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The relationship of age, empathy skill training and cognitive development to nursing students' empathic.. Doyle, Katherine Jane 1989

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THE RELATIONSHIP OF AGE, EMPATHY SKILL TRAINING AND COGNITIVE DEVELOPMENT TO NURSING STUDENTS * EMPATHIC COMMUNICATION SKILLS By KATHERINE JANE DOYLE B.N., McGill University, 1973 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS OF THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department of Counselling Psychology We accept this thesis as conforming to the required standard: THE UNIVERSITY OF BRITISH COLUMBIA February 1989 Catherine Jane Doyle, 1989 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date INWL Kt \<W\ DE-6(3/81) ABSTRACT The interactive skill of empathy is essential to the practice of nursing. The British Columbia Institute of Technology General Nursing Diploma Program has implemented an interactive skills training program that includes the skill of empathy in order to assist nursing students to acquire this skill. The purpose of this study was to investigate the relationships between the interactive skill of empathy and the developmental variables of level of cognitive development and age and the educational variables of empathy skill training and number of years of post-secondary education in nursing students. Developmentally, the ability most relevant to the cognitive component of empathy is perspective and role-taking which is facilitated by the development of formal operational thinking. The constraints on the development of formal operational thinking consequently are constraints on the development of the cognitive component of empathy. It is this cognitive empathic ability, however, that is considered crucial to nursing. The question therefore arises: To what degree do the cognitive constraints evident in nursing students inhibit or impede their development of empathic interactive skills. Data were collected from two groups of nursing students, one that had experienced the empathy training and the other that had not. The variables of empathic interactive skill and level of cognitive development were measured with Carkhuff's Empathic Understanding in Interpersonal Processes Scale and the Arlin Test of Formal Reasoning respectively. Data on age and number of years of post-secondary education were collected with a Biographical Data Sheet. Hierarchical multiple regression analysis was used to investigate the linear relationship of age, empathy skill training, and cognitive level to the subjects' empathic interactive skill. Two nonparametric tests of chi square were used to examine the degree of independence between empathic interactive skill and the variables of number of years of post-secondary education and the cognitive ability to coordinate multiple frames of reference. The findings of this study indicate that there is a significant linear relationship between empathic interactive skill and empathy skill training. Training accounted for the greatest proportion of variance in empathy scores after age had been removed (53%), F_ (3, 50) = 30.64, p_<.00001. Chi square analysis found that empathic interactive skill was shown to be independent of number of years of post-secondary education and the cognitive ability to coordinate multiple frames of reference. It is recommended that the empathy skill training program be continued with the following suggestions. The contextual, process nature of interaction needs to be emphasized including the constraints and realities of nursing practice that generally are not operating in the counselling paradigm from which the skills program is adopted. Subsequently, more emphasis is required on the facilitative skills, including basic empathy rather than the challenging skills. It is suggested that on-going seminars for faculty to clarify the value and practice of empathy plus a team teaching approach would improve the quality of supervision students receive. Suggestions are made for further research. iii TABLE OF CONTENTS PAGE ABSTRACT ii LIST OF TABLES ACKNOWLEDGEMENT vi vii CHAPTER I INTRODUCTION TO THE STUDY The Background of the Problem Statement of the Problem and Purpose of the Study Definition of Terms Assumptions Limitations Hypotheses Description of the Following Chapters 1 .1 3 5 6 6 8 9 CHAPTER II CHAPTER III CHAPTER IV THE LITERATURE REVIEW Conceptual.Definitions of Empathy Operational Definitions of Empathy The Development of Empathy Nursing and Empathy Summary RESEARCH METHODOLOGY Overview Hypotheses Assumptions Subjects The Predictor and Criterion Variables Instrumentation Data Collection and Rating Procedures Data Analysis Summary FINDINGS AND DISCUSSION Characteristics of the Sample Analyses of the Data in Relation to the Hypotheses Evaluation and Discussion of the Findings 10 10 12 19 28 35 38 38 38 39 39 42 44 47 51 52 54 54 55 59 iv TABLE OF COHTEMTS PAGE CHAPTER V SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS 64 Summary and Conclusions 6Discussion and Recommendations 65 Empathy training in nursing education 6Recommendations for research 8 REFERENCES 71 APPENDICES: A. RECRUITMENT LETTER 78 B. EMPATHIC UNDERSTANDING IN INTERPERSONAL PROCESSES RATING SCALE 80 C. DIRECTIONS AND SCRIPT FOR VIDEOTAPE OF PATIENT STIMULUS EXPRESSIONS .82 D. CONSENT FORM 86 E. BIOGRAPHICAL DATA SHEET 87 v LIST OF TABLES TABLE 1. Comparison of Reik's (1949), Keefe's (1976, 1979) and Barrett-Lennard's (1981) Conceptual Definitions of Empathy 13 Reliability and Validity Reports of Cognitive and Affective Measures of Empathy 17 10 Comparison of Communicative Empathy Instruments 20 Recruitment, Participation and Deletion of Subjects 42 Comparison of Scores on Two Orders of Patient Stimulus Expressions 46 Data Collection Schedule 47 Interrater Reliability on 100 Subject Responses Before and After Discussion 9 Comparison of Rater's Rating of No Training Subject -Responses 50 Means, Standard Deviations, and One-way Analysis of Variance of Characteristics of the Sample 55 Means, Standard Deviations, and Pearson Intercorrelations of Dependent and Independent Variables (N =54) 56 11. Hierarchical Multiple Regression Analysis on Empathy Scores of Nursing Students (N_ =54) 57 12. Comparison of Mean Empathy Scores for Training and No Training Groups (N = 54) 513. Distribution of Mean Empathy Scores for Training and No Training Groups (N_ = 54) 58 14. Comparison of Cognitive Development Scores of No Training and Training Groups 61 ACKNOWLEDGEMENTS I would like to express my appreciation to the following people: Dr. P. Arlin, Dr. B. Long, and Dr. R. Young for their constructive criticism and support. The subjects for their participation in the study. The Associate Dean of Nursing and the Nursing faculty of B.C.I.T. for their cooperation, support, and encouragement. Linda Barratt and Barbara Greenlaw for their inspiration, motivation, and sustenance. vii CHAPTER I INTRODUCTION TO THE STUDY The purpose of this study is to investigate the relationship of nursing students' cognitive development, their age, and an empathy skills program that they experience to the students' ability to communicate empathically with patients. Empathy involves the ability to take the role and perspective of another (Byrne, 1973; Selman & Byrne, 1974) and it is suggested that this ability increases as one achieves Inhelder and Piaget's (1958) cognitive developmental stage of formal operations. The finding that only 50 percent of adolescents and adults achieve formal operations (Neimark, 1975) raises a question about nursing students' cognitive prerequisites for the skill of empathizing. Contradictory findings have been reported in the literature about the effects of age and training programs on subjects' ability to communicate empathically (Mynatt, 1985). The Background of the Problem Nurses are expected to communicate effectively with patients. This includes communicating sensitively and empathically. Nursing educators recognize this expectation and include communication skills as an integral and important part of nursing curricula. Numerous communication skills training methods have been developed (Bullmer, 1972; Egan, 1976; Goldstein, 1973, 1981; Ivey & Authier, 1971; Truax & Carkhuff, 1967). These training programs all emphasize the central importance that empathy 1 has in effective interpersonal communication. Some of these training methods have been adopted in diploma and baccalaureate nursing programs. The faculty who teach the diploma nursing program at the British Columbia Institute of Technology (BCIT) have adopted the interactive skills training method of Egan (1976, 1982a, 1982b). It is a didactic-experiential training approach and was described by Goldstein and Michaels (1985) as follows: The essence of this approach is the simultaneous didactic instruction of trainees in a spectrum of interpersonal skills, while at the same time providing a group experience in which the newly learned skills may be experimented with — tried, provided with feedback, modified — in a semiprotective human context. The skills that are taught are derived from the Rogerian (1957) humanistic approach to the helping process and include empathy. Two levels of empathy are taught, the first is basic empathy, which is considered a basic response skill. The second level, advanced empathy, is called a challenging skill. In the BCIT diploma nursing program the didactic component of the skill training program is achieved through the use of independent instructional modules. The modules provide the students with information, explanations, examples, readings and exercises from Egan's (1982b) workbook. All of the skills in Egan's model, including the two levels of empathy, are dealt with this way. The students have small group sessions where discussion occurs and exercises are reviewed. The experiential component occurs in small groups where practice exercises are done using videotaped, collegial and instructor feedback. The students are also 2 expected to use appropriate interactive skills with patients during their clinical practica and to share these experiences with instructors and/or colleagues for feedback. The clinical practica occur primarily in medical, surgical, gerontological, psychiatric, obstetrical and pediatric units of hospitals. The interactive skills are only one component of the many nursing skills that students are expected to apply in their work with the patients to whom they are assigned. This training program is an integral part of the curriculum in each term of the 5-term, 21-month nursing program. The majority of faculty in the nursing department undertook 36 hours of the same skills training with a faculty member from the Department of Counselling Psychology at the University of British Columbia. Although Durlak (1979) has made clear the relative unimportance of level of credentials for interpersonal skills and especially empathy trainers, it is noteworthy that the BCIT nursing faculty are knowledgeable and at least minimally experienced in the Egan skills training method. The faculty training was done in order to enhance the effectiveness and consistency of the implementation of the skills training model in the program. Statement of the Problem and Purpose of the Study An improvement in students' interpersonal effectiveness has been observed informally by the nursing faculty since the implementation of the skills training program in 1985. It is recognized that a systematically-sequenced, comprehensive approach using various teaching/learning techniques is more effective than the less formal and less theoretically 3 based approach that preceded it. However, a concern about the training has become apparent. It has' been noted by the investigator that some skills apparently are understood and mastered by students more consistently and more easily than other skills are. Empathy falls into the latter category. In assessing individual students through discussions with them, from review of written exercises and videotaped interactive sessions and role-plays, and from transcribed interactions with patients, it is apparent that some students achieve a satisfactory level of understanding and communication of the other skills, but not of empathy. The investigator has attempted to understand this problem through discussion with students and instructors and by analyzing transcribed and live interactions. It appears that students' unsuccessful attempts at empathic responses are similar to what Chandler and Greenspan (1972) called a process of projection and a process of stereotyped knowledge. Projection occurs when the student has an affective response to the patient's experience and attributes his or her own affect to the patient. In projection, the student fails first to withdraw from subjective involvement and second, to use the methods of reason and scrutiny. A complicating factor in this process is that sometimes the student's affect and the patient's affect correspond and, through feedback from the patient, the student believes he or she has been empathic. In the case of stereotyped knowledge, the mistake that is made is that the student responds on the basis of his or her knowledge about people in general. Assuming that a woman is sad about the death of her mother because that is a commonly experienced emotion is an example of 4 stereotyped knowledge. Its occurrence implies a lack of individualized attention and objectivity toward the person with whom one is interacting. Borke (1972), in her response to Chandler and Greenspan, said that the processes of projection and stereotyped knowledge were a preliminary form of empathy. Although these three investigators were referring to children's responses, and nursing students' responses are certainly more complex than those of children, the processes of projection and stereotyped knowledge are apparent in the students' interactions with patients and discussions about patients. It is suggested here that a factor that may account for some students' use of projection and stereotyped knowledge instead of empathy, in spite of their having received empathy training, is a general lack of intellectual maturity as reflected in their age and more specifically in their level of cognitive development. The purpose of this study is to investigate the predictive relationship of the variables of age, empathy skill training and cognitive developmental level to BCIT diploma nursing students' ability to communicate empathically with patients. Definition of Terms The terms to be used in this study are as follows: Empathy: Empathy is a' multidimensional process including perceptual/affective, cognitive and communicative components. The focus of this study is the cognitive component, which is the ability to objectively take the role and perspective of another. Conceptual and operational definitions of empathy are reviewed in Chapter II. 5 Level of Cognitive Development: The theoretical framework of this study is Piaget's theory of cognitive development which describes four stages in intellectual growth, culminating in hypothetico-deductive reasoning. Each stage or level comprises specific cognitive operations that one uses to solve problems and understand the world. Interactive Skills Training: Comprehensive, theoretically-based, systematically-sequenced and usually time-limited training methods or programs designed to enhance the interactive effectiveness of professional helpers (counsellors, social workers, nurses, teachers) and lay people in general (parents, adolescents). Assumptions The following basic assumptions underlie this study. 1. Empathic communication is essential to effective nursing care and to the nurse-patient relationship. 2. Empathic communication can be learned through systematic training methods. Limitations The limitations of this study relate to the small population and sample size, the instrumentation, and the methodology. The study group was restricted to BCIT diploma nursing students in order to maintain the homogeneity of the subjects with regard to the program curriculum in general and the empathy skills training program specifically. Other criteria that were held constant by restricting the 6 study to BCIT were the applicant selection criteria (admission prerequisites) and the subjects' exposure to different faculty. The subjects participated in the study on a voluntary basis, hence the sample was not truly representative of the population. Rosenthal and Rosnow (1975) have identified a number of characteristics of volunteers, some of which may be relevant to the dependent variable of this study, that is, empathic communication. Volunteers are thought to be higher in need for social approval, more sociable, more unconventional and less authoritarian than non-volunteers. These characteristics reflect two of the four factors that emerged from a factor analysis of Hogan's 1969 Empathy Scale, namely Social Self-Confidence and Nonconformity (Johnson, Cheek, & Smither, 1983). The independent variables of this study, namely age and cognitive development are also reflected in the characteristics of volunteers. Female volunteers for laboratory research tend to be younger than non-volunteers. As well volunteers tend to be better educated and more intelligent, two characteristics that might have a positive effect on the variable of cognitive development. All these characteristics, except for the one related to age, are ones that Rosenthal and Rosnow (1975) categorized at the maximum and considerable confidence levels. Perhaps, then, those who volunteered in this study were more empathic, had higher cognitive development levels, and were younger than their counterpart non-volunteers. Generalizations therefore, are limited to the volunteers. The results of the study are limited by the sensitivity of the psychological measuring instruments to reflect actual differences in subjects' cognitive development and their ability to communicate empathically. As well, it is recognized that the empathy scores of the 7 subjects who have received empathy training may have been affected by the consistency of the content, delivery method and teacher competence during the training program. The methodology used in this study presented limitations. One such limitation was the fact that, due to the time frames of the curriculum and this study, it was not possible to obtain a measure of the criterion variable, empathic communication, on the Training group prior to their experiencing the training. That is, initial differences on the criterion variable, between the Training and No Training groups were not known. Finally, the protracted length of the empathy skills training presented a limitation. It takes approximately one calendar year from the time students begin to learn about empathy until they have completed the section on advanced empathy. It is reasonable that variables other than the predictor variables of this study could have had an effect on the criterion variable, empathic communication, in the Training group subj ects. Hypotheses 1. There will be a significant linear relationship between the predictor variables of nursing students' level of cognitive development, their age, and training or no training.in interactive skills and the criterion variable of empathic interaction. 2. Subjects with more years of post-secondary education will show greater empathic interaction ability when compared to subjects with fewer years of post-secondary education. 8 3. Subjects with the cognitive ability to coordinate multiple frames of reference will show greater empathic interaction ability when compared to subjects without the cognitive ability to coordinate multiple frames of reference. Description of the Following Chapters A review of selected, relevant literature is presented in Chapter II under the following headings: Conceptual Definitions of Empathy; Operational Definitions of Empathy; The Development of Empathy; Nursing and Empathy. The research methodology is described in Chapter III. It involves the measurement and analysis of the four variables under question. Chapter IV presents the findings and Chapter V is a discussion of the findings and the conclusions. The Appendix contains forms and information related to the measuring instruments. 9 CHAPTER II LITERATURE REVIEW The relationship most central to the practice of nursing, as described in conceptual models of nursing, is the relationship between the nurse and the patient (Flaskerud & Halloran, 1980; Riehl & Roy, 1980). The importance of this relationship is evident in ethical codes and practice standards developed by professional nursing associations (Canadian Nurses Association, 1985; Registered Nurses Association of British Columbia, 1984). Nurse educators, striving to help students and new graduates to meet these standards, include interactive skills as a component of the nursing curriculum. The ability to demonstrate empathy is one skill that is part of that component. This review will focus on the construct of empathy. Both the conceptual and operational definitions of empathy will be reviewed. The section on the development of empathy will emphasize the cognitive aspect of the construct in different age groups. The review will then focus on nursing and how knowledge of the construct of empathy has been applied and investigated in the field of nursing. Conceptual Definitions of Empathy The construct of empathy is a subject of interest to various disciplines within the behavioural sciences and to professional groups such as nurses, social workers, teachers and counsellors. It is apparent from the literature that empathy - evidence for its existence, its determinants and its effects - is not a precise or simple construct. 10 Several reviews of the construct of empathy have been undertaken (Buchheimer, 1963; Deutsch & Madle, 1975; Katz, 1963; Lichtenberg, Bornstein, & Silver, 1984; Smither, 1977). Recently, Goldstein and Michaels (1985) reviewed historical and contemporary definitions of empathy from a conceptual as well as an operational point of view. Their review of diverse fields of inquiry - aesthetics, sociology and psychology - led them to a multidimensional, comprehensive, conceptual description of this elusive construct. The perceptual and affective components of empathy were first described by Lipps in 1897. He coined the term "Einfuhlung" to mean "feeling oneself into," which was later translated by Tichener as empathy (Goldstein & Michaels, 1985). Lipps initially used the term in relation to the perception, contemplation and affective appreciation of an object, but later extended the meaning to include people. "Empathy proceeded by means of projection and imitation [motor mimicry], could involve both objects or persons as targets, and consisted largely of heightened understanding of the other through cue-produced shared feelings" (Goldstein & Michaels, p. 4). The cognitive component of empathy was introduced in the work of Mead (1934). He added, to the perceptual and affective components, the ability to understand the other through the process of role taking or perspective taking. This component of empathy is the focus of this study and will be expanded upon in the section on the development of empathy. The last component of empathy, the ability to accurately and sensitively communicate one's perceptual, affective and cognitive empathy to another, has received most attention from those involved in 11 psychotherapy and other interpersonal helping professions, teaching, nursing, counselling and social work (Carkhuff, 1969; Egan, 1976; Ivey & Authier, 1978; Rogers, 1975; Truax & Carkhuff, 1967). This component provides interpersonal evidence of the other three. Reik (1949), Keefe (1976, 1979) and Barrett-Lennard (1981) have proposed various phase conceptions of empathy. They are presented in Table 1. All three definitions include perceptual, affective and cognitive components and Keefe (1976, 1979) and Barrett-Lennard (1981) include the communicative component. Although similarities and differences are apparent, the essential point is that empathy is not a simple or precise construct, but rather a complex process. This multiple phase conception of empathy is endorsed by Goldstein and Michaels (1985) as a comprehensive conceptual definition of empathy. A discussion and review of literature related to operational definitions of empathy follows. Operational Definitions of Empathy Reviews of operational definitions of empathy, evidenced in measurement instruments, reveal that they are often something less than the comprehensive conceptual definition (Barrett-Lennard, 1981; Chlopan, McCain, Carbonnell, & Hagen, 1985; Davis, 1983; Deutsch & Madle, 1975; Feldstein & Gladstein, 1980; Gladstein, 1977; Kurtz & Grummon, 1972). Harman (1986) wrote: 12 TABLE 1 Comparison of Reik's (1949), Keefe's (1976, 1979) and Barrett-Leonard's (1981) Conceptual Definitions of Empathy Reik Keefe Barrett-Lennard 1. Identification: Absorption in contemplating the other person and his experiences. Perception of the feeling state and thoughts of the other by means of the other's overt behavioural cues (both verbal and non verbal). Empathic attentional set: Openness to the psychological life of the other. 2. Incorporation: Taking the experience of the other person into oneself by introjection. Reverberation: The echoing of the other's experience upon some part of one's own experience. A direct feeling response, an "as-if" experiencing of the other's affective world. Empathic resonation: The other's directly or indirectly conveyed experience becomes experientially alive, vivid and known to one. 3. Detachment: Withdrawal from subjective involvement in order to gain social and psychic distance. Objective analysis through reason and scrutiny. Separating one's own feelings from those perceived and experienced "as-if" the other. 4. Communicating accurate Expressed empathy: feedback to the other. Communication of a quality of felt awareness of the other's experience to the other. Received empathy: The other's perception of the degree of one's understanding of him. 13 That researchers have found little relation among different tests of empathy, as Gladstein (1985) recently observed, is understandable in view of Barrett-Lennard's (1981) assertion that the measures assess different stages of a process, and therefore would not be expected to be highly correlated, (p. 371) Not only is there little relationship amongst the different measures, but there is also evidence which questions the reliability and validity of individual instruments. Various classifications of measurement instruments have been proposed. Deutsch and Madle (1975), as well as Goldstein and Michaels (1985), used the terms "predictive" and "situational" to classify them. Kurtz and Grummon (1972) described two additional approaches, tape-judged ratings and perceived empathy ratings. These latter were called, respectively, "objective" and "subjective" by Feldstein and Gladstein (1980) in their comparison of measures of empathy. Another group of instruments are those that measure empathy as a personality process or trait (Hogan, 1969; Davis, 1983; Mehrabian & Epstein, 1972). The measures will be reviewed briefly according to the components of the conceptual definition, that is, the cognitive, perceptual/affective and communicative processes. Cognitive measures. The cognitive component is approached with predictive measures and with some personality tests. Predictive measures are those in which the subject's accuracy in predicting the self-rating or preferences of another is taken as a measure of the subject's empathy (Deutsch & Madle, 1975). This approach has very limited use in current empathy research owing to methodological problems identified by Cronbach 14 (1955). Deutsch and Madle (1975) also have described problems with the reliability and validity of such measures. The personality tests which measure empathy as a cognitive process are those focused on the subject's role taking ability, such as the Hogan Empathy Scale (Hogan, 1969). The reliability and validity of the instrument have been demonstrated in several studies and reviewed by Johnson, Cheek, and Smither (1983) and Chlopan et al. (1985). Johnson et al. (1983) factor-analyzed the scale and identified four factors — social self-confidence, even-temperedness, sensitivity and nonconformity — that are related to the construct of empathy. Perceptual/affective measures. The affective component of empathy is approached with situational measures and also with some personality tests. Situational measures require that the subject's empathic response be to a person's affect, situation, or both. The subject is required to correctly label the contextual stimuli and/or affective response portrayed. Several test stimuli have been used and are described by Goldstein and Michaels (1985), who state that these measures draw upon both the affective component and also the cognitive analysis component of the conceptual definition of empathy. One such measure that is used in current empathy research is Kagan's Affective Sensitivity Test (Kagan & Krathwohl, 1967). Deutsch and Madle (1975) report that although its reliability is acceptable, its convergent and discriminant validity is not. There is no relationship between Affective Sensitivity Test scores and communicative skill. The affective component of empathy is also measured by personality tests such as the Questionnaire Measure of Emotional Empathy (QMEE, Mehrabian & Epstein, 1972). This measures the subject's ability to vicariously experience the feelings of another. Chlopan et al. (1985) have discussed the reliability and validity of this measure, found them to be satisfactory, and have suggested that the QMEE combined with the Hogan Empathy Scale provides a basis for the measurement of empathy from a cognitive and perceptual/affective point of view. This combined point of view has been promoted by Davis (1983), who developed the Interpersonal Reactivity Index (IRI). He suggested: Rather than treating empathy as a single unipolar construct (i.e., as either cognitive or emotional), the rationale underlying the IRI is that empathy can best be considered as a set of constructs, related in that they all concern responsivity to others but are also clearly discriminable from each other, (p. 113) The IRI consists of four subscales — Perspective-taking (PT), Fantasy (F), Empathic Concern (EC) and Personal Distress (PD) — and Davis states that "as disparate as these four constructs may appear, they accurately reflect the variety of reactions to others that have at some time been referred to as empathy" (p. 114). Davis reported validity tests of the IRI and concluded that the results support a multidimensional view of empathy. The foregoing instruments are outlined in Table 2. 16 TABLE 2 Reliability and Validity Reports of Cognitive and Affective Measures of Empathy Reliability Validity Reference Cognitive - Predictive Scale for the measurement of empathic ability (Dymond, 1949) No No Cronbach (1955) The Empathy Test (Kerr & Speroff, 1954) No No Deutsch & Madle (1975) Personality Empathy Scale (Hogan, 1969) Yes Yes Johnson, Cheek, & Smither (1983); Chlopan, McCain, Carbonell, & Hagen (1985) Affective Situational Affective Sensitivity Test (Kagan, Krathwohl, & Associates, 1967) Yes No Deutsch & Madle (1975) Personality Questionnaire Measure of Emotional Empathy (Mehrabian & Epstein, 1972) Yes Yes Chlopan, McCain, Carbonell, & Hagen (1985) Cognitive/Affective Personality Interpersonal Reactivity Index (Davis, 1983) Yes Yes Davis (1983) 17 Communicative measures. Instruments that measure the communicative aspects of empathy, that is, one's ability to accurately and sensitively communicate one's perceptual, affective and cognitive empathy to another, are the last to be reviewed here. These instruments are referred to as tape-judged (objective) and perceived (subjective) empathy ratings. Feldstein and Gladstein (1980) analyzed four such empathy measures, two objective and two subjective, according to six criteria based on Rogers' (1975) theoretical formulations, in order to determine the construct validity of the measures. The objective instruments were the Truax Accurate Empathy Scale (AES, Truax & Carkhuff, 1967) and Carkhuff's Empathic Understanding in Interpersonal Process Scale (EUS, Carkhuff, 1969). The subjective instruments were the Barrett-Lennard Relationship Inventory (BLRI, Barrett-Lennard, 1962) and the Truax Relationship Inventory (TRI, Truax & Carkhuff, 1967). Feldstein and Gladstein (1980) showed that all four measures failed to meet the same two criteria and thus had limited construct validity. The first criterion not met by the instruments is Affective Empathy, "the aesthetic state of unconscious emotional imitation and identification of counsellors with clients. It involves an internal and unobservable activation of the counsellor's feelings and fantasies" (Feldstein & Gladstein, 1980, p. 50). The authors state that the instruments "only hint at the aesthetic experience of the helper" (p. 51). However, the more serious failure of the instruments relates to their inability to rate helpers on their communication of "not only their understanding of clients' words but also all the non-verbal aspects that accompany these 18 words" (p. 50). This criticism is consistent with previous critiques by Chinsky and Rappaport (1970) and Rappaport and Chinsky (1972). Feldstein and Gladstein conclude that the instruments hold promise as measures of empathy in response to clients' verbalizations only. They are summarized in Table 3. It is suggested here that measurement of empathy is far from precise and accurate and that Gladstein's recommendation to specify "which type of empathy is being measured by which specific type of instrument" (1977, p. 77) be followed. Other recommendations (Feldstein & Gladstein, 1980) regarding instruments are that their limitations be considered and that several instruments may be used to tap the empathic dimensions under study. Carkhuff's Empathic Understanding in Interpersonal Process Scale was used in this study because the investigator considered it to be the best of the measures of communicative empathy. To overcome the weakness in Carkhuff's instrument of having helpers responding to only the clients' words and not their non-verbal communication, the investigator developed videotapes of client stimulus expressions to which the subjects in this study responded. The instrument is fully described in Chapter III. The Development of Empathy Goldstein and Michaels (1985) stated: Training in empathy during adulthood probably must build on a set of naturally developing abilities that begin in childhood and that continue to emerge across the life-span. (p. 61) 19 TABLE 3 Comparison off Conurumicative Empathy Instruments Empathy Criteria (Rogers, 1975) Objective AES EUS Subjective BLRI TRI Cognitive empathy; empathic understanding; role taking skill. Yes Yes Yes Yes Affective empathy; unconscious emotional imitation and identification with clients. No No No No The temporary suspension of one's belief system. Empathy as a process; moment to moment sensitivity to the other; continually evolving behaviour. Yes Yes Yes Yes Yes Yes No No The communication of an empathic experience; communication of an understanding of clients' words and the non-verbal aspects accompanying the words; flexibility in altering and checking their statements. No No No No Additive empathy; the sensing of meanings of which the client is scarcely aware or has chosen not to express. Yes Yes No Yes AES: Accurate Empathy Scale, Truax & Carkhuff (1967). EUS: Empathic Understanding in Interpersonal Processes Scale, Carkhuff (1969). BLRI: Barrett-Lennard Relationship Inventory, Barrett-Lennard (1962). TRI: Truax Relationship Inventory, Truax & Carkhuff (1967). 20 This statement underscores the importance of a developmental process in empathy. The two dimensions of empathy which have received the most attention in the child development literature are the cognitive and affective dimensions. Perception, communication and socialization have also been studied as important in the development of empathy. This review will focus on cognitive development, as it is the dimension most relevant to this study. Both Martin Hoffman (1976, 1977, 1982) and Norma Feshbach (1975, 1978) have proposed multidimensional models of empathy development in children which, though primarily affective, have important cognitive elements. Hoffman has identified empathic distress as the major mediator of prosocial and altruistic behaviour and has described six different modes through which the vicarious affective response is aroused. These modes follow a developmental progression and are dependent, in part, on cognitive processing, in particular the child's ability to differentiate self from others (Goldstein & Michaels, 1985). Some of the cognitive accomplishments which Hoffman sees as significant in self-other differentiation are person permanence in the physical, cognitive and affective realms, role taking, language development, and an appreciation and comprehension of the concept of time and history. Feshbach's model is concerned with the development of a much wider range of empathic experiences in children than Hoffman's narrower focus on empathic distress only. The cognitive components which Feshbach describes as precursors to the child's emotional responsiveness to the experience of the other are, first, the ability to discriminate the emotional state of another and, second, the ability to assume the perspective and role of the 21 other. These two abilities are basic to the broader field of social cognition and have been described at length by theorists and investigators who propose a cognitive theory of empathy development. The cognitive developmental concepts central to empathy development are decentration, role and perspective taking in general, and role and perspective taking specifically in the affective realm. Egocentrism is a state of fusion or undifferentiation between the self and other people which is resolved or reversed progressively through specific cognitive developmental stages. This is decentration and it is the decentration during Piaget's formal operational stage of adolescence and young adulthood that is of most significance to this study. A more detailed discussion of this will follow shortly. Schantz (1983) has stated that non-egocentric reasoning is a prerequisite for role taking as opposed to being the same as role taking. After one is able to see that others may think and feel differently from oneself, the inferential process of role or perspective taking can be used to determine what those differences actually are. It is a sequential process. Flavell (Flavell, Botkin, Fry, Wright, & Jarvis, 1968) has proposed a five-step information processing model of role taking. Selman (1980), on the other hand, has proposed a model more in the Piagetian tradition. "It describes a series of five cognitive advances in the self's understanding and coordination of its own relationship to others" (Goldstein & Michaels, 1985). It is important to emphasize that the role-taking models referred to have been developed to address social cognition in several areas. In 22 order to understand the cognitive component of empathy, one must examine perspective taking in the affective realm specifically. In the early 1970's Helen Borke (1971, 1972), Michael Chandler and Stephen Greenspan (1972) engaged in a seminal debate regarding role and perspective taking in the affective realm. Borke's (1971) research showed that children as young as 3 years old were aware of others' feelings, thus challenging Piaget's belief that egocentrism in children younger than 7 years old precludes empathic awareness. Chandler and Greenspan (1972) argued against Borke's conclusion and said what Borke called empathy in her subjects was in reality a form of projection or stereotyped knowledge. Borke (1972), in her rebuttal, incorporated Chandler and Greenspan's criticism into her hypothesis and stated that young children may use projection and stereotyped knowledge in order to understand others' feelings and that this is a preliminary form of empathy. This debate led other investigators into a microanalysis and description of the process of role and perspective taking. Gove and Keating (1979) conducted research on perspective taking with two age groups, 3 years 10 months and 5 years 2 months, using two types of stories, one in which the emotionally relevant clues were evident in the situation and the other in which psychological inference about the subjects is required to correctly identify the emotions. Goldstein and Michaels (1985) summarized Gove and Keating's (1979) conclusions: in terms of developmental progression, emotions are considered to be a part of the situation itself, with role taking consisting of simply reading off the affective aspect of the event. Later on when children understand that feelings are psychological events or 23 processes they become focused more on the internal state of the particular stimulus person, and role taking becomes the traditional perspective taking described in the developmental research, (p. 25) The development of formal operations further differentiates this ability and enables the adolescent and young adult to focus on increasing complexities and subtleties of the internal state of the stimulus person. Another microanalysis of the stage-like development of perspective taking was undertaken by Urburg and Docherty (1976). They differentiated between the structure and content of particular role taking tasks. Structure they defined as the cognitive operations necessary to perform the tasks, such as the number of aspects of a problem to be considered and whether they can be considered sequentially or simultaneously. Content was defined as the particular content that the cognitive operations work on to produce a solution. They, like Gove and Keating (1979), designed a series of role taking tasks for 3, 4 and 5 year old children. The tasks differed in the complexity of the structural component, the primary focus of the study, while the affective content was kept simple and consistent. Based on their results, Urburg and Docherty (1976) suggested: it is possible to define close to an infinite number of developmental sequences of role taking skills...Rather than considering role taking as a global, unidimensional ability, the variables that are known or hypothesized to affect the role taking process should be examined to determine the developmental course of each as well as the interactions between them. (p. 203) This suggestion related to the complexity of cognitive development of children in Piaget's preoperational stage is applicable in discussion 24 of formal operations and the eventual emergence of less egocentric thought in adolescence and young adulthood. Theoretically, the development of formal operations results in a marked decline in egocentrism and consequently an increase in perspective taking. This is oversimplistic, as a review of the formal operations literature shows. Inhelder and Piaget (1958) identified eight concepts associated with the stage of formal operations which are called the eight formal operational schemata. They are defined as "the concepts which the subject potentially can organize from the beginning of the formal level when faced with certain kinds of data, but which are not manifest outside these conditions" (p. 308). Inhelder and Piaget explain "how a tendency toward equilibrium or its results can lead the subject to organize a formal combinatorial system" (p. 281). They describe the process of transition, what occurs and in what order. According to Elkind (1967) it is this tendency to equilibrium that leads the adolescent into a new form of egocentrism. The adolescent's "conquest of thought" (p. 438) allows him or her to construct all the possibilities in a system and construct contrary to fact propositions (Inhelder & Piaget, 1958 in Elkind, 1967), to conceptualize his or her own thought and to conceptualize the thought of other people. This latter is, according to Elkind, the crux of adolescent egocentrism. The adolescent "fails to differentiate between the objects toward which the thoughts of others are directed and those which are the focus of his own concern" (p. 438). This egocentrism and the consequent impairment of the ability to role take is most evident in early adolescence and is gradually overcome through the development of formal operations. 25 Arlin (1981a, 1981b, 1984a) clarifies the oversimplistic view that the development of formal operations results in a decline in egocentrism and consequently an increase in role and perspective taking by differentiating between competence and performance with respect to the formal schemata. She described three variables that affect the integration of competence and performance. The first variable is the phase-like manner in the integration of competence and performance. The second variable is the possibility of a time lag of approximately five to seven years with respect to the development of both competence and performance of the formal schemata. The third variable relates to "Piaget's (1953-54) insistence on the simultaneity of construction of the eight schemata" (Arlin, 1981b, p. 5). Arlin states that no simultaneity has been identified and she concurs that performance may well require the coordination of actions with appropriate experience (Kuhn, Ho, & Adams, 1979). So, although the resolution of adolescent egocentrism leads to an enhanced ability to take the role and perspective of another and this is accomplished through the acquisition of formal operations, it is evident that formal operations are not a unitary concept and the integration of performance and competence is subject to numerous complex variables. This complexity is a reflection of the complexity identified by Urburg and Docherty (1976) in preoperational children, referred to earlier in this review. Examination of the variables affecting the acquisition of the formal schemata leads to an appreciation of the adolescent's ability to role and perspective take and consequently his or her ability to be empathic. The' schema that reflects the concept of empathy most clearly is the 26 coordination of two or more systems of reference. The empathizer in an interpersonal situation must be affectively identified with another's frame of reference while simultaneously being cognizant of his or her own frame of reference. Because of the ongoing, process nature of interaction these two frames of reference must be in the empathizer's awareness even as they may change moment to moment. This schema is one of the last to develop (Arlin, 1981b, 1984a; Neimark, 1975), appearing late in adolescence, and is thought to be a necessary but not sufficient condition for role taking (Byrne, 1973; Selman & Byrne, 1974). There is evidence for this in other areas as well. Studies that look at such cognitive characteristics as cognitive complexity (Holloway & Walleat, 1980), tolerance for ambiguity (Jones, 1974) and conceptual level (Goldberg, 1974; Harvey, Hunt, & Schroder, 1961) indicate that "more cognitively complex, open-minded trainees usually demonstrate greater skill mastery than less cognitively complex, more dogmatic trainees" (Lutwak & Hennessy, 1981, p. 257). Given the late emergence of the eighth schema and the time lag between competence and performance, it might be evident as early as 17 in a precocious adolescent and as late as 21 in a "late bloomer." This might be so, only given the assumption that the adolescent, in the words of Inhelder and Piaget (1958), "is faced with certain kinds of data" (p. 308). Arlin views this formal schema as an advanced cognitive concept and suggests, "It may be the pivotal concept that marks the transition between adolescent and adult thought structures" (1981B, p. 7). She suggests that it is what moves the adolescent from a hypothetico-deductive logical system into a relativistic logical system. 27 Arlin's proposition regarding the eighth formal schema is seminal in adult cognitive research. It must, however, be juxtaposed with another observation and that is that only approximately 50% of the adult population ever attains the Piagetian state of formal operational thinking (Neimark, 1975). As important as the coordination of two or more frames of reference is for role and perspective taking, and hence the cognitive component of empathy, that ability is not well developed in many people. Nursing and Empathy Nursing theorists have described nursing as a humanistic discipline (King, 1981; Orem, 1971; Rogers, 1970; Roy, 1974; Travelbee, 1966). Central to humanism is the construct of empathy. "Nursing is consistently described as an empathic and compassionate interpersonal process that supports dependent needs of patients and promotes independence" (Fenton, 1986, p. 83). In spite of this agreement, from a theoretical point of view and in spite of Forsythe's (1979, p. 53) suggestion that empathy, as it relates to nursing, "should be subjected to the systematic scientific process of description, explanation, prediction and control," the nursing literature reveals a less than comprehensive research tradition. Nursing research regarding empathy has been derived from the humanistic theoretical framework of Carl Rogers (1957, 1961). It has focused primarily on three aspects, the first being the description of empathic communication skills in nurses. The second area of interest has been in empathy skill training programs. The third area of investigation has looked at the relationship of empathy to demographic variables. 28 1. Mansfield (1973) conducted a study to identify verbal and non verbal behaviours that facilitated empathic communication on initial interactions between an experienced psychiatric nurse and a psychiatric patient. Seven behaviours that conveyed high levels of empathy to the patients were identified. The behaviour categories were: introduction to the patient, head and body positions, verbal behaviour, response to nonverbal cues, facial expressions, voice tones, and mirror images. The applicability of the study is minimal because it was limited to one nurse interacting with six patients. Verbal and vocal communicative behaviours and their relationship to patient-perceived levels of empathy were studied by Stetler (1977). The results indicated that the verbal and vocal behaviours defined in the study were not the critical factors in the patients' perceptions of empathy. In fact, there was no difference between patient-perceived high empathizers and low empathizers on both positive and negative communicative behaviours. 2. Several studies have investigated the effects of empathy skill training on empathy scores (Clay, 1984; Hrubetz, 1975; Kalisch, 1971; Karshmer & La Monica, 1976; Larabee, 1980; Law, 1978; Zimmerman, 1980). Two assumptions that underlie these studies are first that empathy can be learned and second that virtually any nurse can learn it. No attention is given to the fact that there might be individual differences in skill acquisition. All of the studies support the idea that empathy skill training is positively related to increased scores on various standard empathy rating scales. However, the scales themselves, as discussed 29 earlier, have questionable reliability and validity and consequently so do the findings. Clay (1984), in developing an instrument to use to both teach and assess empathic interaction of nursing students, recognized and incorporated the complex and hierarchical nature of the construct. She described a hierarchical model of the behavioural components of an empathic nurse-patient interaction which reflects the perceptual, cognitive and communicative phases of empathy described by Keefe (1979), Reik (1949) and Barrett-Lennard (1981) and outlined earlier. Each category of Clay's model is accompanied by a behavioural list of nursing actions that give evidence of the category. The schedule and guidelines were developed from videotaped and live nurse-patient interactions in a variety of clinical practice settings. Their content and criterion-related validity were found to be satisfactory in videotaped and live nurse-patient interactions. Larabee (1980) also recognized the complex nature of empathy. In a pre-test, post-test research design he used three instruments to measure three different aspects of empathy — the emotional, the cognitive and the behavioural aspects. Results showed significant increases in the first two and no difference in the latter following the treatment. The treatment in this study was remarkably different from the treatments in the other studies. It was essentially a semi-structured verbal interaction group experience, in which the theme of empathy and the research purpose were disguised to prevent biased responses to the questionnaires. The treatment in the other studies was overtly empathy skill training. 30 3. Correlational studies of empathy and demographic variables comprise the third area to be reviewed. Collins (1972) found no significant relationship between dogmatism and empathy as measured by the Barrett-Lennard Relationship Inventory, in 198 baccalaureate nursing students, however, she did report a significant difference between empathy scores of sophomore and senior students which influenced further investigation. Howard (1975) found no significant difference between empathy as measured by the Carkhuff Index of Communication (Carkhuff, 1969) in sophomore, junior and senior students in one nursing school. Turning to nurse practitioners, that is, staff nurses and head nurses in various medical specialty areas, Forsythe (1979) investigated the relationships between empathy scores as measured by the Hogan Empathy Test and various demographics. Increasingly higher education (diploma, associate degree or degree) correlated positively with empathy scores and also, had statistically significant predictive properties, as did length of practice. The last correlational study to be reviewed looked at empathic ability and educational progress of nursing students. Rogers (1986, p. 338) reported that "Educational progression was not associated with significant increases in the ratings of sophomores, juniors and seniors on the ECRS [La Monica, 1981] self-report and patient rating." The results prompted her to reiterate questions raised by La Monica (1981): Do baccalaureate programs fail to teach empathy effectively or do instruments fail to measure the construct? As described, all the correlational studies used different measures of empathy (Barrett-Lennard Relationship Inventory, Carkhuff Index of 31 Communication, Hogan Empathy Scale), hence it is difficult to compare the studies or to reconcile the conflicting results. The two studies using tape-judged objective measures reported similar results, that is, no significant difference between empathy scores and educational progress. The review of the literature on nursing and empathy reveals many conceptual and methodological problems and it is suggested that they are the result of a lack of fit or articulation of psychological and communication theories to the theory and practice of nursing. Kasch (1984, p. 73) has stated that although nursing theories make implicit assumptions about the nature of communication "little attention [has been] directed toward exploring the interface between communication and the delivery of nursing care." Kasch describes three conceptual frameworks that have influenced theory construction in nursing. She points out how two of them have failed to develop and articulate the relationship between communication and nursing and how the third might provide a realistic alternative. 1. The developmental models of nursing have been influenced by the therapeutic perspective which "encourages a style of communication that is not easily actualized in many nurse-patient interactions" (Kasch, 1984, p. 74). The therapeutic or counselling paradigm "tends to ignore the constraints on communication in the health care context and the intense commitment to task activity that characterizes the delivery of nursing care" (Kasch, 1984, p. 74). Gagan (1983) also made this point when she called for a "study to determine the precise nature and characteristics of the empathic process within the confines of the nurse-hospitalized patient relationship" (p. 71). This point is relevant to Mansfield's (1973) and - 32 Stetler's (1977) studies described earlier. In both, the health care context was not normative because of the nurse, the patients or the setting. In both studies there were no constraints on communication that are typical in nurse-patient interactions. Although acknowledging the importance of a helping nurse-patient relationship, Kasch (1984) states that the developmental and psychotherapeutic perspective places an excessive emphasis on the relational dimension — this includes empathy — of communication. In his literature reviews on empathy and counselling outcome, Gladstein (1970, 1977) made a distinction between psychotherapy and counselling, concluding that in educational/vocational counselling and other non-psychotherapy processes such as dealing with a developmental task, the need for a highly empathic approach is less. It is suggested here that nursing is, for the most part, a non-psychotherapeutic process. Of the empathy skill training studies reviewed, Clay's (1984) is the most applicable to nursing because it was developed in the context of nursing practice. 2. Systems theory applications in nursing are seen by Kasch as not having "contributed much to understanding caregiver-patient interactions in the delivery of nursing care" (p. 75). Some criticisms are that a systems model tends to subordinate the individual to the demands of the system; systems concepts are not easily subjected to concrete, empirical investigation; and the systems perspective does riot provide a foundation for understanding individual differences in communicative functioning. 3. Kasch (1984) has identified an interpersonal competence perspective as a link between nursing and communication and.states that it is consistent with the interactionist model of nursing in which "the 33 nursing process essentially involves interpreting the meaning of patient actions and indicating or defining for the patient appropriate actions necessary to achieve an optimal level of wellness" (p. 73). Interpersonal competence is comprised of social, cognitive, behavioural, and cultural resources of communication that enable the nurse to use the nursing process in this way. It is broader than the psychotherapeutic model in that it focuses on more than the helper-helpee relationship. It focuses on development of the above resources of communication in order to facilitate the ability to anticipate, control and flexibly adapt to the demands of the social environment (Kasch, 1984). Social cognitive competence is the component of Kasch's model that is of interest to this study. Kasch's (1984) description of social cognitive competence is consistent with the cognitive developmental view of perspective taking and decentration discussed earlier and as such is related to the cognitive aspect of empathy. A nurse who possesses such a competence has an expanded "range of alternatives or options available for constructing strategic messages and adapting communication to the specific needs of a particular patient" (p. 79). Two questions for nursing arise from this interest in social cognitive competence and subsequent empathy. Who has it and how can it be developed? Instead of asking, as La Monica (1981) did, "do baccalaureate programs fail to teach empathy effectively?" we can ask, "To what degree do the cognitive constraints evident in adolescents and young adults inhibit or impede the development of empathic interactive skills in nursing students?" As was seen in the review of studies of empathy training programs, the assumptions that empathy can be learned and that 34 anyone, regardless of their social cognitive development, can learn it, are prevalent. Kasch (1984) does not agree with these assumptions and recommends research into individual differences in people's capacity to interpret and understand the viewpoint of another. The inconsistent and conflicting results of those studies that sought to find relationships between empathy and various demographic variables might be more fruitful if the independent variable was social cognitive development. Goldstein and Michaels (1985, p. 31) support this. "Understanding the development of higher forms of cognitive empathy may be important for the selection of people for professional training in psycho-therapy education and other professions that call for advanced interpersonal sensitivity." SwjHQcUry It is clear from the literature that empathy is not a simple, one-dimensional construct, but rather a complex, multi-faceted process. It has perceptual/affective, cognitive and communicative components. The complexity of the construct has not always been given adequate recognition in measurement instruments. Recent investigations of cognitive measures (Johnson et al., 1983) have shown that separate subscales or factors can be.identified in the cognitive component alone. Several investigators (Chlopan et al., 1985; Davis, 1983; Feldstein & Goldstein, 1980; Gladstein, 1977; Marks & Tolsma, 1985) have emphasized the complexity of the empathy process and have recommended that be given recognition and consideration in future investigations. Developmental theorists have investigated the development of the various components of empathy. The development of the cognitive 35 component, especially in adolescence and young adulthood, is central to this study and can be elucidated by a Piagetian framework. The formal operational stage of cognitive development consists of eight formal operations schemata and it is the eighth schema, the coordination of multiple frames of reference, that reflects the concept of empathy most clearly. It has been shown, however, that the development of the formal operations schema is subject to many variables and that they are not evident in a large percentage of the adolescent and adult population. This finding is significant to the study of empathy in nursing. Empathy is considered central to the practice of nursing and it is consistent with and part of Kasch's (1984) communication model of interpersonal competence. Social cognitive competence, a communication resource in the model, is derived from decentration and perspective and role taking ability. This finding highlights the important role that cognitive development has in nursing students' ability to communicate empathically. It is not a simple matter of providing them with empathy training. Nursing educators need to recognize the cognitive constraints that may exist in some students and may result in varying levels of performance of empathic interactive skills. The major purpose of this study is to investigate the relationship of the independent variables of nursing students' cognitive development, their age, and an empathy skills training program that they experience to the dependent variable of their ability to communicate empathically with patients. Secondarily the study will investigate the relationship of nursing students' empathic ability both to their number of years of post-36 t secondary education and to their performance on the eighth formal operational schema, the coordination of two or more frames of reference. Chapter III describes the research methodology. It includes a description of the variables, the hypotheses, the sample, the instrumentation, the data collection and rating procedures, and the data analysis. 37 CHAPTER III RESEARCH METHODOLOGY Overview The primary purpose of this study was to investigate the relationship of nursing students' cognitive development status, their age and an empathy skills program that they experience to the nursing students' ability to communicate empathically with patients. A multiple regression research design was used to determine the extent to which empathic communication can be predicted from the three variables that are theoretically linked in this study to empathic communication. Hypotheses Null form 1. There will be no significant linear relationship between the predictor variables of nursing students' level of cognitive development as measured by the Arlin Test of Formal Reasoning, their age, and training or no training in interactive skills, and the criterion variable of empathic interaction as measured by Carkhuff's Empathic Understanding in Interpersonal Processes Scale. 2. Subjects with more years of post-secondary education will show no significant difference in empathic interaction ability as measured by Carkhuff's Empathic Understanding in Interpersonal Processes Scale when compared to subjects with fewer years of post-secondary education. 3. Subjects with the cognitive ability to coordinate multiple frames of reference as measured by subtest #8 of the Arlin Test of Formal Reasoning will show no significant difference in empathic interaction 38 ability as measured by Carkhuffs Empathic Understanding in Interpersonal Processes Scale when compared to subjects without the cognitive ability to coordinate multiple frames of reference. Asstujupti-OIILS The hypotheses are based on the following assumptions. The findings of the study must be considered in the light of these assumptions because the degree of their accuracy both allows and limits the conclusions that can be drawn from the findings. 1. That the instruments used, that is the Arlin Test of Formal Reasoning and the Empathic Understanding in Interpersonal Processes Scale used to rate subjects' responses to the patient stimulus expressions are adequately sensitive to reflect actual differences in subjects' cognitive development and empathic communication. 2. That the implementation of the interactive skills component of the General Nursing program at BCIT is sufficiently consistent as to content, delivery method and teacher competence to ensure that subjects have had similar empathy skills training. Subjects The subjects in this study were students in the British Columbia Institute of Technology diploma nursing program (leading to R.N.). They were solicited by letter and were volunteers. Appendix A. The subjects were recruited on the basis of whether or not they had experienced the empathy skill training component of the curriculum. It begins in the tenth week of Term 1 and is completed in the fourteenth week 39 of Term 3. (Each Term is seventeen weeks long.) Therefore the no-training subjects were recruited at the beginning of Term 1 and the training subjects were recruited as soon after the completion of the training as possible. The subjects were screened on two variables in order to reduce the confounding effects of initial differences among subjects. Those variables were sex and previous training and work as a Registered Psychiatric Nurse. Men were excluded from the study because of the cognitive developmental focus of the study. There is evidence to suggest significant differences between men's and women's cognitive development (Gilligan, 1982). Some of these differences relate to role and perspective taking and interpersonal orientation. The under-representation of men in the volunteer sample warranted their exclusion. Volunteers with training and work as Registered Psychiatric Nurses were excluded because their additional training and experience could be expected to influence, either positively or negatively, their scores on the criterion variable, empathic communication. All of the Registered Psychiatric Nurses in the BCIT diploma nursing program have experienced a communication skills training program including empathy skills in their R.P.N, program and, as stated in the Literature Review, these programs are positively related to increased scores on various standard empathy rating scales. Conversely, Mynatt (1985) found a significantly low negative correlation between students' level of empathy and amount of work experience in nursing. For these reasons the Registered Psychiatric Nurses were excluded from the study. 40 Two participants, one in the Training group and one in the No Training group did not complete the Arlin Test of Formal Reasoning. One dropped out of the nursing program between testing sessions and the other said she could not do the Arlin Test of Formal Reasoning. A possible explanation for the low number of volunteers in the Training group recruited in April (column 5) is that they were recruited at the end of the term one week before their final examinations. This was done in order to test them as soon after the empathy training, as possible. However, the investigator believes the recruits' enthusiasm and energy for additional work was low and hence resulted in a low volunteer rate. The final sample consisted of 54 subjects. Data on recruitment, participation and deletion from the study are shown in Table 4. 41 TABLE 4 Recruitment, Participation and Deletion of Subjects Ho Training Training Grand Jan. AUK. Total Jan. Apr. Total Total Recruited 40 48 88 50 46 96 184 Volunteered 16 23 39 21 7 28 67 (percentage of recruits) (40) (47.9) (44.3) (42) (14.5) (29.1) (36.4) Deleted 3 3 6 2 3 5 11 (percentage of volunteers) (18.7) (13) (15.3) (9.5) (42.8) (17.8) (16.4) Did not complete 1 0 1 1 0 1 2 (percentage of volunteers) (6.2) (0) (2.5) (4.76) (0) (3.5) (2.9) Included in study 12 20 32 18 4 22 54 (percentage of recruits) (33.3) (41.6) (36.3) (27.7) (8.6) (22.9) (29.3) The method of analysis for hypothesis 1 was multiple regression analysis. According to methods described by Cohen (1977) and Cohen and Cohen (1983), the sample size of 54 was sufficiently large to achieve a .5 power level for detecting a minimum of .10 R2 when the alpha level equals .05. The Predictor and Criterion Variables An argument was made in the Literature Review that role and perspective taking ability is required to be empathic and that that ability is dependent upon a certain- level of cognitive development. It was further argued that the specific cognitive concepts necessary for role 42 and perspective taking are not apparent in a large percentage of adolescents and adults. Age, the second predictor variable, is confounded with development. The positive relationship of age to the construct of empathy, especially the cognitive component of empathy, is well-documented in the child and adolescent developmental literature, as was reviewed in Chapter II. In the adult population, however, this relationship is not as clear. Although post-formal developmental researchers describe a cognitive developmental sequence in adults (Basseches, 1980; Brabek, 1983; Kitchener & King, 1981), many adults appear to reach a peak level of cognitive development not beyond the Piagetian formal operations level, yet the passage of time and the acquisition of life experiences continue. It is this aspect of age, that is, time and experience, on empathic communication that is of interest to this study. Empathy skills training was the third predictor variable in this study. The training method used in the diploma nursing program at BCIT was described in detail in Chapter I and as stated there, the investigator has observed that some students seem not to benefit from the training. That is, they do not achieve satisfactory levels of understanding or communication of empathy. There is a confounding variable related to the empathy skills training. By the time the empathy skills training has been completed, the student has also completed 12 months of the other components of the curriculum that could influence, either positively or negatively, the student's ability to interact empathically with patients. This should not be confused with simple chronological age, because students begin the program at differing ages. It is the educational process in general, including clinical experience, that may be influencing 43 empathic communication. This will be discussed in Chapter IV, the analysis and evaluation of the findings. The criterion variable of empathic communication was measured by the Empathic Understanding in Interpersonal Processes Scale (Carkhuff, 1969). It is described in detail later in this chapter. Empathic communication is described as the ability to adopt a patient's frame of reference in order to understand his or her feelings, thoughts and/or behaviour and the ability to convey that understanding to the patient in a way that she or he can understand. One's understanding can be based on the patient's verbal or non-verbal behaviour that is conveyed either directly or indirectly, that is, implied. The fundamental question for this study was which of the above three predictor variables, either singly or in combination, is/are the best predictor(s) of empathic communication with patients. Instrumentation Empathic Communication. The criterion variable, empathic communication, was measured with an adaptation of Carkhuff's Index of Discrimination (1969) and rated with Carkhuffs Empathic Understanding in Interpersonal Processes Scale (EUS). The scale ranges from one to.five with the midpoint, three, being the minimal level of facilitative empathy (Carkhuff, 1969, Vol. 1, p. 175). Appendix B. Ten patient stimulus expressions were used. They are adaptations of client expressions in Carkhuffs Index of Discrimination (1969, Vol. 1, pp. 115-123) and Egan's Exercises in Helping Skills (1982b). Appendix C. All of them are typical and realistic verbal expressions of patients 44 and/or family/friends in general acute medical/surgical nursing units to which nursing students would be expected to respond empathically. The following is a sample patient stimulus expression: A 55 year old woman to her nurse the night before having a breast biopsy: "I don't know what to expect after the operation. I've never had an operation before and this is even worse than an ordinary operation. The doctor explained all the alternatives to me but it's just too much to think about" (adapted from Egan, 1982b, p. 42). The content and face validity of the patient stimulus expressions were ascertained by reference to the professional judgement of a group of six nurse educators and practitioners. They identified the primary affect evident in each patient stimulus expression and made a judgement about the relevance and realism of each one. Only those patient stimulus expressions in which the affect is clear and unambiguous and which are relevant and realistic were used. The design of the patient stimulus expressions was modeled on the Carkhuff Index of Communication (1969, Vol. 1, p. 99, Table 7.1), wherein the stimulus expressions cross different expressions of feeling with different problem areas. The problem area in this study were consistent — health-illness related concerns — and the feelings were depression/distress, anger/hostility, and elation/excitement. Two videotapes of the ten patient stimulus expressions in two random orders of gender and affect were prepared. Thirty subjects, 18 with Training and 12 with No Training, saw videotape A and 24, 4 with Training and 20 with No Training, saw videotape B. This was done to control for 45 any effect that the order of the patient stimulus expressions might have had on subjects' responses. The mean scores of the groups were compared by one-way analysis of variance and are presented in Table 5. There was no significant differences between the means for responses to Tape A or Tape B for either group. TABLE 5 Comparison of Scores on Two Orders of Patient Stimulus Expressions Tape A Tape B n • M SB n M SD F df 4 2.8 1.3 <1 1, 20 20 1.4 .5 <1 1, 30 Cognitive Development. The independent variable of cognitive development was measured with the Arlin Test of Formal Reasoning. It is a 32 item, multiple-choice paper and pencil test designed "to obtain a general assessment of students' levels (or stages) of cognitive development whether 'concrete' or 'abstract-formal'" (Arlin, 1984b, p. 1). It is based on Inhelder and Piaget's-(1958) theoretical framework which includes eight specific concepts or schemata associated with the stage of formal operations. The 32 items are organized into eight subtests, each representative of one of the eight formal schemata. A multi-trait, multi-method validity study of the ATFR was conducted (Arlin, 1982). The study indicated that the ATFR is a valid and reliable measure of formal operations. The reliability measures were as follows: 46 Training 18 2.8 .4 No Training 12 1.5 .5 Test-Retest Hoyt Cronbach Alpha .76 to .89 .71 to .89 .60 to .73 Data Collection and Rating Procedures Each subject participated in two data collection sessions. The Data Collection Schedule is described in Table 6. TABLE 6 Data Collection Schedule No Training Training Jan/88 Aug/88 Jan/88 Apr/88 Term 1 Term 1 Term 4 Term 3 SESSION 1 Week 3 Week 1 Week 3 Week 15 Empathic Understanding SESSION 2 Week 5 Week 1 Week 3 Week 15 - Arlin Test of Formal Reasoning - Biographical Data Sheet Empathic Communication. The subjects were asked, at the first session, to read and sign the Consent Form (Appendix D) and were invited to ask questions about the study. Subjects were told that they would view a videotape of ten separate situations and that they were to respond empathically to each one, in writing, in the response booklet given to them. These instructions plus a description of what an empathic response 47 consists of, were repeated at the beginning of the videotape. Appendix C. There was a 3-minute pause between each patient stimulus expression and subjects were told that if they needed more time the pause would be lengthened. There were no requests for more time in any of the four showings of the videotapes. The subjects' responses were rated by two trained raters. The raters were faculty members in the BCIT diploma nursing program who are responsible for the .interactive skills training. They have also undertaken extensive interactive skills training. Additionally, before doing any ratings they experienced five hours of didactic discrimination training by the investigator, according to criteria described by Carkhuff (1969, Vol. 1, pp. 169-173). It was agreed by the raters and the investigator that, although the rating scale consists of five levels, the raters could only accurately discriminate levels 1, 2, and 3. This was based on Carkhuff's description of the levels (1969, Vol. 1, p. 173-176) that indicates that in order to accurately discriminate between levels 4 and 5 "a minimum of a helpee-helper-helpee interaction" (p. 176) is required. When the raters, in this study, thought a subject's response was better than a level 3 they rated it simply as 3+. When the data were analyzed the investigator arbitrarily gave a value of 4 to responses rated as 3+. In summary then, the raters had to discriminate amongst only four levels of performance. The raters' interrater reliability was determined following the January and April, 1988 data collections, on 10 subjects' responses to all 10 patient stimulus expressions. The 10 subjects' responses were randomly selected from among those of 44 subjects. Four were from the group with 48 no training and 6 were from the group with training. The subjects' responses were given to the raters in random order and the raters were not informed which group the subjects were in, for both the determination of interrater reliability and the rating of all remaining responses. Table 7 summarizes the interrater reliability ratings. The interrater reliability correlation was +.62 and the percentage of agreement was 50%. Through discussion and compromise the percentage of agreement rose to 93%. The investigator averaged the two ratings of the remaining 7% of the responses. The discussion to achieve agreement served as additional training for the raters and subsequent ratings were based on the training. TABLE 7 Interrater Reliability on 100 Subject Responses Before and After Discussion Interrater reliability correlation Interrater agreement Interrater disagreement r = .62 = 50% Before by >1 level by 1 level = 43% = 7% Interrater Agreement Interrater compromise Interrater disagreement = 50% = 43% After by 1 level by >1 level, = 7% = 0 * 2 of these responses were rated as 2 or 3 5 of these response were rated as 3 or 4 The investigator averaged them to 2.5 or 3.5 respectively 49 One of the raters was not able to rate subjects' responses from the final data collection in August. Therefore, all the responses from the August data collection were rated by the same rater. This rater's ratings of No Training subjects' responses, rated in May and August, are shown in Table 8 and appear to be not significantly different from each other. TABLE 8 Comparison of Rater's Ratings of No Training Subject's Responses May rating August rating n M SD n M SD 7 1.6 .4 20 1.4 .5 Cognitive Development. The ATFR was administered to the subjects in this study under the recommended testing conditions at the second session. The rooms were comfortable, well-lighted and well-ventilated and distractions were kept to a minimum. Scrap paper and pencils were provided. Subjects were read the instructions and told they could have as much time as they needed to complete the test. The subjects' tests were scored by the investigator and nine scores for each subject were obtained, that is, the overall or total score and a set of eight subtest scores. The subjects' scores on the Frames of Reference subtest were of particular interest since it was argued that it is the coordination of two or more frames of reference that is conceptually linked most clearly to the construct of empathy. These data were used to test the hypothesis that subjects with high scores on the Frames of Reference subtest would score higher on the Empathic 50 Understanding in Interpersonal Processes Scale than subjects with low scores on the Frames of Reference subtest. Biographical Data. Finally, at the second session, data on subjects' sex, previous work and training, and data on the subjects' ages and their empathy skills training status were collected with a Biographical Data Sheet that were completed by each subject. Appendix E. Additionally, data were collected on the number of full academic years (exclusive of the BCIT General Nursing program) that each subject had completed. These data were used to test the hypothesis that subjects with more years of post-secondary education would score higher on the Empathic Understanding in Interpersonal Processes Scale than subjects with fewer years of post-secondary education. Data Analysis Hypothesis 1 was tested by a hierarchical multiple regression analysis in order to determine the amount of variance in the subjects' empathy scores explained by cognitive level over and above that explained by the other independent variables. The hierarchical order for entry of the predictor variables into the analysis was age, training or no training, and cognitive level. This order was based on assumed causal priority, that is, "no variable can be causally affected by one that appears after it" (Cohen & Cohen, 1983, p. 121). There is some evidence to suggest that cognitive development in adults may be positively affected by age and education (Kitchener & King, 1981), therefore age and education were entered before cognitive level. Training was a dichotomous variable 51 (Training and No Training) that was coded as a dummy variable and entered as 1 or 0. Hypothesis 2 was analyzed with the non-parametric test of chi square. The scores on the Empathic Understanding in Interpersonal Processes Scale were categorized into two categories of "at the mean or greater" and "below the mean." Those two categories were then analyzed as frequencies comparing subjects with zero to one year of post-secondary education, and two or more years. A significant chi square would imply that the scores on the EUS and the number of years of post-secondary education were not independent. Hypothesis 3 was also analyzed with the non-parametric test of chi square. The EUS scores were categorized as in Hypothesis 2. They were then analyzed as frequencies comparing subjects with low scores of 0, 1 or 2 and subjects with high scores of 3 or 4 on the Frames of Reference subtest of the Arlin Test of Formal Reasoning. A significant chi square would imply that the two variables were not independent. Summary This study was designed to investigate the relationship between three predictor variables, that is, nursing students' levels of cognitive development, their ages and an empathy skills program they experience, and the criterion variable of the nursing students' ability to interact empathically with patients. A multiple regression analysis was used to determine the degree of variance in empathic interaction accounted for by each of the predictor variables. Secondarily, an attempt was made to identify if relationships exist between subjects' empathic communication 52 and two other variables, namely their number of years of post-secondary education and their scores on the Frames of Reference subtest on the Arlin Test of Formal Reasoning. 53 CHAPTER IV FINDINGS AND DISCUSSION The results of the analyses of the data are presented in this chapter under the headings: Characteristics of the Sample; Analyses of the Data in Relation to the Three Hypotheses of the Study; and Evaluation and Discussion of the Findings. Characteristics of the Sample The data on the characteristics of the sample were obtained through the Biographical Data Sheet that each participant completed prior to doing the modified Carkhuff Index of Communication and the Arlin Test of Formal Reasoning. Data on age and number of years of post-secondary education were tabulated for both groups of subjects, those with empathy skills training and those with no empathy skills training. The data for the two groups were examined by one-way analysis of variance for differences between means. The analyses indicate that there was no statistically significant difference between the Training group and the No Training group with regard to number of years of post-secondary education but there was a significant difference between the two groups with regard to age, F_ (1, 52) =4.5, p_ <.05. This significant difference was attributed to the fact that two of the subjects in the Training group were outliers with regard to age. A second one-way analysis of variance computed with the outliers removed from the sample revealed no significant difference with regard to age, F_ (1, 50) = 1.9. These data are shown in Table 9. Within the training 54 group, moreover, age had only a low nonsignificant correlation with the dependent variable, empathy scores (r_ = .12). TABLE 9 Means, Standard Deviations and One—Way Analysis of Variance of Characteristics of the Sample Training No Training Variable n M SD n M SD F df £ Age 22 356.5 91.3 32 306.9 77.8 1.7 1, 52 <.05 (in months) Age 20 336.5 67.7 32 306.9 77.8 1.9 1, 50 (outliers removed) Number of 22 1.0 1.3 32 1.0 1.2 <1 1, 52 years of post-secondary education Analyses of the Data in Relation to Each Hypothesis Hypothesis 1 states that there is no significant linear relationship between the predictor variables of nursing students' level of cognitive development as measured by the Arlin Test of Formal Reasoning, their age, and training or no training in interactive skills, and the criterion variable of empathic interaction as measured by Carkhuff's Empathic Understanding in Interpersonal Processes Scale. Descriptive statistics and pairwise correlations are given for all variables in Table 10. The correlation between age and empathy was significant, .34. Correlations with the variable of Training were not significant because it was dichotomous and coded as a dummy variable. 55 Cognitive development showed low relations, less than .2, with the dependent variable and the other independent variables. TABLE 10 Means, Standard Deviations and Pearson Intercorrelations of Dependent and Independent Variables (N = 54) Variable Variable M SD 1 2 3 4 1. Empathy 2.03 .84 2. Age 327.1 87.2 .343 3. Training* .4 .4 .793 .281 4. Cognitive ATFR Level 19.7 4.1 .136 .195 .175 * Training or No Training were coded 1 or 0. p_ < .05 = .27 df 50 p_ < .01 = .35 df 50 The multiple regression equation was significant'at F_ (3, 50) = 30.64, p_<.00001 and the predictor variables, in combination accounted for 64.7% of the variance (adjusted = .62^). The null hypothesis was rejected. Table 11 summarizes the findings. After the effect of age was removed, training accounted for the largest proportion of the variance (AR_2 = .52, adjusted = .63) and was positively related to empathy scores. Age accounted for the second largest proportion of variance (AR2 = .11, adjusted R_^ = .10) and also was positively related to empathy scores. The third predictor variable, cognitive level accounted for. a negligible proportion of the variance (4R2 = .0005). 56 TABLE 11 Hierarchical Multiple Regression Analysis on Empathy Scores of Nursing Students (N =54) Variable R2 R2 adjusted increase F to enter B Age Training Cognitive Level . 117 .647 .647 .100 .117 .633 .529 .626 ,0004 6.93* 76.56** .06 .133 .761 -.022 F (3,50) =. 30.64 p_ < .00001 * p_ < .05 ** p_ < .01 One way analysis of variance indicated a significant difference in the means of the empathy scores for the Training and No Training groups as shown in Table 12. Students in the later terms of the BCIT General Nursing diploma program achieved higher empathy scores than did students at the beginning of the first term. TABLE 12 Comparison of Mean Empathy Scores for Training and No Training Groups (N = 54) Training No Training n M SD n M SD F df p_ 22 2.8 .4 32 1.4 .5 87.6 1, 52 <.00001 57 The distribution of the scores, as shown in Table 13, indicates that 71.2% of the beginning students' responses could be classified as harmful or significantly detracting from the communication of the patient (see Appendix B for descriptions of the levels of the rating scale). In comparison, in the Training group, 63.6% of the responses are neutral and 36.2% are essentially interchangeable with those of the patient and are considered minimally facilitative. TABLE 13 Distribution of Mean Empathy Scores for Training and No Training Groups (N = 54) Training No Training EUS n % n % Level 1 1.0 to 1.4 0 0 21 65 1.5 to 1.9 0 0 2 6.2 Level 2 2.0 to 2.4 5 22.7 7 21.8 2.5 to 2.9 9 40.9 2 6.2 Level 3 3.0 to 3.4 6 27.2 0 0 3.5 to 3.8 2 9 0 0 EUS: Empathic Understanding in Interpersonal Processes Scale, Carkhuff (1969). Hypothesis 2 states that subjects with more years of post-secondary education would show no significantly greater empathic interaction ability as measured by the Empathic Understanding in Interpersonal Processes Scale (Carkhuff, 1969) when compared to subjects with fewer years of post-secondary education. 58 The hypothesis was analyzed by the non-parametric test of chi square. The empathic interaction scores were categorized as below the mean, and at or above the mean and then analyzed as frequencies comparing those subjects with zero to one year of post-secondary education to those with two or more years of post-secondary education. The chi square statistic was not significant,X2 (1, N_= 54) = <1, and indicated that the two variables are independent of one another. The null hypothesis was accepted. Hypothesis 3 states that subjects with the cognitive ability to coordinate multiple frames of reference, as measured by subtest #8 of the Arlin Test of Formal Reasoning, would show no significantly greater empathic interaction ability, as measured by the Empathic Understanding in Interpersonal Processes Scale (Carkhuff, 1969), when compared to subjects without the ability to coordinate multiple frames of reference. The test of chi square was used to analyze the hypothesis. The empathic interaction scores were categorized as in Hypothesis 2 and then analyzed as frequencies comparing those subjects with scores of 3 or 4 on subtest #8 of the ATFR to those with scores of 0, 1, or 2. The chi square statistic was not significant,X2 (1, N_ = 54) = <1, indicating that the two variables are independent of one another. The null hypothesis was accepted. Evaluation and Discussion of the Findings The independent variables in question in this study can be classified as developmental, i.e., age and cognitive development, or educational, i.e., empathy training and post-secondary education. Of 59 these, age and empathy training appear to have had a bearing on the dependent variable of empathic communication. This finding is positive and heartening because much time and effort was applied to the training by students and faculty. However, this finding must be considered in the context of the following discussion. Because there was no significant difference between the Training and No Training groups with regard to age and because, within the Training group, age and empathy scores had an insignificant correlation (+.12), the investigator concluded that, regardless of empathy training, the older subjects in this study, scored higher on the measure of empathy than the younger subjects. Additionally, the third independent variable, level of cognitive development, was not related to age. In summary then, it appears that age had a significant effect on empathy scores and also that its effect was not compounded by or related to training or level of cognitive development. The consistency of the implementation of the training program was not measured in this study. The learning materials, that is,, text books, videotapes, self-directed learning modules, and workbooks remained consistent but neither the student/faculty ratio, the teaching strategies nor the faculty who taught the interactive skills component were monitored. The importance of certain trainer and training characteristics has been described by Carkhuff and Berenson (1967). A greater understanding of the efficacy of the training might be reached if such variables were explored. Other factors that may have had an effect, either positive or negative, on students' ability to apply the empathy training relate to the 60 protracted length of the empathy training. Variables such as the nature and quality of the students' clinical experiences, their personal experiences, and the supervision and role modelling that they experienced over the 12-month period were not measured. The lack of a pre-training empathy score for the Training group raises the question of whether there were significant initial differences in the two groups on the criterion variable. The investigator does not believe this was the case in light of the group homogeneity that the BCIT General Nursing diploma program admission requirements fosters, however it remains an unknown variable. An explanation for the lack of significance of the measure of cognitive development, specifically formal reasoning, as a predictor of empathic interaction relates to by the lack of variance in cognitive development in the sample. The majority of the subjects were formal reasoners as is shown in Table 14. TABLE 14 Comparison of Cognitive Development Scores of No Training and Training Groups n M SD Formal Non-formal No Training 22 18.9 4.0 71.8% 28.2% Training • 32 21.0 4.6 81.8% 18.1% Total 54 19.7 4.1 75.9% 24.0% 61 As well as the lack of variance in cognitive development in the sample as a methodological limitation, the lack of relationship between measures of the various components of empathy as a conceptual limitation must be addressed. As was discussed in the Literature Review, when operationalized and measured, the components of the multidimensional construct of empathy stand alone and show little relationship to each other. If a measure of the cognitive component of empathy specifically, shows little relation to a measure of communicative empathy it is not surprising that a general measure of cognitive development does not show a relationship to communicative empathy. The findings of this study reflect the idea that the components of empathy are distinctly different stages of a process and one cannot be predicted from another. A second explanation for the lack of significance of the Arlin Test of Formal Reasoning (ATFR) as a predictor of empathic interaction relates to its appropriateness as a measure of cognitive development in terms of the construct of empathy. In the Literature Review, the investigator drew a theoretical parallel between the cognitive component of empathy, role and perspective taking, and the development of formal operations, specifically the coordination of multiple frames of reference. Perhaps the findings of this study indicate that the relationship is only theoretical or that achievement on the ATFR cannot reflect the relationship. Although Arlin (1984b, p. 2) has stated that the concepts associated with the stage of formal operations "represent[s] a form of thinking and not necessarily the content of that thinking" the investigator believes that the ATFR is more suited to the measurement of cognitive development as it relates to science or mathematics. 62 The scores achieved by the subjects in the Training group in this study are comparable to scores reported in other studies. Lutwak and Hennessy (1981) reported empathy scores (M 2.8, SD .8) for 97 first year graduate students in counsellor education or advanced undergraduates taking a graduate level interview skills course. Their responses were rated with Carkuff's Empathic Understanding in Interpersonal Processes Scale (1969). La Monica (1979) reported scores for graduate nursing students and graduate psychology students that also were below the minimally facilitative level. She suggested the following explanations: "either the undergraduate and graduate curricula fail to provide necessary communication skills content or the instrument fails to detect it" (La Monica, 1979). This investigator believes both factors influenced subjects' scores in this study; the former will be discussed in the final chapter, the latter remains a limitation of the study both in terms of the instrument's validity per se and the interrater reliability achieved in this study and reported earlier. 63 CHAPTER V SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS Summary and Conclusions The ability to communicate empathically with patients is an essential skill in the practice of nursing. In order to provide nursing students with this skill the nursing faculty of the BCIT General Nursing diploma program implemented, in 1985, the systematic, didactic-experiential interactive skills training method of Egan (1982a). The skill of empathy is fundamental in the Egan model. An overall improvement in students' interpersonal effectiveness has been noted. The implementation of the training program has provided faculty with comprehensive, structured framework in which to teach, train, observe and give feedback to students about interactive skills. In spite of these benefits, the investigator has observed that the ability to communicate empathically is not well-developed in some students and that sometimes the processes of projection and stereotyped knowledge are used instead of empathy. These processes are indicative of a lack of the cognitive developmental task of perspective or role taking. This observation lead to the problem identification of this study. The purpose of this study was to investigate the predictive relationship of the developmental variables of age and level of cognitive development and the educational variable of an empathy training program to nursing students' ability to communicate empathically with patients. Secondarily the degree of independence between empathic ability and two 64 additional variables — number of years of post-secondary education and the ability to co-ordinate multiple frames of reference —was examined. Empathy was described in the Literature Review as a multidimensional, interdependent construct. The focus of this study was the relationship between the cognitive and communicative components of empathy. It was thought that the ability to communicate one's understanding of another's thoughts, feelings and experiences to the other would be dependent to some degree on the ability to cognitively take on the role of that other. The investigator believed that the value of training and the expectations regarding performance, held by trainers, are limited by and must be tempered by the cognitive developmental constraints existent in the trainees. The hypotheses of the study were tested by measuring the subjects on the four variables in question and statistically examining the relationships among and degree of independence of selected variables. The findings do not support the idea that cognitive development or the related variables of age and number of years of post-secondary education are important influences on the subjects' ability to interact empathically with patients. The empathy skills training on the other hand, was significantly related to greater empathy scores. Discussion and Recommendations Empathy training in nursing education. Empathy has been described, in this study, as a trained skill that nurses are expected to demonstrate. The results indicate that with training the nursing students achieved better empathy scores. The training moved the students from making 65 harmful responses to making neutral or minimally facilitative responses. This questionable progress could be reflective of the empirical limitations of the rating scale. An alternative explanation is the lack of fit between the interactive skills training program and the remainder of the nursing curriculum. As described earlier the elapsed time from the first seminar on basic empathy to the one on advanced empathy is approximately 12 months. During this time students are also expected to learn and implement complex psychomotor skills, nursing assessment and intervention, and related physical and social sciences. They attend clinical practica and are assigned to patients with varying degrees of illness for whom they must provide safe competent nursing care. It is a reality that the focus on empathy as a desired nursing skill is sometimes not as sharp as is required to become skillful beyond the minimally facilitative level. This lack of fit between the interactive skills program and the nursing curriculum is most evident in clinical practice and this was described in the Literature Review. It is not reasonable given the constraints on communication and the task orientation in most nursing situations for nurses to interact in the manner prescribed by Egan's (1982a) model of helping. The model prescribes using skills in order to help the patient thoroughly explore his or her situation, set realistic goals and determine actions to achieve those goals. In other words, the skills are to be used within the context of a helping relationship. The best that can be achieved in many clinical situations in which nursing students find themselves is the isolated use of a particular skill or skills out of context of a patient-centred, goal directed relationship. Looked at in this light, the subjects' progress 66 from predominantly harmful responses to either neutral or minimally facilitative ones is positive. The decontextualization of empathic interaction and the competing demands of the curriculum and clinical experience provide additional explanation for the lack of relationship in this study between cognitive development and empathic ability. As suggested in the Literature Review there is a difference between competence and performance with regard to cognitive development. One of the factors that Arlin (1981, 1984) described as affecting the integration of competence and performance is the coordination of actions with appropriate experience. It is suggested that, although the majority of subjects in this study were formal reasoners and many of them achieved positive scores for the eighth schema — the coordination of multiple frames of reference — perhaps they have not had clinical learning experiences that facilitated the integration of their competence and performance and that would have resulted in highly facilitative empathic responses. The minimally facilitative level is reflective of the basic empathy described by Egan (Goldstein & Michaels, 1985) and perhaps that is a more reasonable goal for diploma nursing students, given the constraints referred to above, than the advanced empathy level. It is possible that the introduction in the curriculum of the higher level of empathy, and the expectation that this be implemented by students, is confusing and discouraging for them and leads to feelings of inadequacy or incompetence. It is suggested that advanced empathy continue to be introduced but that factors inhibiting its application be explicitly discussed and that the focus clinically remain on the basic empathy level. In situations where 67 it might be possible and desirable for students to go beyond the basic level, it would be incumbent upon the clinical nursing instructor to help students move to the advanced level. An example of this would be in the psychiatric nursing experience where the focus for both the patients and students is on interpersonal relationships and communication and the students have more opportunity to develop a helping relationship with their patients. The clinical instruction, supervision and role modelling that students receive is critical in helping them to recognize clinical situations in which to use specific interactive skills. Although it is not possible for nursing students or instructors to entirely overcome the communication restraints and task orientation of many clinical situations, the investigator believes that a focus on clinical supervision could help students to apply interactive skills more effectively. One such approach would be professional development seminars for faculty to renew and clarify the value of caring, interactive skills and specifically empathy to the practice of nursing, followed by refresher seminars in the practice of specific skills. Because most clinical situations are complex and instructors have expertise in limited aspects of practice a team teaching approach in clinical conferences would allow discussion of diverse facets, for example physical assessment and the interactive dynamics, to be facilitated by instructors with the required expertise. Recommendations for research. This study could be replicated with more controls for differences among subjects by testing the same group of 68 subjects before and after training. In this way initial differences on the dependent variable and selected independent variables, for example, age could be measured. Another approach to look at the effectiveness of systematic, didactic-experiential interactive skills training would be to compare interactive effectiveness of subjects from different diploma nursing programs, one with an interactive skills training program as part of the curriculum and one without. A specific skill such as empathy could be the focus or a more general measure of interactive effectiveness could be taken. Because the training appears to have made a difference in the empathy scores of the subjects in this study, further research could focus on both identifying and maximizing effective training implementation strategies. An approach to this would be to investigate and compare students' achievement and the teaching strategies used in different nursing programs with similar interactive skills training programs. It is recommended that further research be conducted on the variable of age and its effect on empathy scores. First, the relationship between age and empathy scores indicated in this study could be validated. Second, and perhaps more importantly, more specific aspects of the variable of age, for example age-related experiences, and how they effect empathy could be elucidated. Examining specific variables related to students' clinical experience is another focus for research. Variables such as the amount of time spent with patients, and the kind of patients assigned to students could be investigated. The application of empathy skills is effected by 69 such variables as the severity of illness patients experience, their language, and sociocultural background. 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Dissertation Abstracts International, 41 1314B. 77 Dear Student: APPENDIX A For my Master's thesis in the Department of Counselling Psychology at U.B.C, I am gathering data about how nursing students learn about the concept of empathy. I am focusing specifically on which developmental factors enhance and/or inhibit the ability to understand and'to demonstrate empathy in interaction with patients. Empathy is considered to be an essential element in nurse-patient relationships, yet very little has been written about what factors facilitate empathy in beginning nurses. Your participation in this project is important because your experiences can provide valuable insights about how nursing students learn about empathy and they can point to new teaching strategies that will facilitate this learning. The Associate Dean of Nursing has given me permission to approach you regarding participation in this project. This will involve completing: 1. A measure of empathic communication; 2. A Biographical Data Sheet; 3. The Arlin Test of Formal Reasoning (ATFR). In the first session you will view a videotape of 10.different patient statements. Your task is to write an empathic response to each one of them. This will take approximately 1 hour for you to complete. The ATFR will be done in the second session. It is a 32 item, multiple-choice paper and pencil test that measures your reasoning and problem solving ability. It will take approximately 45 minutes for you to complete it. Finally, you will be asked to complete a Biographical Data Sheet which will allow me to ensure that the subjects in the study are as similar to each other as possible. This will take less than 5 minutes to complete. Your responses on all the variables will be kept confidential. No information about your scores or responses will be given to the faculty or staff of B.C.I.T. You have the right to refuse to participate or to withdraw from any part of the project at any time; such refusal or withdrawal will not influence your class standing in any way. Dates, times and locations for the two sessions will be announced shortly in your nursing class. If you are willing to participate in the project, please attend the sessions. I realize that your schedule at B.C.I.T. is very busy and I appreciate your interest in this project. A summary of the results of the research will be made available through the office of the Associate Dean of Nursing. 78 APPENDIX A (cont'd...) This study is being conducted under the supervision of Dr. Richard Young of the Department of Counselling Psychology, U.B.C. • Thank you for your time and participation. Sincerely, Kathy Doyle 79 APPENDIX B Empathic Understanding in Interpersonal Processes  a Scale for Measurement Level 1 The verbal and behavioral expressions of the helper either do not attend to or detract significantly from the verbal and behavioral expressions of the helpee(s) in that they communicate significantly less of the helpee's feelings and experiences than the helpee has communicated himself. Example: The helper communicates no awareness of even the most obvious, expressed surface feelings of the helpee. The helper may be bored or disinterested or simply operating from a preconceived frame of reference which totally excludes that of the helpee(s). In summary, the helper does everything but express that he is listening, understanding, or being sensitive to even the most obvious feelings of the helpee in such a way as to detract significantly from the communications of the helpee. Level 2 While the helper responds to the expressed feelings of the helpee(s), he does so in such a way that he subtracts noticeable affect from the communications of the helpee. Example: The helper may communicate some awareness of obvious, surface feelings of the helpee but his communications drain off a level of the affect and distort the level of meaning. The helper may communicate his own ideas of what may be going on, but these are not congruent with the expressions of the helpee. In summary, the helper tends to respond to other than what the helpee is expressing or indicating. Level 3 The expressions of the helper in response to the expressions of the helpee(s) are essentially interchangeable with those of the helpee in that they express essentially the same affect and meaning. Example: The helper responds with accurate understanding of the .surface feelings of the helpee but may not respond to or may misinterpret the deeper feelings. 80 APPENDIX B (cont'd...) In summary, the helper is responding so as to neither subtract from nor add to the expressions of the helpee. He does not respond accurately to how that person really feels beneath the surface feelings; but he indicates a willingness and openness to do so. Level 3 constitutes the minimal level of facilitative interpersonal functioning. Level 4 The responses of the helper add noticeably to the expressions of the helpee(s) in such a way as to express feelings a level deeper than the helpee was able to express himself. Example: The helper communicates his understanding of the expressions of the helpee at a level deeper than they were expressed and thus enables the helpee to experience and/or express feelings he was unable to express previously. In summary, the helper's responses add deeper feeling and meaning to the expressions of the helpee. Level 5 The helper's responses add significantly to the feeling and meaning of the expressions of the helpee(s) in such a way as to accurately express feelings levels below what the helpee himself was able to express or, in the event of on going, deep self-exploration on the helpee's part, to be fully with him in his deepest moments. Example: The helper responds with accuracy to all of the helpee's deeper as well as surface feelings. He is "tuned in" on the helpee's wave length. The helper and helpee might proceed together to explore previously unexplored areas of human existence. In summary, the helper is responding with a full awareness of who the other person is and with a comprehensive and accurate empathic understanding of that individual's deepest feelings. Carkhuff, 1969. 81 APPENDIX C Directions and Script for Videotape of  Patient Stimulus Expressions The following vignettes or scenes portray statements or expressions by a patient, of feelings and content related to some aspect of her or hi hospitalization. You may conceive of the patient as a patient to whom you are assigned and to whom you want to be helpful, specifically empathic. An empathic response is one in which you convey to the patient, in way that she or he can understand, your understanding of her or his feelings, thoughts and behaviour. There are 10 vignettes or scenes in this exercise. Your task is to view each scene attentively and then to write an empathic response to the patient. Write your responses in the spaces provided in the response booklet. VIGNETTE 1 The person speaking is this scene is Mrs. Simpson the mother of a 6 year old boy who has been in the hospital for investigation of possible cystic fibrosis. It has been determined that he had pneumonia and he is being discharged today. Mrs. Simpson: "This is the best news I've had in two weeks. I've been so worried thinking the worst all the time. My husband and I tried to be calm about Jim being in hospital but we were getting pretty irritable with one another. It's just so wonderful he's okay and we can go home." VIGNETTE 2 In this scene the patient is Mrs. Brown, a woman who is dying from long-standing cardiac and respiratory problems. Mrs. Brown: "I can understand it from my children but not from my husband. I know I'm dying. But he comes here with a brave smile every day, hiding what he feels. We never talk about my dying. I know he's trying to protect me but it's so unreal. I don't tell him that his constant cheerfulness and his refusal to talk about my sickness are actually painful to me. I'm being careful of him." 82 APPENDIX C (cont'd...) VIGNETTE 3 Mr. Martin is the patient in this scene. He is a 28 year old man who has been in the hospital for 2 weeks for investigation and treatment of leukemia. You have just brought his lunch to him. Mr. Martin: "This place is driving me crazy. I can't stand it. I feel like a guinea pig. First a bunch of doctors come in and look at me and talk about me. then they give me a student nurse, who looks like she's afraid of me. They all pretend they know so much but they don't know anything about me. They don't want to." VIGNETTE 4 The patient in this scene is Mrs. Jones. She is 42 years old and has been admitted to the hospital today for treatment of ulcerative colitis. You have just told her when visiting hours are. Mrs. Jones: "I hope they all stay away. I'm always in the middle. The kids complain about my husband and then he complains about them and blames me when he can't manage them. I could walk out on them right now. Who the hell do they think they are?" VIGNETTE 5 Mrs. Lee is the patient in this scene. She is a 55 year old woman who has been in hospital for 6 weeks because of a stroke. Mrs. Lee "I'm so excited to be going home. For awhile things weren't looking so good and I didn't know if I'd ever get home. Being able to get a homemaker has made all the difference. I know things will be different since I've been sick but it's like a second lease on life." 83 APPENDIX C (cont'd...) VIGNETTE 6 The patient you will see in this scene is Mr. Gold. He has arthritis and has been hospitalized for 1 month. He needs assistance with many activities including dressing and getting in and out of bed. You have just answered his call bell. Mr. Gold: "Who do you think you are! You call yourself a nurse? Here I am in pain most of the time having to wait around 'til you can find the time in your busy schedule to help me out. You don't think of me one minute. All you can think of is when you're getting off work. Well I'm sick of you and this place. Get out of here." VIGNETTE 7 Mr. Sawchuck is the patient in this scene. He has just learned that he has lung cancer. Mr. Sawchuck: "Why me? Why me? I'm not even that old. And I don't even smoke. Look at me. I thought I had some guts. I'm just a slobbering mess. What are these next months going to be like!" VIGNETTE 8 The patient in this scene is Mr. Whelan. You have just said 'good morning' to him and told him you'll be his nurse today. Mr. Whelan: "I'm so happy you're my nurse today. I get the feeling you like your job. You're a good listener and you seem to understand me so well. I feel great when you're on duty." 84 APPENDIX C (cont'd...) VIGNETTE 9 The patient you will see in this scene is Miss McLeod. She is a 55 year old woman who is having a breast biopsy the next morning. You have just brought her a sedative to help her sleep. Miss McLeod: I don't know what to expect after the operation. I've never had an operation before and this is even worse than an ordinary operation. The doctor explained all the alternatives to me but it's just too much to think about." VIGNETTE 10 The person who is speaking in this scene is Mr. Bryant. He is the father of an 11 year old girl who was hit by a car. Mr. Bryant: "I should never have let her go to the movies alone. I don't know what my wife will say when she gets here. She says I'm careless - but being careless with the kids - that's something else! I almost feel as if I'd broken Karen's arm, not the guy in the car. 85 APPENDIX D CONSENT FORM Predictors of Bnpathic Interactive Skills In Diploma Nursing Students The purpose of this research is to investigate the effect of level of cognitive development, age, and an interactive skills training program on nursing" students' ability to interact empathically. The specific focus of the research is on cognitive developmental factors which enhance and/or inhibit the ability to understand and to demonstrate empathy in interactions with patients. Participation in this research requires that subjects complete the following: 1. The Arlin Test of Formal Reasoning (45 minutes); 2. A measure of empathic communication (1 hour); 3. A biographical data sheet (5 minutes). The subjects' responses and scores will be kept confidential. Subjects' responses and scores will be rated and recorded by number and not name. No information about individual responses or scores will be given to faculty or staff of B.C.I.T. In an effort to ensure that subjects fully understand the purpose and procedures of the research, the investigator will answer subjects' questions prior to participation and will provide opportunity for individual or group discussion following participation. Subjects have the right to refuse to participate or to withdraw from any part of the research at any time; such refusal or withdrawal will not influence subjects' class standing in any way. I consent to participate in the above research and I acknowledge receipt of a copy of this consent form. Investigator: Katherine Doyle M.A. Candidate Department of Counselling Psychology, U.B.C. Date Name Signature 86 APPENDIX E Biographical Data Sheet Please answer the following questions on the answer sheet provided. Print your name and your birthdate in the space provided on the answer sheet. 1. In which term of the nursing program are you currently registered? a. 1 b. 3 c. 4 2. What sex are you? a. Female b. Male 3. How many full academic years of post-secondary education (exclusive of the BCIT General Nursing program) have you completed? a. 0 c. 2 e. 4 g. 6 b. 1 d. 3 f. 5 h. 7 4. Have you repeated any nursing courses in the BCIT General Nursing program? a. yes b. no 5. Have you trained or worked as a nurse, a nurse aide or a practical nurse for one year or more? a. yes b. no 6. Are you an R.P.N.? a. yes b. no Thank you for participating in this research. 87 

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