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Original Research

Clinical empathy with cancer patients: a content analysis of oncology nurses’ perception

, &
Pages 1089-1098 | Published online: 21 Jun 2018

Abstract

Background

Empathy is one of the most important communication skills in clinical practice, specifically in the field of oncology. Empathic competences have a significant meaning for caring and therapeutic relations in nurses’ responsibilities. Clinical empathy brings positive performance, thus patients’ emotions are perceived and expressed more easily. Clinical empathy is contextual, interpersonal and affective, but it is also difficult to study. Awareness of oncology nurses’ perception of this phenomenon might help them to plan for more effective patient-centered consultations within interventional programs. Therefore, the aim of this study was to explore the content of clinical empathy with cancer patients from the perspective of oncology nurses.

Patients and methods

In this qualitative study, 15 oncology nurses were selected by purposive sampling. A semi-structured face-to-face interview was conducted with each of the participants. After data collection, all interviews were transcribed and reviewed, and then primary codes, sub-categories and categories were extracted. The data were analyzed with the conventional content analysis method by MAXQDA 10 software.

Results

Clinical empathy showed a composite construct with five main categories, including co-presence (physical and emotional presence), metacognition (self-awareness of mental processes), perception (knowing about awareness of individuals), inherent (genetic) and didactic (instructive) nature.

Conclusion

Clinical empathy as an effective strategy can be taught through three areas of “co-presence”, “metacognition” and “perception” in the context of cancer care. Thus, clinical empathy should be considered as one of the competency standards which can be taught to oncology nurses.

Introduction

There is still no widely accepted definition for empathy in the area of medical sciences.Citation1 Some scholars define empathy as a cognitive ability to acquire the perspectives, perception of thoughts, intentions, affections and beliefs of others.Citation2 Some others emphasize emotional responses to feelings and emotions of individuals.Citation3 When analyzing the concept of empathy, it is necessary to consider the difference between similar words, like sympathy and compassion. Sympathy includes emotional connection through feelings and expression of concern or compassion. Compassion is defined as the feeling and emotion toward an individual’s problems and the internal tendency to remove them. In contrast, empathy is an objective perception of a situation and emotions or values.Citation4 In other words, empathy means the perception of emotions and concerns of individuals and attention to the world from the viewpoints of the other individuals.Citation5 Results of a review study on empathy showed that there are five conceptualizations since 1990. Empathy has been disclosed as a human trait, a professional state, a communication process and as caring, also a special relationship.Citation6 The exploration of the concept of empathy in coach–athlete communication by a qualitative study indicated that empathy includes five themes: advocacy, communication, approachability, access and competence.Citation7

Empathy is a multidimensional construct and includes cognitive, affective, behavioral and ethical dimensions.Citation8 The cognitive dimension involves analytical and intellectual skills for perception of individual’s views. The affective dimension is the ability to share internal and emotional conditions of other individuals. The behavioral dimension reflects an empathetic relationship based on perception and communication skills, including active listening. The ethical dimension includes altruistic motivation.Citation9 The most controversial side of empathy may be the cognitive or affective aspects.Citation10 According to the results of a review, most researchers believed that empathy included both cognitive and affective aspects.Citation1 Mercer and ReynoldsCitation8 defined another type of empathy as clinical empathy. This is a perception of the situation, perspectives and emotions of the patient, communication with the patient, and evaluation of performance based on the patient’s perception in a helpful or therapeutic way. Clinical empathy is contextual, interpersonal, affective and it is difficult to study.Citation11 The humanistic psychologist Carl Rogers discussed genuineness or congruence in empathy as most important in facilitating communication.Citation12 The congruence has clearly two components, an internal component involving awareness of one’s own experience and an outer component, transparency which refers to obvious communication.Citation13

A review of nursing literature shows that some authors addressed the concept of empathy in their models or theories.Citation14 For example, one of the concepts in the Travelbee model is the phase of empathy. In her human-to-human relationship model of nursing, she stated that nurses were able to be empathetic with patients who showed similar behavioral and ethical features with them. Peterson and Zedrad described nurse–patient communication as a mental transaction. This, together with empathy, opinion exchange and discussion are the foundations of nursing.Citation14

Evidence indicates that the skill of clinical empathy is necessary for oncology nurses. Clinical empathy brings positive performance, thus patients’ emotions are perceived and expressed more easily.Citation15 Cancer patients are in a vulnerable situation due to changes in their quality of life and deterioration of their health, following multiple side effects of treatments. It is more challenging to communicate with these patients.Citation16 Development of nurse–patient empathic communication in the oncology ward is essential for patients to relieve their psychological distress.Citation17 Cancer patients are frequently hospitalized during their illness and nurses have more opportunity to build an empathetic relationship with them, to attract their trust and to support them and their families.Citation18 Nurses are able to identify empathetic opportunities and respond to patients’ needs, which can help patients to adapt to their illness.Citation19 A review studyCitation20 showed that empathetic relationship can improve outcomes of caring and treatment in patients in two ways: first, it can lead to self-disclosure of most signs and concerns of patients, acquiring more information, more accurate diagnosis, perception and responsibility of therapist to personal needs of the patient, thus better outcomes. Second, empathetic relationship causes a sense of being listened to, valued as an individual, understood, and accepted, leading indirectly to the improvement of patient outcomes.Citation20 A study of 710 patients in Germany indicated that there was a significant relationship between therapists’ empathy, reduced depression and promotion of patients’ quality of life.Citation21 In addition, results of a retrospective study showed that therapists’ empathy was associated with higher satisfaction and lower distress in patients.Citation22

An extensive review of international and Iranian databases, such as Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science, PubMed, Google Scholar, Ebsco, Iranmedex and Scientific Information Database (SID) using keywords of clinical empathy, empathy, oncology, qualitative research and quantitative research, nurse and cancer patient within 10 recent years (2007–2017) indicated that most previous studies were conducted quantitatively on physicians and medical students’ empathy with patients.Citation22Citation24 There were few quantitative studies about Iranian nurses’ empathy with patients in the oncology ward,Citation25 surgical wardCitation26 and intensive care unit.Citation27 We found only two qualitative studies in nurses,Citation28,Citation29 but they did not explore the content of empathy. Thus, the present study was conducted with the aim of exploring qualitatively the nature of clinical empathy with cancer patients from the viewpoint of oncology nurses.

Patients and methods

Study design

This qualitative study is part of a mixed method project which was conducted by a conventional content analysis method.

Participants

By purposive sampling, 15 nurses were employed from oncology wards (oncology, hematology-oncology and stem cell transplantation wards), including nine women and six men. Inclusion criteria were: working in oncology wards as a nurse with a minimum 6-month experience, and having at least a bachelor’s degree in nursing.

Data collection

Data were collected from February 2015 to September 2016. Based on the aim of the main project and according to oncology nurses’ responses to the Persian version of the Jefferson Scale of Empathy-Nursing Student version R (JSE-NS version R) on the normal distribution curve,Citation30 nurses as participants were selected from seven educational hospitals affiliated to three Tehran Universities of Medical Sciences. After obtaining informed written consent from each participant, semi-structured interviews were conducted with 15 oncology nurses. During sampling, variation in age, gender, work experience, marital status, and job title was maintained in participants.

Interviews were held in a private room of selected hospitals, and lasted 17–45 minutes. They were conducted with only the interviewer and interviewee present. The content of the interviews was based on the oncology nurses’ perception and their actual experiences of empathy with cancer patients. General questions were asked regarding the participants’ experiences of close communication with cancer patients and definition of empathy. Participants’ responses directed the process of continuing the interview. To obtain more information and more specific answers, the participants were asked to provide objective examples. Examples of the interview questions include: “What experience do you have about close communication with your cancer patients?”, “What experience do you have about empathetic communication with your cancer patients?”, “What’s the meaning of empathy from your perspective?” All interviews were recorded by a digital voice recorder, and then transcribed. Data gathering continued until data saturation, ie, when new information did not emerge. After 12 interviews, there was no new information, but to be sure, three more interviews were performed.

Ethical consideration

This study was approved by the Research Ethics Committee of School of Nursing and Midwifery at Shahid Beheshti University of Medical Sciences in Tehran, with the ethical code of SBMUZ.REC.1394.55. The required permissions were obtained from all of the selected educational hospitals. Objectives and procedures of the study were explained to the participants. The authors noted the ethical principles of anonymity, confidentiality of information, and the right for voluntary withdrawal from the study at any stage.

Data analysis

In this qualitative study, data analysis was done using a conventional content analysis method based on five steps of Graneheim and Lundman.Citation31 Data analysis was started immediately after the data gathering. To do content analysis, the second author (MSK) listened to the recorded interviews, transcribed them, and read them several times. After that, all transcriptions were given to the first author (CR), and she randomly checked several transcriptions. For analysis, at first, “meaning units” were found from expressions of the participants, then primary codes were extracted. To draw out the codes, the data were reviewed word by word, and related codes were written. Afterwards, similar codes were placed in one subcategory and similar subcategories formed the categories. The data were analyzed by MAXQDA 10 Software.

Rigor

In this study, four important criteria, credibility, conformability, dependability, and transferability, were assessed to obtain the study rigor.Citation32 Regarding credibility, the researcher was continually involved with participants and research data for seven months during data collection, analysis and interpretation. Transcribed interviews and extracted codes, as well as subcategories were discussed with and confirmed by three participants and five university members (three doctoral students in nursing and two faculty members in the Nursing and Midwifery school with a doctoral degree in nursing). To obtain rich data, oncology nurses with different demographic characteristics were chosen as participants. In addition, participants with different scores of empathy based on a previous measurement by the Persian version of the JSE-NS version R were entered into the study.Citation30 After interviewing with 15 nurses and analyzing the results, three hospitalized cancer patients were interviewed and the codes were confirmed. The authors tried to maintain conformability of the study by reporting the obtained data in detail, recording them accurately and keeping all the documents. To assess dependability of the study, the research process stages were independently checked by three qualitative researchers with doctoral degrees in nursing, as external supervisors. A comparison of these results showed similar consequences. Despite the limitation of transferability in qualitative studies, the authors attempted to explain the method section of the study in detail, including participant selection, data collection and the research process for subsequent studies.

Results

Demographic characteristics of the participants

Participants were 15 oncology nurses (6 male and 9 female nurses) from oncology, hematology-oncology and bone marrow transplantation wards in educational hospitals affiliated to three universities of medical sciences in Tehran. They were between 24 and 50 years old. The characteristics of the participants are shown in .

Table 1 Participant characteristics (n=15)

Content analysis results

When analyzing and identifying the nature of clinical empathy of oncology nurses, 518 primary codes, 25 subcategories, and 5 main categories were extracted. The main categories were co-presence, metacognition, perception, inherent and didactic nature. The categories and subcategories together with an example of quotations are shown in .

Table 2 Categories, subcategories and examples of participant quotations

Category 1: Co-presence

Co-presence includes mental experience, perception and the sense of being with others. The sense of people of being with each other is a psychological phenomenon which may or may not match the real state of co-presence. This category includes 12 subcategories: access; altruism; giving information and keeping good communication; moral communication; relationship based on honesty; empathic concern; paying attention to spirituality; being open in communication; relationship based on trustworthiness; the elixir of love; compassionate attention; and approachability.

Category 2: Metacognition

Metacognition is a self-awareness of mental processes, with self-control and perception of circumstances in a creative way. The category includes six subcategories: self-control; self-awareness; recognition of the situation; flexibility; emotional reflection; and aesthetic feeling.

Category 3: Perception

Perception can be defined as knowing about awareness of individuals. The category includes three subcategories: seeing from the patient’s perspective; seeing from the family of the patient’s perspective; and emotional connection.

Category 4: Inherent nature

The inherent nature of clinical empathy indicates its genetic constructs. This category includes two subcategories: trait; and automatic response.

Category 5: Didactic nature

The didactic nature of clinical empathy indicates its instructive construct. The category includes two subcategories: training; and role model.

Discussion

Cancer patients are mostly in distressing situations and need emotional support. However, distressed patients don’t always disclose their issues,Citation33 and sometimes nurses are not aware of what they should do for clinical empathy with their patients. Exploring the nature of clinical empathy might help to remove some of these barriers in the future. Therefore, this descriptive qualitative study aimed to explore the content of clinical empathy with cancer patients from the perspective of oncology nurses. Results showed that clinical empathy has a composite nature in the context of cancer care. Five main categories in this study were “co-presence”, “metacognition”, “perception”, “inherent nature” and “didactic nature”.

The first main category, “co-presence”, means the physical and emotional presenceCitation34 of oncology nurses with their cancer patients. Co-presence includes availability, attention, affection and mutual behavior.Citation35 Results of a study in Sweden showed that when the patient was in need, the presence of a nurse caused physical contact, a sense of warmness and closeness to the patient.Citation36 Furthermore, Godkin et al explained that nursing presence is synonymous with caring and includes communication, comfort, respect and informing to the patient.Citation34 Similarly, we also found the subcategory of “giving information and keep good communication” with the patient in our study.

In the present study the subcategories of “altruism” and “moral communication” in the co-presence area emphasize ethical empathy at the clinical level. Ethical empathy is one of the dimensions of empathyCitation8 and the authors believe that it includes altruistic motivation.Citation9 Moreover, “trust” appeared as an important factor in the relationship between the oncology nurse and the patient in subcategory “relationship based on trustworthiness” in our study. Indicators that can improve “trust” in this relationship are as follows: honesty, trustworthiness, confidentiality, providing the best care, having a holistic view of the patient and their situation, perceiving the patient’s problems, accepting their culture and beliefs without judgment and presenting a high-quality consultation.Citation37

The role of patients’ spiritual concerns in their health care conditions has been revealed in the past two decades.Citation38 Paying attention to spirituality raised among subcategories of co-presence in our results. It can help cancer patients to keep their hope after diagnosis and during the process of treatment.Citation39 Paying attention to spirituality includes compassion, presence, listening and encouragement of the patient’s hope.Citation40 In a qualitative study on spiritual needs of cancer patients in Iran, seeking for tranquility appeared as one of the main categories, with subcategories of hope, relationship with God and prayer.Citation41

“Being open in communication”, “the elixir of love”, and “approachability” were extracted from the sense of co-presence of oncology nurses. In a qualitative research on “what is the meaning of empathy for doctors?” having an open communication with the patient was a main component. Also, respecting patients’ emotions and thoughts was reported as an attitudinal-communication skill.Citation42 Most physicians described that empathy appeared to be verbal and non-verbal communication skills. They described affection in facial expression, keeping eye contact and leaning forward or toward a patient to emphasize listening, as non-verbal communications. Others referred to the importance of physical contact, such as putting a hand on the shoulder of the patient, hugging, and giving tissues to the patient when she/he is crying.Citation42 Consistent with this study, in the present research oncology nurses stated that they take the patient’s hand to transfer their empathy to the patient. Oncology nurses in our study called it “elixir of love”. Sitting beside the patient, taking his/her hand and caressing his/her face and hands show caring characteristics of the caregiver.Citation36 “Compassionate attention” in our study was also similar to care and compassion, which appeared as subcategories of “genuine empathy” in a research on optimization of empathy in patient-centered care.Citation43

When exploring the nature of clinical empathy in the present study, the second main category was extracted as “metacognition”. Metacognition is an essential factor for the development of clinical empathy.Citation44 Being aware of many variations in human cognition causes the individual’s mind to move from self-orientation to other-orientation, leading to acceptance and deep empathy.Citation44 Evidence shows that “metacognition” emerged as one of the factors following exploratory factor analysis of the concept of empathy in quantitative studies,Citation25,Citation45 but the components were not clear. The authors of those studies defined “metacognition” as an active effort for thinking the same as the patient.Citation45 Results of our current research presented a better perception of “metacognition”, as part of the nature of clinical empathy. It included a personal ability to control special emotions and tendencies and behavior in special and difficult situations. Also, it contained self-awareness, identification of situations, being flexible when caring for the patient, showing emotional reflection to affective states of patients and a sense of aesthetics. The results of a study at Surrey University, UK on 24 right-handed participants who were screened for using transcranial magnetic stimulation showed that the ability to control themselves and others assisted empathy as well as other social interactions.Citation46 Additionally, “internal awareness” is the simplest aspect of “genuine empathy”.Citation47 “Internal awareness” means the awareness of self-emotions and reactions. This awareness helps therapists make reliable explicit interpersonal communication with the patient. Such “internal awareness” and contact naturally originate from being truly present with the patient. Awareness of internal experiences is effective, especially those that are created by moment interactions with patients.Citation47 Results of a research on empathy in Iran showed that most nurses predicted patients’ needs, and nurses provided some opportunities for tears and expression of emotions by the patient.Citation26 We found the subcategory of “emotional reflection” in the area of “metacognition”. Bayne et alCitation43 discussed the concept of “accurate reflection” in medical students at Medical School of Eastern Virginia.Citation43 “Accurate reflection” means to perceive a patient at a genuine empathic level. Health care providers should be able to convey their empathic perceptions to the patient through showing accurate emotional expressions and statements.Citation43 Results of our study indicated the subcategories of “recognition of situation” and “flexibility” as part of the nature of clinical empathy in the metacognitive area. These results are consistent with a finding which showed that nurses changed their work schedule to find an opportunity to talk with a depressed patient.Citation26 A striking result of our study is the “feeling of aesthetics” as a part of the nature of clinical empathy in subcategories of “metacognition”. Davis described this sense as “fantasy” which was manifested as a subscale in the Interpersonal Reactivity Index for measuring empathy.Citation48 Davis found this creative sense led to better empathy with others.Citation48 Carper also describes the concept of “nursing aesthetics” and defines it as appreciation of and empathy toward patients’ experiences and the capacity for designing comprehensive creative care.Citation49

During exploration of the nature of clinical empathy in the present study, the third main category was extracted as “perception”. This means knowing about the awareness of individuals.Citation50 Results of the current study showed that the category of “perception” included seeing from the family of the patient’s perspective, and “emotional connection”. In the literature it has been argued that “perception” should be considered a result of perspective taking, one of the aspects of cognitive empathy.Citation51 In a phenomenological study, it was found that seeing from the patient’s perspective created a better perception for nurses.Citation52 In a qualitative content analysis study with physicians in Netherlands, most physicians stated that emotional connection with the patient is necessary for empathetic communication.Citation42

Thus in our study, three important categories of “co-presence”, “metacognition” and “perception” appeared to be an important part of the nature of clinical empathy of oncology nurses with cancer patients. The concept of “congruence” was proposed by Rogers, an American psychologist.Citation47 It seems that this concept can cover these three main categories directly and indirectly. Congruence is a holistic concept. It refers to a complex phenomenon that is set in a connection with attitudes, beliefs and intentions.Citation47 Being congruent, means a process of awareness of own internal experiences and a willingness to have explicit communication, openness and honesty in the moment.Citation53 Therapeutic presence can be a precondition to congruence.Citation47 Our results did not show a clear boundary between different kinds of empathy, as opposed to quantitative studies (cognitive, affective, ethical and behavioral empathy).Citation54,Citation55 Thus, the nature of clinical empathy in the context of our study showed an integration between different types of empathy, with a predominance of cognitive and affective empathy. The effects of the cognitive element are seen more frequently in the categories of “metacognition”, “perception” and “didactic nature”. Because of a broad interaction between cognitive and affective empathy, some authors have rejected separation of these two concepts.Citation1 A new perspective that the authors argued about, is that, during the time that affective empathy is automatically drew out, manipulation of the cognitive component can regulate affective component.Citation1 Another perspective suggested that the affective component is the content of empathy, whereas the cognitive component is the process of making up this content.Citation1

In the rest of the content analysis of clinical empathy, the “inherent” and “didactic nature” of empathy appeared as fourth and fifth categories. “Inherent empathy” means genetic empathy which is transferred from one generation to another.Citation56 The tendency toward empathy is a stable characteristic of the personality.Citation57 Researchers studied the responses of above 800 monozygotic and dizygotic twins in terms of empathy and they concluded that genetic factors had a role in empathic attention and personal distress as components of empathy.Citation58 However, empathy can also be an automatic reaction.Citation1 Neuroscientific studies showed that empathy is automatically raised up perception of an emotional issue.Citation1 Furthermore, some individuals have more tendency to empathy than others and either low or high empathy can be a personality trait of individuals.Citation59 The evidence suggests that empathy is a result of the interaction between state and trait. Therefore, the role of situational factors is not negligible in this area.Citation1 Another point is that the didactic nature of clinical empathy showed that it can be controlled,Citation5 modified, and strengthened by training.Citation60 Evidence shows that among various kinds of empathy, cognitive empathy can be trained successfully in the medical sciences area through role play, empirical education and education about human communications.Citation61

The clarification of the nature of clinical empathy can assist more effective future studies in cancer patients with longitudinal or interventional designs. Future research is suggested by focusing on these concepts in the framework of a model. It is necessary that this concept is added to the curriculum of education in nursing schools and in-service education programs in hospitals.

In summary, the nature of clinical empathy of oncology nurses with cancer patients, in the context of cancer care, includes five categories of “co-presence” (physical and emotional presence), “metacognition” (self-awareness of mental processes), “perception” (knowing about awareness of individuals), “inherent” (genetic) and “didactic” (instructive). Clinical empathy is a skill which can be taught. Thus, it should be considered as one of the competency standards for oncology nurses. Clinical empathy in therapeutic communication with cancer patients can be taught through three areas of “co-presence”, “metacognition” and “perception” in the context of cancer care. The focus should be on education in nursing schools and hospitals, regular assessment of clinical empathy by valid tools, applying feedback techniques, describing and sharing actual experiences of oncology nurses with their colleagues. Introducing role models is also advisable in nursing schools and hospitals.

The strength of this study is the selection of participants with maximum variety in terms of demographic characteristics, and empathy scores from a primarily quantitative study.Citation30 However, all those selected oncology nurses were eligible to be interviewed, some of them did not agree, and this could affect the study results.

Conclusion

The complex nature of clinical empathy of oncology nurses with cancer patients was manifested in five categories of “co-presence”, “metacognition”, “perception”, “inherent” and “didactic” nature. Clinical empathy as an effective strategy in therapeutic communication can be taught in the context of cancer care through three areas of “co-presence”, “metacognition” and “perception”. Clinical empathy should be embedded as one of the competency standards for oncology nurses. Therefore, to develop empathetic communication in oncology nurses, the focus should be on education, regular assessment, applying feedback techniques and describing and sharing actual experiences of oncology nurses with their colleagues. Introducing role models is also advisable in nursing schools and hospitals.

Author contributions

CR and MSK planned and designed the study. The study was supervised by CR, and MSK was the leading author for drafting of the article and responsible for identifying relevant references. JM contributed to labeling of categories and subcategories. All authors were in close collaboration and responsible for critical revisions of the manuscript. All authors contributed toward data analysis, drafting and revising the paper and agree to be accountable for all aspects of the work. All authors read and approved the final manuscript.

Acknowledgments

This study is part of the Doctoral Thesis of MSK, which was directly supervised by CR. This study was partially financed by the School of Nursing and Midwifery of Shahid Beheshti University of Medical Sciences. We would like to thank all oncology nurses who participated in this study.

Disclosure

The authors report no conflicts of interest in this work.

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