nursing, empathy and perception of the moral

Nursing, empathy and perceptionof the moral

W. Reynolds PhD RMN RGN

Reader in Nursing, Department of Nursing and Midwifery,

University of Stirling

P.A. Scott PhD RGN

Senior Lecturer, Department of Nursing and Midwifery,

University of Stirling, Scotland

and Wendy Austin PhD RN

Associate Professor, Faculty of Nursing, University of Alberta,

Edmonton,1 Canada

Accepted for publication 9 December 1999

REYNOLDSREYNOLDS WW., SCOTTSCOTT PP.AA. && AUSTINAUSTIN W. (2000)W. (2000) Journal of Advanced Nursing 32(1),

235±242

Nursing, empathy and perception of the moral

Over the last 15±20 years we have witnessed a dramatic interest in the moral

domain of clinical practice. There has also been a growing focus on the patient

as an individual whose individuality and perspective must be respected. It is

argued in this paper that a key to both these concerns is a consideration of the

role of empathy in both perceiving the moral aspects and issues of practice, and

in providing adequate support for patients. In this paper the meaning and

components of empathy are discussed in the context of human receptivity and

preconditions of moral performance. However, we also draw attention to

empirical studies which suggest that even following adequate educational

preparation, if the clinical environment and the structures within which care is

delivered are not supportive, the practitioner's ability to perceive the moral is

limited. In such circumstances, patients are in danger of receiving less than

appropriate care Ð from both the moral and professional perspective.

Keywords: moral domain, moral perception, whole person, components of

empathy, helping relationships, client outcomes, professional conduct

INTRODUCTION

There has been much emphasis in the nursing literature,

on both sides of the Atlantic, regarding the need to focus

on the whole person (Smith 1992, Savage 1995, Lanara

1996). Many nursing authors have argued that this focus

on the whole person is an important distinguishing factor

between nursing and medicine (Liaschenko & Davis 1991,

Liaschenko 1998). This focus on the whole person who is

a patient, involves a recognition that patients are more

than the disease or illness condition which urges them to

seek nursing and health care. It also involves a recognition

that emotional, psychosocial and spiritual elements as

well as physical elements will in¯uence patient healing

and treatment. Inherent in this type of recognition is the

need to come to know and understand the patient, albeit

necessarily to a limited extent (Dillon 1992).

Correspondence: W. Reynolds, Department of Nursing and Midwifery,

University of Stirling, Highland Campus, Old Perth Road,

Inverness IV2 3FG, Scotland.

Ó 2000 Blackwell Science Ltd 235

Journal of Advanced Nursing, 2000, 32(1), 235±242 Philosophical and ethical issues

Bergum (1994) proposes that the knowledge needed for

ethical care is constructed when the professional and

patient strive together to understand what meaning the

disease factors have within the experience of the patient.

Schultz & Carnevale (1996) seem to concur, believing that

when caregivers fail to understand their patients' experi-

ences, meanings and choices, bio-ethical problems are

promoted. Nursing theorists such as Gadow (1980) in

North America underline further this need to know the

patient by arguing that the proper philosophical founda-

tion of nursing lies in existential advocacy. Accurate

perception and understanding of the perspective of the

patient is elemental in such advocacy.

Much has also been written in the nursing literature in

terms of the importance of caring to the nursing role. An

important element of the literature on care also embraces

recognition of the patient as a unique individual, with a

unique perspective and individual needs. For example,

Scott (1995) argues that a signi®cant factor in the provi-

sion of constructive care is the ability of the practitioner to

identify imaginatively with the patient, as the basis for

gaining accurate insight into patient need. This enables

the subsequent nursing care to be patient-centred. Scott

argues that this sensitivity to the person and perspective

of the patient draws our attention to the existence and

relevance of the moral domain of clinical practice.

This notion of the importance of the moral domain of

practice was taken up formally in the Project 2000

pre-registration programmes (United Kingdom Central

Council for Nursing, Midwifery and Health Visiting,

UKCC 1986). Indeed, all Project 2000 pre-registration

programmes have a compulsory ethics input. Nurse

educators, in developing their courses, sensibly looked to

the disciplinary experts in this area Ð moral philosophers.

However, the principle-based approach favoured by many

moral philosophers (DuBose et al. 1994), dominated as it

is by the Kantian principle of autonomy, is beginning to

meet with some resistance from health care practitioners

and scholars who have entered the health care ethics

debate.

Dillon (1992), for one, rejects the dispassionate and

detached valuing of persons explicit in the Kantian

perspective, regarding it as morally incomplete. She

argues instead for an `affectively rich responsiveness to

others' as the basis of an active engagement in which one

can make a positive contribution to another's existence

(Dillon 1992 p. 120). This attitude, which she terms `care

respect' involves a profoundness of feeling, rather than its

absence.

That an absence of emotion has a negative effect on

moral judgement (as well as on other forms of decision

making and action) is argued by Damasio (1994), from a

neurological standpoint. Drawing on his work with

patients affected by brain damage, he states that:

¼ feelings, along with the emotions they come from, are not a

luxury. They serve as internal guides and they help us communi-

cate to others signals that can also guide them. (Damasio 1994 p. xv)

In terms of the moral signi®cance of emotions, Oakley

(1992) argues that being emotionally sensitive is a neces-

sary feature of, in Artistotle's terms, living a ¯ourishing

human life. For example, experiencing emotions is a

necessary part of experiencing love and friendship,

because such relationships essentially involve emotions

and `these relationships are central to various kinds of

good lives' (Oakley 1992 p. 57). He also suggests that

experiencing certain emotions is a vital part of broadening

one's perspectives and deepening one's understanding of

certain aspects of the human condition. In other words,

experiencing certain emotions is a necessary part in

enabling one to interact with and successfully communi-

cate with persons in distress. Oakley sees emotion as

having three interacting and dynamic components: a

cognitive component, an affective component and a desire

component.

The Norwegian philosopher Vetlesen goes a step further

to an analysis of the importance of emotion in moral

perception and judgement. His interest in the emotions is

in terms of the importance of emotion as a means of access

to the moral domain of human life. He expresses his thesis

thus:

¼emotions Ð or more accurately the emotion of empathy Ð are

indispensable in providing us with access to the domain of the

moral. I conceive the domain of the moral in a wide sense, I take it

to include every `other' whom we look on as a moral addressee,

that is as an object of respect and concern. The morally relevant

features in a situation are the features that carry importance for

the weal and woe of human beings involved in it. (Vetlesen 1994

p. 6)

Vetlesen describes what he terms the preconditions of

moral performance as comprising four elements:

· human receptivity Ð which he calls `basic empathy';

· moral perception;

· moral judgement; and

· moral response or action.

He argues that it is human receptivity, basic empathy

with other human beings, which awakens moral percep-

tion and gives it direction. It is thus crucial to the entire

moral enterprise, in that empathy is central to accurate

moral perception, moral judgement and moral action.

Oakley indicates that though emotion is present this is

not a guarantee of perfect morally good action or

judgement. He puts this down to the weakness of will

from which many of us suffer. However, Oakley and

Vetlesen agree that in the absence of emotion, our

ability to perceive the moral is likely to be stulti®ed or

dulled. It would nevertheless be somewhat short sighted

W. Reynolds et al.

236 Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(1), 235±242

to think that individual emotional and cognitive

response is all that is of relevance in moral perception

and judgement.

THE MEANING AND COMPONENTSOF EMPATHY

The discussion thus far suggests that moral perception is

dependent on the existence of empathy in helping rela-

tionships. While the hypothesized relationship between

empathy and moral perception is a reasonable proposi-

tion, a review of the literature reveals that there is a lack of

clarity on what is meant by empathy. For example there is

a debate concerning how empathy is best conceptualized:

as a personality dimension, an experienced emotion, or an

observable skill (MacKay et al. 1990). Vetlesen (1994) does

not explain in detail what he means by basic empathy Ð

apart from suggesting that it is a basic receptivity to other

human beings. If one views empathy as an emotion in

Oakley's sense of the term, then one is claiming three

components to the emotion of empathy: a cognitive

component, an affective component and a desire compo-

nent. This latter component may or may not be manifest in

one's behaviour. Oakley and Vetlesen, along with moral

philosophers such as Blum (1980) are in agreement that

certain emotions may be necessary for understanding

some features of the world. This conclusion is reinforced

by the tendency of theorists to describe emotional

empathy as an ability subjectively to experience and share

in another's psychological state or intrinsic feelings

(Morse 1991).

Oakley's understanding of emotion and thus, empathy,

if it is an emotion, is more complex than most descriptions

of emotional empathy in the literature. While Carper

(1978) refers to empathy as the capacity to participate

vicariously in and understand the experience and emotion

of others, most descriptions refer only to the affective

component. For example, Davis (1983) describes empathy

as being a visceral emotional reaction and Williams (1990)

refers to an innate biological tendency to react emotionally

to the emotions of others. Similarly, Peplau (1987)

described empathy as an ability to feel in oneself the

feelings being experienced by another person. Peplau,

who makes frequent references to empathic linkages,

appears to view empathy as an emotion that is triggered

by non-verbal cues, but not restricted by them.

The extent to which empathy as an emotion can

contribute to an understanding of another's experience is

poorly understood. It is possible that emotional empathy,

in certain circumstances, might be harmful or used for

sel®sh purposes. Mehrabian & Epstein (1972) reported that

subjects who scored highly on emotional empathy (a

vicarious emotional response to the other person's experi-

ence) were more likely (than low scorers) to be sensitive to

rejection and to engage in behaviours related to approval-

seeking tendencies and sociability. It is interesting to note

that the notion of emotional empathy as vicarious

emotional response seems a step beyond Vetlesen's

understanding of `basic empathy'. That is, Vetlesen sees

basic empathy as the ability to be touched by the weal and

woe of another. Vicarious experience may well come later.

Mehrabian and Epstein's data suggest that those high in

emotional empathy are emotionally responsive to the

other person's needs. To what extent, however, do these

tendencies result in aiding distressed persons to meet

their needs or resolve their problems? Arguably, if `high

scorers' are vulnerable to rejection, this could act as a

barrier to understanding the needs of the other person.

Although emotional empathy or sympathy may contribute

to `liking' in social relationships, several studies have

found a negative relationship between helping (therapeu-

tically) and social attractiveness (Krebs 1970). That is not

to say that emotional empathy is non-therapeutic, but the

possibility remains that there may be relatively ®xed

(minimum) amounts of emotional empathy necessary in a

helping relationship. The amount of emotional empathy

necessary in a helping relationship is unknown at the

present time. It is possible also that the cognitive compo-

nent of empathy (the intellectual ability to identify and

understand another person's feelings and perspectives

from an objective stance) and the behavioural component

of empathy (an ability to convey understanding of

another's perspective) are the therapeutic components of

empathy.

This would suggest that, at least for the emotion of

empathy, Oakley's desire component of emotion needs

some tightening up. For what is being suggested from the

clinical literature is that to be effective, the desires

component of empathy must manifest itself in supportive

behaviours. In spite of frequent references to empathy as a

human quality emphasizing personality and emotive

qualities, there is an increasing tendency to emphasize

its cognitive-behavioural components. Thus Truax (1961

p. 2) wrote that:

Accurate empathy involves more than just the ability of the

therapist to sense the client's `private' world as if it were his own.

It also involves more than just the ability of the therapist to know

what the client means. Accurate empathy involves the sensitivity

to current feelings and the verbal facility to communicate this

understanding in language attuned to the client's feelings.

Truax's de®nition of empathy is congruent with Gadow's

concept of existential advocacy. Since existential advo-

cacy involves inquiry into human beings' experience of

themselves and actively supporting another person, it is

dif®cult to understand how this could be achieved unless

nurses are able to become sensitive to their patients'

current feelings and to understand what they would like

to happen, as patients. Consequently, it is logical to

suggest that education designed to enable nurses to offer

Philosophical and ethical issues Empathy and perception of the moral

Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 32(1), 235±242 237

the interpersonal conditions alluded to by Truax, would

be relevant to nurses' moral education. Since the health

care system contains many distressed individuals, it

seems essential that nurses learn how to support patients'

efforts to meet needs, as perceived by them.

BARRIERS TO EMPATHY AND RELATEDETHICAL PROBLEMS FOR NURSES

The literature suggests that major barriers to clinical

empathy exist in nurses' clinical environments (MacKay

et al. 1990). Holm (1997) reports similar ®ndings from the

wider health care practice arena. Barriers to empathy may

include the way in which nursing work is organized

traditionally, and a fear of risk taking when the patient's

emotional distress is too overwhelming (Carver & Hughes

1990). Support for this assumption was found during a

study of the effects of an empathy education programme

on registered nurses' empathy (Reynolds 1998).

Reynolds reported the development of a client-centred

measure of empathy. The scale was based on an opera-

tional de®nition of empathy that is relevant to clinical

nursing, since scale items re¯ected clients' perceptions of

empathy. For example, clients wanted nurses to seek

clari®cation of confused messages, but they did not want

nurses to manipulate their communications. This suggests

that some components of empathy can be given by one

person to another. If clients are able to perceive the

amount of empathy existing in a helping relationship, they

are in a position to advise professionals how to offer

empathy. However, the client's perception of empathy has

generally been ignored in the construction of measures of

empathy. While it is not being suggested that the views of

professionals are unimportant, clients may have percep-

tions that contribute to our understanding of a construct of

empathy that is relevant to clinical nursing.

An issue relating to measurement of empathy is that it is

a multidimensional construct. How each element interacts

with the others is currently unclear. A fuller discussion on

the complexity of this area may be read in Reynolds

(1998). This study reports the development of an empathy

scale which re¯ects clients views and which is compatible

with La Monica's de®nition of empathy. An examination

of the La Monica de®nition of empathy illustrates that at

least four different dimensions of empathy need to be

considered in any attempt to measure clinical empathy.

Empathy signi®es a central focus and feeling with and in the

client's world. It involves accurate perception of the client's

world by the helper, communication of this understanding to the

client, and the client's perception of the helper's understanding.

(La Monica 1981 p. 398)

Twelve items on the new empathy scale can be examined

in Appendix 1. Using this scale, a course was designed

and implemented which does help nurses to learn how to

show the cognitive and behavioural components of

empathy. Results, discussed later, revealed that nurses'

gains in empathy persisted for some time after the course

had ®nished (3±6 months). The major aims of this study

were: (1) the development and evaluation of the empathy

scale; (2) the investigation of variables that may affect

nurses' ability to offer empathy; and (3) the evaluation of

the empathy course. Data consisted of three empathy

scores for each nurse who completed the study, and

nurses' responses during semi-structured interviews and

to a questionnaire probing the context of care.

Findings from the qualitative phase of the study

revealed that a challenge to offering empathy is presented

by variables existing in clinical areas. Important variables

are lack of time (n� 8/20) and the clinical problems of

clients (e.g. confusion and lack of trust, n� 9/20). Further

variables are: lack of privacy (n� 10/20), interruption to

clinical work (n� 13/20) and lack of support from unsym-

pathetic colleagues (n� 10/20) in circumstances where

the skills mix is inadequate (n� 7/20). These data suggest

differences among clinical environments, but some

nurses' descriptions of barriers to offering empathy to

the patient were likely to have been in¯uenced by the fact

that they chose to conduct clinical interviews in their own

time (n� 6/20).

The problems faced by nurses in Reynolds's (1998)

study are illustrated by the following comment:

Before the interview with my patient I had to participate in a

rescheduled ward round. I wasn't the primary nurse for any of the

patients being discussed and this was holding back my scheduled

interview. This increased my nervousness and I felt unsupported.

(Reynolds 1998 p. 338)

The potential of the organizational context of nursing to

pose ethical problems for staff is emphasized by the

following quote:

I felt angry because this type of clinical work is supposed to be so

important to the aim of individualized care. I felt that nobody

cared. (Reynolds 1998 p. 329)

While it can be argued that nurses need to be ¯exible in

the real world, there may be limits to the extent that

nurses can manipulate work schedules. This assumption

is indicated by reports in the nursing literature that major

barriers to clinical empathy exist in nurses' clinical

environments (MacKay et al. 1990, Bowman 1996, Holm

1997).

Environmental expectations, as well as support and

reinforcement available to nurses, are clearly critical to

their tendency to offer empathy and their perception of the

moral. If nurses feel that nobody cares, this is likely to act

as a barrier to empathy and, as a consequence, nurses are

less likely to appreciate the meaning of the patient's

experience. This assumption is supported by the ®nding

that most nurses in Reynolds' study (n� 17/20) varied the

W. Reynolds et al.


planned length of clinical interviews from 30 minutes to

15 minutes. Furthermore, while all nurses were able to

formulate objectives for counselling interviews (n� 20/20)

and most were able to identify clinical problems of

patients (n� 19/20), they seldom described patients'

needs in terms of speci®c health outcomes desired by

their patients. Most nurses experienced tension and/or

self doubt (n� 19/20) as a consequence of the barriers to

offering empathy.

It was concluded that the offer of empathy within a

prolonged one-to-one relationship, for the purposes of

talking about needs, was not a situational norm in many of

the clinical areas studied. This suggests that there is a need

for nurse educators to ®nd an effective way of teaching

nurses how to offer empathy. Additionally, there is a need

for educators, and colleagues, to recognize the need to

remove barriers to offering empathy in clinical areas.

AN EFFECTIVE WAY OF TEACHING NURSESHOW TO OFFER EMPATHY

The quantitative phase of Reynolds's (1998) study

involved the investigation of the effectiveness of an

empathy development course designed to teach nurses

how to offer empathy to their patients during a series of

counselling interviews. The components of the course are

outlined later. The construct of empathy taught had some

of its antecedents in patients' views about helpful and

unhelpful nurse±patient relationships (Reynolds 1994).

The development of an empathy scale that measured the

concept of empathy in patients' terms provided the means

of investigating nurses' ability to empathize prior to

education, during education and following education.

Nurses in experimental and control groups were rated

`blindly' on the empathy scale from audio-taped records of

clinical interviews. Investigations of the empathy scale for

content validity, concurrent validity, construct validity,

test±retest reliability, internal reliability, internal discrim-

ination and inter-rater reliability were satisfactory (see

Barker & Reynolds 1997).

An initial examination of scores on the empathy scale

(prior to education) suggested that the scores of the

experimental and control group were similar on the ®rst

occasion (see Table 1). This was con®rmed by analysis of

variance (see Table 2).

ANOVAANOVA of interview 1 shows no signi®cant effect of

group. Since the control and experimental groups were

indistinguishable, prior to education, they could be

considered to be well matched samples.

ANOVAANOVA of interviews 2 and 3 shows a signi®cant effect

of group on empathy scores. Examination of mean scores

(see Table 3) reveals that the experimental group had

gained considerably in their empathy scores during

education, while the control group had remained

static. Following education (3±6 months later) the mean

empathy scores had declined slightly but the experimental

group had maintained its advantage over the control group

(Table 3).

The difference in mean empathy scores of the experi-

mental and control groups on the three occasions of

interviewing were investigated by a t-test (see Table 4).

The t-test between scores on interviews 1, 2 and 3 shows

no signi®cant difference for the control group between any

pairs. For the experimental group there was a signi®cant

change between interviews 1 and 2 and between 1 and 3,

but not between 2 and 3 (P < 0á01). This outcome indicates

that there was a difference which persisted and which was

due to education.

Table 1 Means and standard deviations for empathy scores prior

to empathy education

Variable label Mean SDSD Cases

Entire sample 29á51 9á48 37

Control group 28á20 9á14 15

Experimental group 30á40 9á81 22

Table 2 Analysis of variance of scores of control and experi-

mental groups on three clinical interviews

Main effect of group F-value Signi®cance

Interview 1 (pre-course) 0á26 ns

Interview 2 (during education) 46á61 P < 0á001

Interview 3 (post-education) 60á51 P < 0á001

Table 3 Means and standard deviations for empathy scores

during and following education

During

education

Following

education

Variable label Mean SDSD Mean SDSD Cases

Entire sample 42á45 15á27 38á42 14á91 33

Control group 28á00 7á28 23á61 6á95 13

Experimental group 51á85 11á10 48á05 9á81 20

Table 4 t-Test of differences between empathy scores on the ®rst,

second and third interviews

Value of t for group

Pairs of interviews Control Experimental

1 and 2 0á44 6á84*

1 and 3 2á48 6á01*

2 and 3 1á84 2á22

*P < 0á01. All other values are not signi®cant.



These ®ndings indicate that the empathy course is

effective. This was established by signi®cant gains among

measures on the new empathy scale for the experimental

group. It was established also by the fact that nurses on the

empathy course achieved gains on all items on

the empathy scale, following pre-course measures, while

the control group did not change. Nurses' gains in

empathy persisted for some time (3±6 months) after the

course ®nished. These outcomes were con®rmed by

nurses' graphic descriptions of their learning during

post-course interviews.

OUTLINE OF THE EMPATHY COURSE

The course consisted of several components. These were:

· A self-directed study pack that focuses the student's

attention upon events in clinical practice.

· Wider literature searches.

· Regular one-to-one meetings with a supervisor, sched-

uled by the student, for the purpose of re¯ection on

theory and practice.

· A 2-day workshop to prepare the student for practice in

the real clinical world.

· A supervized review of six (audio-taped) clinical inter-

views.

· A measure of cognitive behavioural empathy which

re¯ects course aims. This instrument is used to focus

workshop and clinical activity.

Of interest to educators are those aspects of education

which facilitated favourable learning outcomes. This

question was investigated also during post-course inter-

views with nurses in the experimental group. Data

revealed that the nature of the supervisory relationship

and re¯ection on clinical experience were considered to

be the most effective course components. The most

frequently mentioned concepts in relation to supervision

were an open, two-way, non-defensive relationship with a

supervisor and direction with clinical work.

Re¯ection on clinical work was facilitated by students'

review of audio-taped records of their clinical interviews

with clients. This method, referred to in the literature as

interpersonal process recall (IPR) (Kagan 1990), was

considered to be the most effective course component.

This result is similar to Stockhausen's (1994) ®ndings that

the process of re¯ection on practice allows the clinical

facilitator to be an integral component of the student's

learning in clinical contexts. This is important in view of

the barriers to offering empathy in clinical environments

reported earlier. Nurses in Reynolds' study reported that

barriers to clinical work were most commonly overcome

by seeking supervisory support. It was also shown that the

ability to judge when learners want freedom to re¯ect on

experience, or when direction is required, is dependent on

an empathized sensitivity to the learner's needs.

IMPLICATIONS FOR HEALTH SERVICE

The relevance of empathy and moral perception to the

goals of the health service are suggested by the Patients'

Charter. The National Health Service (NHS) (Scotland)

Patients' Charter (1992) sets the following standards for

health care. Patients should:

· share in the responsibility for their own health;

· tell professionals what they want; and

· be entitled to be treated as a person, not a case.

While the aims of the Patients' Charter seem desirable, it

is dif®cult to understand how they might be achieved

unless nurses are provided with an appropriate moral

education. Such education should enable nurses to offer

an empathized awareness of the patient's expectations

and needs. This point is emphasized by Reynolds (1998)

who pointed out that users, such as women infected with

human immunode®ciency virus, or those with the experi-

ence of living with pain, have different expectations and

needs of the health service from professionals.

The dif®culty of understanding the expectations and

needs of these patients is indicated by barriers to empathy

in clinical areas and the pre-course levels of empathy

reported in Reynolds' study. Pre-education levels of

empathy indicated that nurses possessed levels of

empathy that were likely to be too low for understanding

the concerns of patients. This conclusion is not only based

on the mean score of 29á5 for the test. It is also indicated by

the low scores on the instrument for individual items on

the empathy scale which are hypothesized to be critical

for investigating the concerns and preferences of patients.

An example is:

ITEM 1: Attempts to explore and clarify feelings

This item frequently scored less than two on a seven-

point Likert scale. Scores of less than two points indicate a

tendency to investigate a patient's feelings and percep-

tions infrequently. It means that nurses were likely to

utilize less than 25% of the opportunities to assist a

patient to describe or evaluate feelings.

CONCLUSIONS

In spite of Reynolds's (1998) ®ndings that nurses on an

empathy course achieved gains on pre-course measures of

empathy, a concern is that clinical areas presented barriers

to the use of empathy in practice. One barrier was the

unsympathetic views of colleagues. A possible explan-

ation for the negative attitude of some colleagues is that

staf®ng levels, workload, rapid discharge and a lack of

understanding of the therapeutic potential of empathy,

prevents empathy from being regarded as a situational

norm. While supervisory support protected nurses to

some extent from barriers in clinical environments, there

W. Reynolds et al.


is a concern about nurses who do not have access to the

type of supervision provided for nurses on the empathy

course.

Anxiety about peer attitudes to talking one-to-one with

patients might decrease if offering empathy to patients

was a clear expectation of the workplace. In order to

achieve that situation, those in positions of leadership

(clinical service managers) need to promote empathy and

encourage its use. Such encouragement should include

the provision of staf®ng levels which allow time for

prolonged one-to-one relationships and investigation of

the effect of rapid discharge from hospital on the oppor-

tunity for nurses to know their clients. Additionally, those

who purchase education for nurses need to consider

whether any empathy course purchased will, in reality,

translate to nurses offering empathy in their clinical

environments.

It has been argued that the emotion of empathy appears

to play a fundamental role in perceiving the moral

dimension of clinical practice. However, the amount of

emotion necessary to respect the perspective of the client

is unknown. Since it has also been argued that therapeutic

communication involves an ability to listen and respond

to the client's perspective, it seems logical to suggest that

cognitive-behavioural empathy is crucial. This notion of

empathy appears to play a fundamental role in perceiving

the moral dimension of clinical practice.

Concerns regarding perceptions of the moral dimension

of practice chime with the UKCC Code of Professional

Conduct (UKCC 1992) and with the work of nursing

theorists such as Sally Gadow. Such work demands that,

as individual practitioners, we recognize the signi®cance

which the moral domain has for clinical practice.

However, what this paper also points out is that this is

not simply a matter for the individual practitioner. The

indication, from two recent empirical studies (Holm 1997,

Reynolds 1998), that professional and organizational

structures may mitigate actively against the practitioner

perceiving the moral in a clinical situation provides much

food for thought. Such ®ndings are of relevance and

should be of interest to our professional organizations and

the UKCC. They are also of relevance to those of us who

prepare future generations of practitioners for practice and

to the general public.

The suggestion in the Patients' Charter that clinicians

need to collaborate with users of the health service in the

prioritizing of clinical need cannot be achieved unless the

issues discussed in this paper are addressed. If profes-

sionals continue to fail to offer an empathized awareness

of clients' needs it is unlikely that they will be able to

understand the client's responses to health problems, or to

achieve outcomes desired by the client. In such circum-

stances, patients are in danger of receiving less than

appropriate care Ð from both the moral and professional

perspective.

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APPENDIX 1: THE EMPATHY SCALEAND USER'S GUIDE

Instructions

The instrument contains 12 items that describe behaviours or

attitudes of a counsellor (e.g. a nurse) during verbal interaction

with his/her client or patient. Read each statement and decide thedegree to which you perceive the person that you are rating (e.g.

yourself, your nurse helper, or an associate, etc.) as like or unlike

the statement when applied to a recent relationship. You are

asked to give an opinion on every statement according to thefollowing scale.

1. Always like (100%)2. Nearly always like (90%)

3. Frequently like (75%)

4. Quite often like (50%)5. Occasionally like (25%)

6. Seldom like (10%)

7. Never like (0%)

Please read each statement on the empathy instrument and

consult the operational de®nitions and clinical examples

(provided in the User's Guidelines) before scoring the instrument.Tick one response for each item on the scale.

Ó W. Reynolds. Not to be reproduced without written permission.

Always

like

100%

Nearly

always

like 90%

Frequently

like

75%

Quite

often

like 50%

Occasionally

like

25%

Seldom

like

10%

Never

like

0%

1. Attempts to explore and clarify feelings

2. Leads, directs and diverts

3. Responds to feelings

4. Ignores verbal and non-verbal communication

5. Explores personal meaning of feelings

6. Judgmental and opinionated

7. Responds to feelings and meanings

8. Interrupts and seems in a hurry

9. Provides the client with direction

10. Fails to focus on solutions/does not answer

direct questions/lacks genuineness

11. Appropriate voice tone, sounds relaxed

12. Inappropriate voice tone, sounds curt

W. Reynolds et al.


nursing, empathy and perception of the moral

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