learning through bodily experience: a possibility to enhance healthcare students’ ability to...
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ORIGINAL ARTICLE
Learning through bodily experience: A possibility to enhancehealthcare students’ ability to empathize?
ANNE RIISER SVENSEN1 & ASTRID BERGLAND2
1Faculty of Health Sciences, Department of Physiotherapy, University College of Oslo, Box 4, St. Olavs plass 0130 Oslo,
Norway, 2Faculty of Health Sciences, University College of Oslo, Box 4, St. Olavs plass 0130 Oslo, Norway
AbstractThe purpose of this study was to explore whether learning through bodily experience in Movement Practice facilitated thedevelopment of empathy. A qualitative approach based on interviews with six women and three men between 22 and26 years. The data were analysed with the aid of Steinar Kvale’s ‘‘meaning condensation’’ and ‘‘meaning interpretation’’.Three categories emerged: (i) from a tacit knowledge of empathy to the recognition of empathy; (ii) empathy � beingtouched and emotionally involved; (iii) empathic � and still open for new insight. These categories clarify the importance ofstudents being in touch with their own feelings and being able to reflect on them. Learning through bodily experience takesinto account the body as a subject and carrier of meaning. Bodily experience creates opportunities for the developmentof empathy after time has been given for reflection. For the student to acquire empathy, self-understanding is fundamentalto his/her professional attitude. Only when the students are aware of their own feelings, can they deal with them. Moststudents seem to want to start reflecting upon their own emotions, but find it hard to recognize themselves as empathicprofessionals so early in their course. Empathy is described by the students as ‘‘intersubjective’’ and reflects understandingand awareness of the feelings and behaviour of another person and the ability to respond to the clients as unique humanbeings.
Key words: Bodily awareness, bodily experience, empathy, learning, physiotherapy, student
Introduction
The acquisition and nurturing of human skills and
attitudes is an important aim of training in phy-
siotherapy. Empathy is a key concept in many
disciplines. In a health care context, empathy is
defined as a cognitive attribute that involves an
understanding of the inner experiences and perspec-
tives of the patient as a separate individual, com-
bined with the capacity to communicate this
understanding to the patient (1�7). Empathy relates
to behaviour and has a personality dimension and
experienced emotions (8,9). Reynolds & Scott (10)
conclude that empathy is crucial to a non-defensive
relationship and can facilitate satisfactory and pro-
ductive outcomes for the clients. Peloquin (11)
suggests that empathy is central to the interactions
of therapists who value the personal dignity of their
clients. Thornquist (12) uses the expression ‘‘bodily
empathy’’ and considers it vital in all kinds of health
work to describe how you ‘‘feel’’ about what another
person is experiencing. The Norwegian physiother-
apy curriculum states that learning by using your
own body is an extension of the techniques and skills
related to the exercise itself. The students are given
the opportunity to interpret the body based on their
own experience (13).
Nerdrum (2) focuses on programmes for training
in empathic communication for future social work-
ers. He concludes that specific training seems
necessary to help them progress towards a signifi-
cantly higher degree of empathy. Kelly & Wykurz
(14) suggest that students should work with patients
to enhance empathy and communication skills.
Others suggest that teaching empathy should take
place in the ambulatory care setting (15) early in the
course of health workers’ training (16,17) and
be reinforced by taking patient histories (18).
Correspondence: A. Riiser Svensen, Faculty of Health Sciences, Department of Physiotherapy, University College of Oslo, Box 4, St. Olavs Plass 0130 Oslo
N-407, Norway. E-mail: [email protected]
Advances in Physiotherapy. 2007; 9: 40�47
(Received 4 November 2005; accepted 18 October 2006)
ISSN 1403-8196 print/ISSN 1651-1948 online # 2007 Taylor & Francis
DOI: 10.1080/14038190601090711
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Furthermore, students should be given opportu-
nities to reflect on their learning experiences (19).
Results of earlier studies are inconsistent with
regard to the students’ development of empathy
during their study programme; both increased and
decreased empathy have been reported (7,20�22)
prior to and following clinical experience. To our
knowledge, no research has yet been performed to
indicate whether working with the body’s awareness
may be a way to help health workers develop their
empathy. Thus the purpose of this study is to explore
whether and how learning through bodily experience
facilitates the development of empathy in first-year
physiotherapy students.
Material and method
Seventy first-year students at a Norwegian Bachelor
Programme of Physiotherapy were given information
about the purpose of the study and were asked if they
were willing to participate in one in-depth interview
concerning their learning through bodily experience.
Nine students, aged 22�26 (mean age 23) years,
volunteered: six women and three men. All the
students except one have 1 year or more of education
at university level in addition to various work
experience before starting the physiotherapy course.
The number of women and men reflects the total
number of students with respect to age and gender.
Having interviewed the nine students, the study
reached the point of saturation (23).
Arenas for learning through bodily experience
One aim of teaching physiotherapy is to enhance
students’ attitude towards empathy. Bodily experi-
ence in this study relates to Movement Practice
(MP), massage and nine days of clinical practice in
hospital (supervised patient treatment), spread over
the first year of the course. The main focus during
MP, is that the students perform different move-
ments and activities, for instance imagining they are
stretching towards the sky and pushing the clouds
around or sitting in pair back to back and just
leaning against one another. Afterwards they reflect
on their experience in a discussion group. Particular
points to discuss are body awareness, consciousness
of the other, knowledge about movement and com-
munication, ‘‘Veronica Sherborne activities’’ (24).
Body awareness is a broad concept, often used in
physiotherapy. It comprises body consciousness and
different aspects of motor behaviour. The students
are taught to attend both to how the movements are
performed and what they experience during the
performance. This stimulates mental presence and
increases the awareness of the strengths and limita-
tions of one’s own body.
While the students are performing these activities,
the main focus is on their own bodily experience.
During class, an introduction is given on different
theories relating to the body and movement
(24�27). In this paper a bodily experience points
to a phenomenological understanding where the
person is regarded as at the same time ‘‘having’’
and ‘‘being’’ the body (27). According to this view,
the body is seen as a source of information, along
with the person’s own idea of the situation. Peirce et
al. (26) refers to a kind of experience which he calls
‘‘firstness’’, which comes into force at a level prior to
what can be expressed in words � the experience is at
a ‘‘prelinguistic level’’. This means that the experi-
ence is perceived directly as a feeling. The informa-
tion or experience is described as ‘‘bodily’’ or
‘‘momentary’’.
Interviews
Qualitative interviews were used in order to find out
what the students had learned through their own
bodily experience during their first year of the
physiotherapy course. The interviews were per-
formed once in the first month of their second year
at a Norwegian Bachelor Program of Physiotherapy.
They took place at the college in a separate room,
with only one student and one of the authors
present. Examples of questions were: Describe one
or more situation(s) and your feelings during your
training where you were very close to another
person, physically or emotionally. Describe your
opportunity to reflect upon your experience? How
did you experience the reflection situation? In the
course of the interview, the interviewer tried to verify
her interpretation of the subject’s answer (28). The
interviews were taped and later transcribed verbatim
for analysis by one of the authors.
Analysis
The data analysis can be described with what Kvale
(28) calls a ‘‘meaning condensation’’ and ‘‘meaning
interpretation’’. Meaning condensation entails
abridgement of the opinions expressed by the inter-
viewees in short formulations. Long statements are
compressed into briefer statements in which the
main sense of what is said is rephrased in a few
words. Interpretation goes beyond a restructuring of
the manifest meanings of the text to deeper or more
speculative interpretation of the text. Through this
interpretation process, the three student categories
presented in the results emerged. Verbatim extracts
from the students’ interviews have been used to
Learning through bodily experience 41
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show what these interpretations are based upon.
This kind of interpretation goes beyond what the
informants have said directly so as to reveal the
opinions and relations that are not evident.
Verification was built into the research process by
continual checks on the credibility, plausibility and
trustworthiness of the findings � see presentation of
the results. The two authors used a hermeneutic
perspective to gain consensus about the interpreta-
tion in the data analysis (28), trying to obtain an
interpretation free of contradiction. Both researchers
adopted a critical outlook on the analysis, explicitly
stating their perspective on the subject matter
studied, trying to counter any selective perspective
in order to avoid bias, and in general playing the
devil’s advocate towards the other researcher’s point
of view. The project was approved by the regional
ethics committee.
Results
The outcome of the interviews is presented in the
three categories that emerged during the analyses.
The three categories: ‘‘from tacit knowledge of
empathy to recognition of empathy’’; ‘‘empathy �being touched and emotionally involved’’; ‘‘em-
pathic � and open to further insight’’ � seem to be
characteristic features in a model of the process of
developing empathy.
From tacit knowledge of empathy to recognition of
empathy
The students, except for one, were not sure whether
they were empathic. They seemed to believe that
beginners could not be empathic, but in the mean-
time they could at least be kind and pleasant with
their patients. One student put it like this:
The teacher said that we were too gentle with the
patient. We are supposed to torture them a little
bit, to give them some pain � we might say �ooops, did that hurt? If we recognize their illness
we might make them obsessively concerned about
being acknowledged (. . .) and we are not supposed
to be like that, but at the same time I don’t think
that you can teach yourself to be empathic from a
book. I work in a retirement home and there you
are very kind to the patients and care about them,
especially in the one-to-one-situations. I don’t get
to know patients I meet during my practical
sessions. Maybe it is like that in the beginning,
that you are just extremely kind and pleasant?
Another student described some of her experiences
during MP. She developed her bodily awareness and
learned to feel her own strength, boundaries, com-
fort and discomfort.
I thought it was important to be aware of my body,
to feel certain movements and perhaps to be a bit
creative and loosen up a little, which is important
when you are a physiotherapist . . . and I also
learned about myself and my limitations, what I
was comfortable with and what I wasn’t comfor-
table with, it was both (. . .) there are many things
to become aware of in MP. This awareness will
probably be useful in clinical practice.
A female student thought the development had
started by just being on the course, in class and in
practice sessions without being able to point out
definite elements. She had learnt much about body,
‘‘soul’’ and feelings:
I have now realized that it’s all linked together,
body and shall we call it ‘‘soul’’ � that they are
connected, right. When I try to think about it, we
have learnt a lot about it in theory, I am not so
sure if we have learnt about it in practice � it’s not
as if I can say � but I think I have anyway, without
being able to say anything about it (. . .) but it’s like
they say, it’s a bodily experience and then it’s
rather a slow process and not like this [snapping
her fingers]. I think that perhaps when I experi-
ence something with my body, I have a greater
chance of understanding how others experience
the same thing with their bodies, even though we
are completely different persons: being lifted and
moved around and treated. So I feel I am better
qualified to take good care of my patient as a
therapist now, than I would have been if I hadn’t
experienced it at first hand.
When talking about the development of empathy,
one female student said:
when it comes to empathy, I think it’s not just that
you develop it, it’s something that lies within you,
developed from � I don’t know � sometimes
too much focus is put on how to learn empathy,
learning to put ourselves in the patient’s situation,
it isn’t always that easy to learn, it is some-
thing that comes by itself when you meet the
patient.
They expressed the wish to be able to concentrate on
one thing at a time. This was particularly noticeable
when they were trying to master practical skills,
which demanded their undivided attention. One
male student put it this way:
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In the early stages of learning, you are very
concerned about what you are supposed to do,
so that you have trouble combining things; I do, at
least. I guess I thought I would have become more
skilful with the technical aspects of massage, if
there had been a sharper focus on techniques.
Empathy � being touched and emotionally involved
When asked about experiences that have made a
special impression on them during their external
practice, many chose to present dramatic meetings
with their patients � some very dramatic. Concern
and empathy for another person’s situation is im-
portant. Most of the students said that they had
either written about the experience or talked to their
tutor about it. This is one of the stories:
Last year when I was in practice, I met a patient
who had been in a car accident. He had a multiple
trauma. I was alone with the patient for the first
time. It was a very positive experience. That’s
what comes to mind when I think about special
experiences. He was very easy to deal with, though
severely injured. He had lost his wife and every-
thing. To come so close to a situation like his,
which I had never experienced before, made a
huge impression on me. To be alone with the
patient and to be in control of everything � though
it was just an examination � as I said, it was a very
positive experience, I felt that it was good. This
was a paradox, I mean, it was terrible to be with
someone in that situation and yet to watch them
being so cheerful and pleasant.
The story is quite typical, the paradox of having
sympathy for patients enduring a cruel situation and
yet satisfaction in being able to meet them appro-
priately and maybe offer them some help and
support.
A male student described a situation that he did
not feel he had managed very well. A patient
began to cry violently when he asked her about her
family situation and he did not know what to do.
He disliked the situation and wanted it to stop, so
he began to ask her some other questions � about
her free time and whether she had any hobbies.
I think it is much easier to comfort the patient
when you are alone with her because you do not
have to think about others; and then I am male,
she was female; you know, it is much easier for
girls to comfort. I got it wrong, I only held her
hand a little, that was the closest I dared to go.
After that episode, he said that he went home and
read about what he should have done � let the
patient cry and say why she was crying, instead of
trying to stop her.
Some students find empathy hard to learn, believ-
ing that it is supposed to come naturally when
meeting the patient. They think it is hard to be
empathic on demand. It becomes theoretical, artifi-
cial and, in a patient situation with the room filled
with fellow students and the tutor, performance
anxiety may occur. One of the male students said:
I think it’s hard, to be able to show empathy, to
put yourself in the situation of the patient at the
same time as you are performing function exam-
inations that you are uncertain of. I think it is hard
to keep both things in focus. When you also have
fellow students and a tutor listening to the case
history or observing a functional examination, you
feel the pressure to perform. Sometimes I find that
very difficult to deal with . . . there are so many
other things to keep in mind.
He expressed an issue that recurred in many of the
interviews. The students repeated that there are
many forms of knowledge that they must acquire,
and they do not have the capacity to handle more
than one thing at a time. The need to perform
practical skills correctly neither allows the student to
see the patient/fellow student (when practising their
skills in class), properly, nor to take their own bodily
experiences of the situation personally. Moreover,
they experience the pressure of being observed in a
situation where they are trying to be empathic, which
by itself requires much of their attention.
In order to be empathic with another person you
must have some experience in common. One student
tells about MP as a way of being placed in situations
of which you have no prior experience.
I do see the point, many of the movements were
strange and awkward, but you have to go through
it to be able to put yourself in someone else’s
situation.
Empathic � and still open to new insight
There was only one student who characterized
herself as empathic. She felt that she had always
been empathic, and had just become more and more
conscious of it:
I feel that I have always been quite empathic, but I
think I have become more conscious about my
body language and my way of touching and giving
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the patient the feeling that I am there and part of
the situation. I really think that I am becoming
more conscious about it in my manner and my
conduct now than I was before.
When asked if MP had been an arena to bring the
body and the ‘‘soul’’ together, her answer was:
Yes, you might say that, but it’s hard to know
really because I think it is implanted in us from the
beginning that they are so separate. I believe, there
were in fact many students who thought it was
very strange, that they didn’t realize that this was
actually what we were doing, that we were trying
try to keep the body and soul together and not
separate � it’s a bit difficult to explain (. . .) it’s
something you haven’t experienced before . . . �you have had gymnastics and stuff, but it’s not
really the same thing.
She knew that some of the students had not had the
same experience as her, and she had had some
thoughts about it.
I am one of the eldest (26 years old), and I don’t
feel that all of the students in this class are mature
enough for this, it goes over their heads because
they are not mature enough to understand that
you actually don’t have to understand everything,
and ascribe a meaning to everything � you can just
do it. Perhaps in general everyone has to have the
answers and know how to do things and know
everything, but I don’t think that it’s always
supposed to be like that, and I suppose that’s
what is meant by ‘‘bodily experience’’, that you
only experience it, you don’t have to analyse it.
Maybe just be a bit open to new things and not be
so critical towards other people’s ideas and
thoughts, attacking everything at once before
you’ve even tried.
After the session with movement practice (MP)
there had been a discussion, but she felt it had been
rather unsuccessful. She had these thoughts about
the timing:
If the teacher asks: ‘‘Was this any good?’’, everyone
goes silent, even though this is something that
everyone can have an opinion about, whether it
was good or bad, but of course, things that are a
bit more emotional, you have to offer a part of
yourself, and then I realize that it might be hard to
give an answer, you don’t always have an answer
ready (. . .) it may take some time to process. With
regards to MP, we always have a discussion right
afterwards, and it is perhaps too soon, it’s too
close, I don’t know.
Discussion
The purpose of this study is to find out whether and
how learning through bodily experience facilitates
the development of empathy. Our data indicate that
it is possible to enhance empathy through bodily
experience during MP. Empathy is described by the
students as interactive and reflects understanding
and awareness of the feelings and behaviour of
another person. An empirical model (Figure 1)
emerged from the data presented as three categories
in the result section. The interpretation of the results
relates to the two categories ‘‘Development of
empathy’’ and ‘‘Empathy: From Impression to
Interactive Experience’’ presented in the following
discussion. In this study, the students start with
doing something in practice which could produce
knowledge different from attending lectures or read-
ing books. It seems to be crucial to reflect after
action. This reflexivity seems to give access to own
experience. A key prerequisite for understanding
reflexivity in this way is the recognition that experi-
ence takes place all the time (29). In the work of
health professionals, body communication acquires a
special meaning. According to biomedicine, the
body as biology is in focus. The body as a means
of expression, the body as I�me, is easily forgotten
(30). Since our body is always present, and never
silent (31) it is difficult to conclude whether the
accounts from the students are related to MP or
other experiences.
Development of empathy
The empirical material revealed that learning
through bodily experience leads to an awareness of
an inner disposition and provides a starting point
From tacit knowledge of empaty to recognition of emapthy
Empathy: from impression til interactive experience
Empatic – and still open to new insight
Empathy – being touched and emotionally involved
Development of empathy
Figure 1. Learning through bodily experience: from students
accounts to interpretation of students’ accounts.
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and context for reflection. Vetlesen (32) describes
empathy as a fragile product of developmental
psychology. He believes empathy is by its very nature
and origin interpersonal. The interpersonal aspect
was pointed out by one of the students who found
empathy hard to learn and said it was ‘‘something
that comes by itself when you meet the patient’’.
Nerdrum (2) asks whether health workers need a
different sort of empathy in their work than what
they have in their private lives. One student seemed
to recognize a change in her own empathy from
always being quite empathic, to developing a higher
consciousness on meeting the patient. She talked
about her body language, her way of touching and
how she was able to give the patient the feeling of
being there for him. Nerdrum (2) raises critical
questions that should be clarified before empathy
can be introduced into various care disciplines
regarding the helper’s motive is for being empathic.
It is very important to have sufficient self-knowledge
to be able to see when one uses empathy for one’s
own sake, and when one uses it to help patients. The
professional situation is characterized by a systemic
lack of balance, the therapist being the giver and the
patient the receiver, a situation experienced by one
of our students. She told the interviewer about her
feeling of well-being in having control and power
when she was alone with the patient. This asymme-
trical relationship was grounded in an ethical dimen-
sion of which she seemed to be aware. When this
student said that the situation was rewarding for her
too, we could interpret that in the light of what Holm
(33) refers to as fulfilling your own needs in your
profession.
Holm points out the necessary alternation be-
tween emotional perception and intellectual assess-
ment, without which we risk being engulfed by the
other person’s emotions. In the case of the weeping
patient, the student reflected on his way of handling
this situation � he experienced his own lack of
professional skill and withdrew from the patient’s
emotional reactions. The students seemed to recog-
nize that changes require reflection on the situations
and processes. A purely emotional approach may
result in confused reactions that provoke anxiety
because we have mixed our own feelings with the
other person’s feelings (33). Among the cognitive
elements, we find theoretical knowledge about reac-
tions to crises, for instance, and psychological
defence mechanisms. This student had tried to learn
from his own experience using theoretical knowledge
gained from books.
Although our body is always present, and never
silent (31), the difference between learning empathy
through bodily experience, i.e. doing, compared to
learning empathy when listening, talking or reading
is revealed by the students. Some students thought
that it was not possible to teach oneself empathy
from books. This seems to correspond well with
Holm (33), who warns against overstressing cogni-
tive elements. Such overstressing may inhibit the
ability to let our usual controlled and logical
approach go a bit, which would allow us to give
way to fantasies and a visual way of thinking �prerequisites for new and innovative efforts. How-
ever, just as cognition devoid of emotional under-
standing will not generate empathic understanding,
we cannot understand the other person exclusively
on the basis of our own emotions. For the new
student, Holm’s warning (33) goes too far. New
students found the demand to ‘‘show empathy’’
impossible while at the same time learning new
skills. In addition, they found it tough being ob-
served by the tutor and fellow students.
Empathy: From impression to interactive experience
The teacher aims in class to create a climate free of
defensiveness in order to enable the students to talk
about their perceptions. The students’ difficulties in
doing so may possibly be understood in the light of
Peirce et al.’s theories of levels of experience (26).
The student knows she has learnt something by
experience but is not capable of saying anything
explicit about it. The form of experience that Peirce
calls ‘‘firstness’’ comes into force at a level prior to
that which can be expressed in words � the
experience is at a ‘‘prelinguistic level’’. This means
that the experience is perceived directly as a feeling.
A student expressed the opinion that some experi-
ence is a ‘‘bit more emotional, offering part of
yourself ’’, and difficult to verbalize and ‘‘these are
things it may take some time to process.’’ The
information or experience that was produced is
referred to as ‘‘bodily’’ or ‘‘momentary’’. Perhaps
more practice with this kind of experience is needed
in order to become aware of it and be able to express
it.
The students mentioned the importance of being
creative, daring to ‘‘loosen up’’ a bit. ‘‘You do not
necessarily have to understand everything � you can
actually just do it’’, bodily experience may be just
experienced and not necessarily analysed. Thorn-
quist (12) points out that health personnel have a
particular responsibility in this respect. One of the
informants said something important about bodily
experience when she referred to it as ‘‘a slow
process’’. The ‘‘firstness experience’’ itself is prob-
ably immediate and momentary, the process, how-
ever, of becoming aware of the experience takes
time. The same informant pointed out that it takes
time to process the experience; the discussion came
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too soon after the class. Moreover, she has received a
greater understanding of how her patient will
experience lifting and touching, activities they per-
formed in class. The fact that the student has the
‘‘same’’ bodily experiences that will be her patient’s
experience later on, builds up a mutual experience,
related to body and movement. Being able to reflect
on their own bodily feelings in communication with
others may increase the chances of understanding
other people. The students’ experience may be
interpreted as knowledge about themselves and the
other. A number of authors (2,33) claim that
empathy involves focusing on aspects of how a
person understands another person’s experience. In
this case, the student’s approach to understanding
the other was bodily, and she also said that she had
become aware that she could make the patient feel
she was there and part of the situation. This
interaction is related to what Stensland (34) presents
as bodily empathy.
The informants brought up several elements that
are fundamental in MP. Awakening the body; the
distinction of movements, creativity, courage, feeling
your own limitations, preparing for pleasant and
unpleasant things, and their conclusions were all
directed towards the meeting with the patient.
Several writers (12,32,34�36) emphasize the impor-
tance of health personnel being in touch with their
own feelings and being aware of situations that bring
out pleasure or unease in them. According to the
students’ experience, empathy seems to organize
their perception, facilitates their awareness of them-
selves and others, increases sensitivity and promotes
respect. Empathetic expression has to be accepted by
the other and held open for reinterpretation all the
time (35).
Limitations
Unlike quantitative research, qualitative research
does not necessarily aim to produce findings that
are representative of a larger population (37). There-
fore, the findings of our study are not necessarily
generalizable. In our study the content of the
categories are mostly based upon several students,
except for the category ‘‘Empathic � but still open to
new insight’’, which is based upon one student.
Thus, her comments are not validated by the other
students, which could be a limitation. However, her
comments are validated theoretically. In a larger
sample, perhaps other students would support her
comment. Because students voluntarily signed up for
the study, they are a self-selected group. They are
probably more prone to self-reflection and more
capable of answering our questions than the ‘‘re-
fusers’’. However, the data may be interpreted as
honest and highly valid in the context in which they
had been produced. We received information from
the students only once and have had no opportunity
to verify that they actually experienced any change in
their empathic ability over time. Transferability may
be limited with similar demographics. In addition,
the researchers served as the study’s instruments.
From a quantitative research perspective, this could
potentially increase the risk of bias in the data
analysis (38). However, as Kvale (28) states, the
interview as such is neither an objective nor a
subjective method, its essence is an intersubjective
interaction. With an increased sample size, we would
have had the opportunity to make statistical general-
izations. In our study, we could only make analytical
generalizations by specifying the supporting evi-
dence to make the argument explicit in the inter-
pretation of the data (28). By using the triangulation
method, we could have increased the content validity
of the study (38).
Conclusion
For the student to acquire empathy, self-under-
standing is fundamental in his/her professional
attitude. The awareness of their problem areas,
knowing their own typical ways of reacting in a given
situation and with particular people, is part of the
students’ development of empathy. Most students
find it hard to recognize themselves as empathic
professionals so early in their course. The verbaliza-
tion of bodily experiences is a way for physiotherapy
students to learn empathy. Empathy is described by
the students as interactive and reflects understanding
and awareness of the feelings and behaviour of
another person. According to our results, a model
for developing empathy in the first year students
consists of the ability to recognize, to be involved and
to be open-minded. The implication is that in order
to become empathic, learning strategies are required
that allow students to expose their own mistakes and
insecurities to others, so that they may increase their
self-awareness and benefit from the experience.
References
1. Moore ES. Empathy as a hermeneutic practice. Theor Med.
1996;/17:/243�54.
2. Nerdrum P. Training of empathic communication for helping
professionals, Dissertation for the degree of Dr Psychol.
Institute of Psychology. Oslo: University of Oslo; 2000.
3. Kunyk D, Olson JK. Clarification of conceptualisations of
empathy. J Adv Nurs. 2001;/35:/317�25.
4. Hojat M, Mangione S, Nasca TJ, Cohen MJM, Gonella JS,
Erdmann JB, et al. The Jefferson scale of physician empathy:
Development and preliminary psychometric data. Educ
Psycho Meas. 2001;/61:/349�65.
46 A. R. Svensen & A. Bergland
Adv
Phy
siot
her
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Uni
vers
ity o
f A
uckl
and
on 1
1/02
/14
For
pers
onal
use
onl
y.
5. Hojat M, Gonella JS, Nasca TJ, Mangione S, Vergare M,
Magge M. Physician empathy: Definition, components,
measurements and relationship to gender and speciality. Am
J Psychiatry. 2002;/159:/1563�9.
6. Hojat M, Gonella JS, Mangione S, Nasca TJ, Magge M.
Physician empathy in medical education and practice: Ex-
perience with the Jefferson Scale of Physician Empathy.
Semin Integr Med. 2003;/1:/25�41.
7. Hojat M, Mangione S, Nasca TJ, Rattner S, Erdmann JB,
Gonnella JS, et al. An empirical study of decline in empathy in
medical school. J Med Educ. 2004;/38:/934�41.
8. Williams C. Biopsychosocial elements of empathy: A multi-
dimensional model. Issues Mental Health Nurs. 1990;/11:/
155�74.
9. Morse J, Anderson G, Booter J, Yonge O, Obrien B, Solberg
S. Exploring empathy: A conceptual fit for nursing practice.
Image: J Nurs Scholarsh. 1992;/24:/273�80.
10. Reynolds WR, Scott B. Empathy: A crucial component of the
helping relationship. J Psychiatr Ment Nurs. 1999;/6:/363�70.
11. Peloquin SM. The fullness of empathy, reflections and
illustrations. Am J Occup Ther. 1995;/49:/24�31.
12. Thornquist E. Conceiving function. A dissertation for the
degree of Doctor Philosophiae. University of Oslo; 1998
13. Curriculum. Rammeplan og forskrift, Fysioterapeututdan-
ning. Fastsatt av Kirke-, utdannings- og forskningsdeparte-
mentet. Curriculum for Physiotherapy Education, edited by
the Department for Church, Education and Research (in
Norwegian). Oslo: Faculty of Health Science; 1997.
14. Kelly D, Wykurz G. Patients as teachers: A new perspective in
medical education. Educ Health. 1998;/11:/369�77.
15. Devera-Sales A, Poaden C, Vinson DC. What do family
medicine patients think about medical students’ participation
in their health care? Acad Med. 1999;/74:/550�2.
16. Yarnold RR, Martin GJ, Soltysik RC. Androgyny predicts
empathy for trainees in medicine. Percept Mot Skills. 1993;/
77:/576�8.
17. Marcus E. Empathy, humanism, and the professionalization
process of medical education. Acad Med. 1999;/74:/1211�5.
18. Spiro M. Empathy and the practice of medicine. New Haven,
CT: Yale University Press; 1996.
19. Branch WT Jr. The ethics of caring and medical education.
Acad Med. 2000;/75:/127�31.
20. Kramer D, Ber R, Moore M. Impact of workshop on
students’ and physicians’ rejecting behaviour in patients
interviews. J Med Educ. 1987;/62:/904�10.
21. Winefield HR, Chur-Hansen A. Evaluating the outcome of
communication skill teaching for entry-level medical student:
Does knowledge of empathy increase? J Med Educ. 2000;/34:/
90�4.
22. Wilkes M, Milgrom E, Hoffman JR. Toward more empathic
medical students: A medical student hospitalisation experi-
ence. J Med Educ. 2002;/36:/528�33.
23. Guest G, Bunce A, Johnson L. How many interviews are
enough. Field Methods. 2006;/18:/59�82.
24. Sherborne V. Developmental movement for children. Cam-
bridge: Cambridge University Press; 1990.
25. Laban R. Mastery of movement. Plymouth: Northcote House
Publishers; 1980.
26. Peirce CS, Hartshorne C, Weiss P. Collected papers. Cam-
bridge, MA: Harvard University Press; 1958�60.
27. Merleau-Ponty M. Phenomenology of perception. London:
Routledge Classics; 2002.
28. Kvale S. Interviews. An introduction to qualitative research
interviewing. Thousand Oaks, CA: Sage Publications, Inc;
1996.
29. Carey S. Cultivating ethos through the body. Hum Stud.
2000;/23:/23�42.
30. Rudebeck CE. The doctor, the patient and the body. Scand J
Prim Health Care. 2000;/18:/4�8.
31. Thornquist E. Body communication is a continuous process.
The first encounter between patient and physiotherapist.
Scand J Prim Health Care. 1991;/9:/191�6.
32. Vetlesen AJ. Perception, Empathy and judgement: An inquiry
into the preconditions of moral performance. Penn State
University Press; 1994.
33. Holm U. Empathy and professional attitude in social workers
and non-trained aides. Int J Soc Welf. 2002;/11:/66�75.
34. Stensland P. Approaching the locked dialogues of the body �Communicating symptoms through illness diaries. Disserta-
tion for the Degree of Dr. Med. Division for General Practice,
Department of Public Health and Primary Health Care,
University of Bergen, Norway; 2003.
35. Ekerholt K, Bergland A. The first meeting the Norwegian
psychomotor physiotherapy: Users’ experiences as a basis for
knowledge development. Scand J Pub Health. 2004;/32:/
403�10.
36. Schibbye A-LL. The role of ‘‘recognition’’ in the resolution of
a specific interpersonal dilemma. J Phenomenol Psychol.
1993;/24:/175�89.
37. Pope C, Mays N. Qualitative research in health care, 2nd edn.
London: BMJ Publishing Group; 2000.
38. Polit DF, Hungler BP. Nursing research � Principles and
methods. Philadelphia, PA: JB Lippincott Company; 1995.
Learning through bodily experience 47
Adv
Phy
siot
her
Dow
nloa
ded
from
info
rmah
ealth
care
.com
by
Uni
vers
ity o
f A
uckl
and
on 1
1/02
/14
For
pers
onal
use
onl
y.