” However, due to the self/other distinction at the core of Stein’s empathy, the empathiser leaves the interaction with further knowledge about themselves and the empathee, having never lost their own sense of self.

Stein states that the empathiser might not always reach stages two and three of the process, although reaching stage one can still be counted as empathy as it provides at least an initial understanding of the empathee’s emotional state. However, the empathiser’s thoughts and emotions, or aspects of the situation might prevent them from progressing from stage one (Svenaeus, 2018). In health and social care practice, previous painful experiences might inhibit the empathy response. For example, inhibition can be protective for nursing students, who find it difficult to manage their emotions in a caring encounter (Kav et al., 2013).

Using poetry to enhance empathy

There is a burgeoning body of evidence highlighting the profound influence of poetry in nurturing empathy within health and social care education. Through poetry writing exercises, students can uncover a trove of empathic perspectives, offering a liberating channel for emotional expression (Coleman & Willis, 2015; Jack & Illingworth, 2017; Joshi et al., 2022). The act of immersing oneself in carefully chosen verses can also provide an intriguing dislocation from individualised perceptions, allowing an expansive journey into the realms of others, broadening one’s empathic horizons (Roberts, 2010, p. 240).

Recent studies across multiple disciplines have proposed benefits of poetry engagement for enhancing empathy in readers and writers (Fancourt & Finn, 2019; Hojat, 2009; Shapiro & Rucker, 2003). For example, the immersive experience of reading poetry can promote perspective-taking as readers inhabit the depicted scenarios and characters’ internal states, supporting an appreciation of diverse vantage points (Lüdtke et al., 2014). Writing poetry may enable deeper emotional processing and expression surrounding challenging situations, allowing writers to articulate and reframe experiences through metaphor and symbolic language (Kind & Kind, 2007). Sharing and discussing poetry communally can also facilitate social bonding, feelings of universality, and mutual understanding between group members as they find common ground in poetic expressions (Coogler et al., 2022).

Several key mechanisms have been proposed to explain poetry’s impacts on empathy. Cognitive perspective-taking occurs as readers project themselves into poems’ scenarios and characters, imagining different viewpoints and affective states through a simulation process (Henry & Thorsen, 2019). The emotional exposure and reflective processing involved in expressing oneself through poetic language can externalise inner experiences, providing psychological distance to reframe difficult emotions (Jack & Illingworth, 2017). Finally, the shared community and resonance created through reading, writing, and discussing poetry together can fulfil core human needs for belonging and mutual understanding between members (Koelsch et al., 2020).

In the pursuit of augmenting empathy among undergraduate nursing students, Levett-Jones et al. (2019) champion immersive and experiential simulations as key strategies, which allow students to experience the world through “another’s eyes”. Poet and physician Rafael Campo (2006) has contemplated the intersections of medicine and humanities, envisaging poetry as a crucial facet of medical education. Aligning with this view, Joshi et al. (2022) posit that poetry composition can serve as a catalyst in fostering empathy among medical students, forming a symbiotic bond between the humanistic and technical dimensions of learning.

From the perspective of social work, Gair (2012) explored the use of haiku to foster empathy, advocating for the cultivation of creative writing skills as a reflective tool for social work practices. Poetic metaphors can serve as empathic bridges, aiding students in discussing challenging topics through non-literal terms, thus fostering a deep-seated connection between observed realities and personal emotions (Fox, 1997). Poetry offers a conduit for free expression, often elusive in other areas of health and social care curricula. Students can articulate their feelings about experiences in a metaphorical sense, promoting understanding of the root of their emotions, rather than just the emotions themselves (Kross et al., 2005).

While reading and writing poetry are related activities that can both contribute to empathy development, other research suggests they may also have differential effects. For instance, the camaraderie fostered within writing groups can bolster students’ mental well-being (Oates et al., 2020). As time elapses, the communal bond built around poetry mitigates dependence on group leaders, as students draw strength from each other and from within themselves (Mazza, 2022), creating a supportive environment that Vygotsky would consider the domain of the more knowledgeable other.

Empathy, as Gerdes and Segal (2011, p. 123) argue, is the heart of communication in social work, calling upon learners to fortify their “mental flexibility and self-regulation”. Such flexibility is invaluable in preserving one’s sense of self during demanding situations in practice, underscoring the significance of poetry as an empathic tool in health and social care education.

Poetry in practice

Often unwittingly, poets become unseen therapists, their words touching the hearts and minds of readers they may never encounter. This unspoken bond between poet and reader, as indicated by Chavis (2011), forms the foundation that can make poetry a potent tool for those in helping professions. Poetry presents a gamut of experiences – some works inspire personal growth, while others resonate with readers’ lives, thereby mitigating feelings of isolation (Birx, 1994).

Consider the anthology These are the Hands (Alma & Amiel, 2020), penned by a diverse group of poets and poet-practitioners, vividly illustrating both the fatigue and joy inherent in healthcare. This anthology serves as a mirror for learners, reflecting their own potential emotions. By recognising these parallels, learners foster self-awareness – a critical component in understanding others empathically. Articulations (Mukand, 1994), another anthology, extends beyond poet-practitioners to include caregivers and patients, offering learners an intimate insight into the experiences of those receiving care. Such encounters can enable learners to confront the vulnerability faced by those in health or social care, providing a rehearsal ground for empathic engagement ahead of real-life clinical settings.

Poetry may provide a unique platform for learners to interrogate their own preconceptions and beliefs, a fundamental process in cultivating empathy. Stereotyping by healthcare professionals can occur based on a range of factors, such as age, disease type, gender, ethnicity and perceived likability and such implicit biases reflect broader societal tendencies (Clerc Liaudat et al., 2018; FitzGerald & Hurst, 2017; Liang et al., 2019; Rivenbark & Ichou, 2020). Poetry, with its uncanny ability to encapsulate the essence of life, can help to dismantle these assumptions.

For example, the poem Health Check by Penny Feinstein (2007) offers penetrating insight into how healthcare professionals may inadvertently diminish an older person’s dignity and autonomy through well-intentioned directives (reproduced in full with kind permission of Five Leaves Publications).

Health check

Shorter by two inches, you tell me,

wider by…a distance;

and my cholesterol, the wrong sort,

makes you knit your pencilled brows

and “Tut!”

You batter me with measurements

-your articles of faith – that sum up

my unfitness. “Life choices” you coo,

but I hear One hundred lines

to be written in your lunch hour.

What do you want? Isn’t it enough

that I can walk the gritstone edge among rocks

green with lichen in the flat winter light,

the bare birch woods on the slope below

shimmying like drifts of purple smoke?

You are so fearful of death! You would have me

clamber into my nineties and think the job well done,

when they would feed me khaki pap on a plastic spoon

and tuck my grey fringe off my face with a little girl hair slide –

“My, aren’t we pretty today!”

The pointed line, “Life choices’ you coo,//but I hear One hundred lines//to be written in your lunch hour” might be seen to convey the resentment felt by the older person, towards the practitioner’s paternalistic assumptions and lack of empathy for her lived experiences and priorities. This illustrates how even very brief poetic expressions can convey profound meanings about remaining open and person-centred as caregivers. Analysing this kind of poetry can encourage deep reflection on how students communicate with older or vulnerable populations and nurture a stance of humility.

Illustratively, the poem “Chemotherapy” by Julia Darling from her collection Sudden Collapses in Public Places (2003) delves into themes of chronic illness, death, and the celebration of life. Darling, diagnosed with breast cancer at 38 and dying a decade later, injects her poetry with humour and compassion, offering alternate perspectives on life with enduring illness. Her poetry demystifies the experience of living with cancer and opens students to different viewpoints about life with illness. Encouraging readers to step into her shoes, Darling’s poetry fosters an understanding of suffering as experienced by the sufferer – a vital skill in empathic engagement (Hall et al., 2015). Upon introducing a poem, learners can embark on their own poetic journey, guided by a line that resonates deeply. Writing from a poetry therapy context, Chavis (2011, p. 79) proposes that participants select a line which “calls” to them and use it as the steppingstone for their own creative endeavours. In an educational context, a line such as, “The smallest things are gifts…” could encourage learners to appreciate the significant impact of insignificant aspects of life, thereby nurturing self-compassion. Alternatively, it may ignite memories of past care recipients, bringing empathic recollections to the surface.

Pennebaker & Evans (2014) highlight potential risks of expressive writing about emotionally charged experiences, such as loss of control or feelings of humiliation. Our recommendations for using poetry in class are designed to be time-limited, with a clear beginning and end, ensuring that learners are not coerced into sharing their work unless they feel comfortable. Yet, the power of connection through writing can dispel feelings of isolation as learners realise, they share common experiences and emotions. Adhering to Pennebaker & Evans’s “flip out” rule ensures topics likely to cause distress are respectfully avoided.

Embracing self-empathy and exploring diverse perspectives, strategically chosen poetry can stimulate a journey of self-discovery and acceptance. Consider Robert Frost’s poem, The Armful (Frost, 1928), which aptly encapsulates the pressures faced by learners. Frost’s description of dropping and picking up parcels resonates with the challenges of time management and prioritising learning goals. By illuminating these struggles, poetry helps learners recognise their challenges and respond with self-compassion, turning the often-daunting journey into an insightful and therapeutic learning experience.

Frost’s poem, with its empathic undertone, signals the need for a better arrangement of the “parcels” to prevent further losses. Specifically, the metaphor of continually dropping “parcels” that represent the potential responsibilities and pressures resonates with the self-care struggles healthcare providers experience. Students may connect this to their own mounting academic, clinical, and personal demands, providing the opportunity to brainstorm concrete strategies for preventing burnout, compassion fatigue, and maintaining empathy over time. Frost concludes, “I had to drop the armful in the road//And try to stack them in a better load”, emphasising the need for self-care and support to sustainably manage difficulties just as the speaker tries to redistribute his burdens. Reading the poem together validates those challenges while offering an artistic starting point to discuss helpful solutions, underscoring the need for self-care for health and social care professionals to support quality, empathic care to others.

The interpretation of this poem might lead to discussions emphasising the significance of self-care in health and social care students, further highlighting the fact that insufficient self-care can precipitate burnout and compassion fatigue. Coined in a nursing context by Joinson (1992), compassion fatigue is a form of professional stress, fuelled by personal traits and past trauma exposure, which can result in emotional desolation and detachment, thus undermining the capacity to empathise (Sabo, 2011). Our own research (Jack, 2017; Jack & Illingworth, 2017) in this field has shown how poetry can be used as a way for students to address compassion fatigue in a manner that is effective, nurturing, and empathic.

For example, in several of our undergraduate nursing modules, we have used poetry written by other student practitioners to explore their own experiences of providing end of life care. Reflecting on these often-vivid expressions of both despair and resilience, students gained insight into the psychological and emotional complexities of serious illness, which helped prepare them for difficult conversations during clinical placements.

Reflecting on our experiences facilitating student poetry groups within nursing education, we have observed how the shared exploration of carefully selected poems created a sense of universality between group members. As students discovered common themes and emotions expressed in different ways through each other’s original poetry, they reported feeling less alone in their training experiences and more closely bonded with their peers.

To foster social ties within a poetry group, Gladding (2016) recommends crafting a group poem. Group members contribute lines embodying their learnings, which are subsequently woven into a collective poem. Initiation lines like “Today I say hello to/Today I say goodbye to” could be used to signify transformations within the participants and the larger group. Techniques like these can facilitate a shift in perspective, enabling a fresh review of experiences crucial to nurturing self-empathy, self-understanding, and personal growth.

When pondering the application of poetry in educational contexts, Mazza’s (2022) framework provides a valuable guide. This model incorporates a wide array of poetic techniques for diverse participants, addressing not just the cognitive but also the affective and behavioural dimensions of human experience, making it a potent tool for empathy exploration. This model consists of three components:

1. The receptive/prescriptive aspect, involving the introduction of poetry or literature.

2. The expressive/creative aspect, involving the act of writing.

3. The symbolic/ceremonial aspect, involving the use of metaphor and storytelling.

Drawing on the insights from this literature and our own classroom and practice-based experiences, we propose the following strategies for learners to engage with poetry, enabling them to explore empathy towards their patients, colleagues, and themselves:

1. Share and read poetry. Encourage students to seek out, read, and share poetry that resonates with their experiences. Poems can serve as conversation starters about the emotional realities of health and social care and provide an opportunity to connect with others’ experiences. For example, the anthology These are the Hands could be used as a starting resource. Other resources might include sites such as the Poetry Foundation (https://www.poetryfoundation.org/) and the Poetry Health Service (https://www.poetryhealthservice.com/), where learners can have a poem “prescribed” for them, after answering a few questions. Remind students that poetry is a diverse field with something for everyone, and that one does not need to be a literary expert to appreciate or find value in it.

2. Facilitate poetry groups. Create safe spaces for students to share and discuss poetry related to healthcare experiences. These groups can facilitate shared understanding and empathy between members and can meet either in-person or online. They can explore poems written by practitioners, patients, and caregivers, allowing them to understand the different perspectives in health and social care.

3. Write poetry. Encourage students to write their own poetry; for example, by using a line from a previously read poem as a prompt. This can be a creative and therapeutic way to process their experiences and emotions. It can also help them to develop empathy by thinking deeply about the experiences of others. By writing, they get a chance to express their feelings and thoughts that might be difficult to articulate in prose.

4. Share poetry. Create platforms where students can share their poetry with others, whether it is through a printed collection, a website, or at a spoken word event. This not only gives students a voice, but also allows others to relate to their experiences and learn from them. It can also foster a sense of community among learners.

5. Poetry journals. Students could maintain a personal poetry journal where they can privately express their thoughts and feelings, either as part of a summative or formative assessment. Over time, their entries can serve as a record of their growth and changing perspectives. It can also be a safe space to express their concerns and stresses, just like Robert Frost did in his poem “The Armful”.

Remember that incorporating poetry into learning can be a gradual process. Some students may initially be hesitant, especially if they are new to poetry. Encourage open-mindedness and reassure them that there is no right or wrong way to interpret or write a poem. As they continue to read and write poetry, they may find it a powerful tool for self-reflection, empathy-building, and emotional processing.

Conclusion

This paper has aimed to explore the crucial role of poetry within health and social care education, with a specific focus on Stein’s philosophy of empathy. It makes a case for poetry as a means of nurturing both self-awareness and empathic connections with others, under the safe and supportive umbrella of a classroom setting. The strategic use of poetry can create a space for learners to practice empathy, which can be especially beneficial in preparing them for emotionally charged situations when situated in practice. This is particularly crucial for learners who are often confronted with high-stress scenarios, such as providing end-of-life care, where they are grappling with their own emotions and anxieties about communicating effectively (Cunningham et al., 2016; Kav et al., 2013; Thyson et al., 2022).

Stein’s philosophy of empathy proves instrumental for health and social care learners. It equips them with the ability to understand others and simultaneously fosters their self-awareness and self-evaluation capabilities. Poetry, in this context, can serve as a beacon of alternative perspectives, challenging learners’ existing views and leading them towards heightened self-awareness. As Stein (1989: 116) insightfully states: “encountering different values awakens our own, often dormant, values.” This journey of self-discovery is vital for the cultivation of empathic abilities, fostering more insightful responses to practice-based situations (Jack & Levett-Jones, 2022).

Poetry can serve as an accessible bridge, enabling students to voice their emotions while providing a buffer against potential emotional distress. It eliminates the need for avoidance tactics, which can hinder empathy development and interpersonal relationships. The incorporation of carefully chosen poetry and a structured framework, like the one proposed by Mazza (2022), can guide writing sessions, providing both direction and purpose. However, it is important to strike a delicate balance between acknowledging unavoidable pain and instilling hope without negating students’ genuine emotions or contributing to feelings of isolation. Hence, ensuring the selected poetic material resonates with learners is key.

In these learning contexts, students should not be assessed or evaluated based on their literary prowess. Instead, the focus lies in encouraging them to connect with poetry and its relation to their own experiences, thoughts, and emotions. By creating a conducive environment for discussion, poetry becomes a communal “meeting place”, facilitating empathic interaction and understanding amongst peers.

Given that empathy-related traits can wane over time due to high-stress environments and repeated exposure to distress (Bourgault et al., 2015; Kachel et al., 2020), continual engagement with poetry is vital. It should not be regarded as an ancillary part of the curriculum, but rather, it should form a fundamental component of a comprehensive empathy education. This could potentially contribute to a more resilient, compassionate, and empathic healthcare workforce, capable of extending kindness not only to others but also to themselves.

The integration of poetry within health and social care education offers a rich, multifaceted approach to fostering empathy and self-awareness among learners. Its potential extends beyond the aesthetic appreciation of words, serving as a conduit for meaningful expression, empathic connection, and personal growth. The nurturing of these vital skills is not only paramount to the development of future health and social care professionals, but it also directly contributes to the quality of care people receive. With an increasing focus on holistic, person-centred care, the importance of empathy within health and social care cannot be overstated. As such, the strategic use of poetry as a vehicle for empathy education represents a tangible and impactful method for the formation of a compassionate, resilient, and empathic health and social care workforce. It underscores the profound truth that poetry and empathy, woven together, can enhance the fabric of health and social care education and practice.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.