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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., M c G i l l U n i v e r s i t y , 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 C o u n s e l l i n g  Psychology  We accept t h i s t h e s i s as conforming to the r e q u i r e d  standard:  THE UNIVERSITY OF BRITISH COLUMBIA February 1989 C a t h e r i n e Jane Doyle, 1989  In  presenting  degree freely  at  this  the  available  copying  of  department publication  of  in  partial  fulfilment  of  University  of  British  Columbia,  I agree  for  this or  thesis  reference  thesis by  this  for  his thesis  and study. scholarly  or  her  for  Department  Date  DE-6(3/81)  INWL K  t  Columbia  \<W\  purposes  representatives.  financial gain  permission.  The University of British 1956 Main Mall Vancouver, Canada V6T 1Y3  I further  the  requirements that  agree  may  be  It  is  shall not  that  the  Library  an  granted  by  allowed  advanced  shall make it  permission  understood be  for  the that  without  for  extensive  head  of  my  copying  or  my  written  ABSTRACT The i n t e r a c t i v e s k i l l of empathy i s essential to the practice of nursing. The B r i t i s h Columbia Institute of Technology General Nursing Diploma Program has implemented an i n t e r a c t i v e s k i l l s t r a i n i n g program that includes the s k i l l of empathy i n order to assist nursing students to acquire this s k i l l .  The purpose of this study was to investigate the  relationships between the i n t e r a c t i v e s k i l l of empathy and the developmental variables of l e v e l of cognitive development and age and the educational variables of empathy s k i l l t r a i n i n g and number of years of post-secondary education  i n nursing  students.  Developmentally, the a b i l i t y most relevant to the cognitive component of empathy i s perspective and role-taking which i s f a c i l i t a t e d 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 i s this  cognitive empathic a b i l i t y , however, that i s considered  c r u c i a l to  nursing.  The question therefore a r i s e s :  To what degree do the cognitive  constraints evident i n nursing students i n h i b i t or impede their development of empathic interactive s k i l l s . Data were collected from two groups of nursing students, one that had experienced the empathy t r a i n i n g and the other that had not. The variables of empathic i n t e r a c t i v e s k i l l and l e v e l of cognitive development were measured with Carkhuff's  Empathic Understanding i n Interpersonal  Processes Scale and the A r l i n 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 i n v e s t i g a t e the t r a i n i n g , and Two  l i n e a r r e l a t i o n s h i p of age,  empathy  skill  c o g n i t i v e l e v e l to the s u b j e c t s ' empathic i n t e r a c t i v e s k i l l .  nonparametric t e s t s of c h i square were used to examine the degree of  independence between empathic i n t e r a c t i v e s k i l l  and  number of years of post-secondary education  the c o g n i t i v e a b i l i t y  coordinate The  m u l t i p l e frames of  and  is a significant  r e l a t i o n s h i p between empathic i n t e r a c t i v e s k i l l T r a i n i n g accounted f o r the g r e a t e s t  empathy scores p_<.00001.  a f t e r age  had  to  reference.  f i n d i n g s of t h i s study i n d i c a t e that there  training.  the v a r i a b l e s of  and  empathy  proportion  linear  skill  of v a r i a n c e  been removed (53%), F_ (3, 50)  in  = 30.64,  Chi square a n a l y s i s found that empathic i n t e r a c t i v e s k i l l  was  shown to be independent of number of years of post-secondary e d u c a t i o n the c o g n i t i v e a b i l i t y to c o o r d i n a t e It  m u l t i p l e frames of  i s recommended that the empathy s k i l l  w i t h the f o l l o w i n g s u g g e s t i o n s .  The  i n t e r a c t i o n needs to be emphasized i n c l u d i n g the of n u r s i n g  p r a c t i c e that g e n e r a l l y are not  on the f a c i l i t a t i v e  c o n s t r a i n t s and  operating  r a t h e r than the c h a l l e n g i n g  skills.  seminars f o r f a c u l t y to c l a r i f y team t e a c h i n g receive.  skills,  i n the  and  counselling  i n c l u d i n g b a s i c empathy on-going  p r a c t i c e of empathy p l u s a  approach would improve the q u a l i t y of s u p e r v i s i o n  Suggestions are made f o r f u r t h e r  iii  realities  Subsequently, more  I t i s suggested that  the v a l u e  continued  process nature of  paradigm from which the s k i l l s program i s adopted. emphasis i s r e q u i r e d  reference.  t r a i n i n g program be  contextual,  and  research.  students  TABLE OF CONTENTS PAGE  ABSTRACT  ii  LIST OF TABLES  vi  ACKNOWLEDGEMENT  vii  CHAPTER I  CHAPTER II  CHAPTER III  CHAPTER IV  INTRODUCTION TO THE STUDY The Background of the Problem Statement of the Problem and Purpose of the Study D e f i n i t i o n of Terms Assumptions Limitations Hypotheses Description of the Following Chapters  1 .1 3 5 6 6 8 9  THE LITERATURE REVIEW Conceptual.Definitions of Empathy Operational Definitions of Empathy The Development of Empathy Nursing and Empathy Summary  10 10 12 19 28 35  RESEARCH METHODOLOGY Overview Hypotheses Assumptions Subjects The Predictor and C r i t e r i o n Variables Instrumentation Data C o l l e c t i o n and Rating Procedures Data Analysis Summary  38 38 38 39 39 42 44 47 51 52  FINDINGS AND DISCUSSION Characteristics of the Sample Analyses of the Data i n Relation to the Hypotheses Evaluation and Discussion of the Findings  54 54 55 59  iv  TABLE OF COHTEMTS  PAGE  CHAPTER V  SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS Summary and C o n c l u s i o n s D i s c u s s i o n and Recommendations Empathy t r a i n i n g i n n u r s i n g e d u c a t i o n Recommendations f o r r e s e a r c h  64 64 65 65 68  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  .  8  2  D.  CONSENT FORM  86  E.  BIOGRAPHICAL DATA SHEET  87  v  LIST OF TABLES  TABLE 1.  Comparison of R e i k ' s (1949), Keefe's (1976, 1979) and B a r r e t t Lennard's (1981) Conceptual D e f i n i t i o n s of Empathy  13  R e l i a b i l i t y and V a l i d i t y Reports of C o g n i t i v e and A f f e c t i v e Measures of Empathy  17  Comparison  20  of Communicative Empathy Instruments  Recruitment, P a r t i c i p a t i o n and D e l e t i o n of S u b j e c t s Comparison  of Scores on Two Orders of P a t i e n t  Stimulus  Expressions  46  Data C o l l e c t i o n Schedule  47  I n t e r r a t e r R e l i a b i l i t y on 100 Subject Responses Before and After Discussion Comparison of R a t e r ' s R a t i n g of No T r a i n i n g Subject Responses  10  11.  12.  13.  14.  42  49 50  Means, Standard D e v i a t i o n s , and One-way A n a l y s i s of V a r i a n c e of C h a r a c t e r i s t i c s of the Sample  55  Means, Standard D e v i a t i o n s , and Pearson I n t e r c o r r e l a t i o n s of Dependent and Independent V a r i a b l e s (N = 5 4 )  56  H i e r a r c h i c a l M u l t i p l e R e g r e s s i o n A n a l y s i s on Empathy Scores of N u r s i n g Students (N_ = 5 4 )  57  Comparison of Mean Empathy Scores f o r T r a i n i n g and No T r a i n i n g Groups (N = 54)  57  D i s t r i b u t i o n of Mean Empathy Scores f o r T r a i n i n g and No T r a i n i n g Groups (N_ = 54)  58  Comparison of C o g n i t i v e Development Scores of No T r a i n i n g and T r a i n i n g Groups  61  ACKNOWLEDGEMENTS  I would l i k e to express my appreciation to the following people:  Dr. P.  A r l i n , Dr. B. Long, and Dr. R. Young for their constructive c r i t i c i s m and support.  The subjects for their participation  i n 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 t h i s study i s t o i n v e s t i g a t e the r e l a t i o n s h i p of  n u r s i n g s t u d e n t s ' c o g n i t i v e development, t h e i r age, and an empathy s k i l l s program t h a t they experience t o the s t u d e n t s ' a b i l i t y empathically with p a t i e n t s . and p e r s p e c t i v e of another suggested Piaget's  Empathy i n v o l v e s the a b i l i t y (Byrne,  that t h i s a b i l i t y  to communicate to take the r o l e  1973; Selman & Byrne, 1974) and i t i s  i n c r e a s e s as one a c h i e v e s I n h e l d e r and  (1958) c o g n i t i v e developmental  stage of formal o p e r a t i o n s .  f i n d i n g t h a t o n l y 50 percent of a d o l e s c e n t s and a d u l t s achieve operations  The  formal  (Neimark, 1975) r a i s e s a q u e s t i o n about n u r s i n g s t u d e n t s '  c o g n i t i v e p r e r e q u i s i t e s f o r the s k i l l  of empathizing.  Contradictory  f i n d i n g s have been r e p o r t e d i n the l i t e r a t u r e about the e f f e c t s o f age and t r a i n i n g programs on s u b j e c t s ' a b i l i t y (Mynatt,  to communicate e m p a t h i c a l l y  1985).  The Background of the Problem Nurses are expected  to communicate e f f e c t i v e l y w i t h p a t i e n t s .  i n c l u d e s communicating s e n s i t i v e l y and e m p a t h i c a l l y .  Nursing  This  educators  r e c o g n i z e t h i s e x p e c t a t i o n and i n c l u d e communication s k i l l s as an i n t e g r a l and important  p a r t of n u r s i n g c u r r i c u l a .  t r a i n i n g methods have been developed Goldstein,  Numerous communication s k i l l s  (Bullmer, 1972; Egan, 1976;  1973, 1981; Ivey & A u t h i e r , 1971; Truax & C a r k h u f f ,  These t r a i n i n g programs a l l emphasize the c e n t r a l importance  1  1967).  t h a t empathy  has i n effective interpersonal communication.  Some of these training  methods have been adopted i n diploma and baccalaureate nursing programs. The faculty who teach the diploma nursing program at the B r i t i s h Columbia Institute of Technology  (BCIT) have adopted the interactive  s k i l l s training method of Egan (1976, 1982a, 1982b).  It i s a didactic-  experiential training approach and was described by Goldstein and Michaels (1985) as follows: The essence of this approach i s the simultaneous  didactic  instruction of trainees i n a spectrum of interpersonal s k i l l s , while at the same time providing a group experience i n which the newly learned s k i l l s may be experimented feedback, modified —  with —  t r i e d , provided with  i n a semiprotective human context.  The s k i l l s 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 f i r s t i s basic empathy, which i s considered a basic response s k i l l .  The second l e v e l , advanced empathy, i s called a  challenging s k i l l . In the BCIT diploma nursing program the didactic component of the s k i l l training program i s 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.  A l l of the s k i l l s i n 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 i n small groups where practice exercises are done using videotaped, c o l l e g i a l and instructor feedback.  2  The students are also  expected to use appropriate interactive s k i l l s with patients during their c l i n i c a l practica and  to share these experiences with instructors and/or  colleagues for feedback.  The  c l i n i c a l practica occur primarily  medical, surgical, gerontological, units of hospitals.  The  in  psychiatric, o b s t e t r i c a l and  interactive s k i l l s are only one  pediatric  component of  the  many nursing s k i l l s that students are expected to apply i n their work with the patients to whom they are assigned.  This training program i s an  i n t e g r a l part of the curriculum i n each term of the 5-term, 21-month nursing program. The majority of faculty i n the nursing department undertook 36 hours of the same s k i l l s training with a faculty member from the Department of Counselling Psychology at the University  of B r i t i s h Columbia.  Although  Durlak (1979) has made clear the r e l a t i v e unimportance of l e v e l of credentials  for interpersonal  s k i l l s and especially empathy trainers, i t  i s noteworthy that the BCIT nursing faculty are knowledgeable and at least minimally experienced i n the Egan s k i l l s training method. training was  done i n order to enhance the effectiveness  and  The  faculty  consistency of  the implementation of the s k i l l s training model i n the program.  Statement of the Problem and Purpose of the Study An improvement i n students' interpersonal observed informally  effectiveness  has been  by the nursing faculty since the implementation of  s k i l l s training program i n 1985.  It i s recognized that a  the  systematically-  sequenced, comprehensive approach using various teaching/learning techniques i s more e f f e c t i v e than the less formal and  3  less t h e o r e t i c a l l y  based approach that preceded i t .  However, a concern about the training  has become apparent. It has' been noted by the investigator that some s k i l l s apparently are understood and mastered by students more consistently and more easily than other s k i l l s are.  Empathy f a l l s into the l a t t e r 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, i t i s apparent that some students achieve a s a t i s f a c t o r y l e v e l of understanding and communication of the other s k i l l s , but not of empathy. The investigator has attempted  to understand this problem  through  discussion with students and instructors and by analyzing transcribed and l i v e interactions. empathic  It appears that students' unsuccessful attempts at  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 f a i l s f i r s t to withdraw from subjective involvement and second, to use the methods of reason and scrutiny.  A  complicating factor i n this process i s 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 i s made i s that the student responds on the basis of his or her knowledge about people i n general.  Assuming that a woman i s sad about the death of her  mother because that i s a commonly experienced emotion i s an example of 4  stereotyped knowledge.  Its occurrence implies a lack of individualized  attention and o b j e c t i v i t y toward the person with whom one i s interacting. Borke (1972), i n her response to Chandler and Greenspan, said that the processes of projection and stereotyped knowledge were a form of empathy.  preliminary  Although these three investigators were r e f e r r i n g 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 i n the students' interactions with patients and discussions  about patients.  It i s suggested here that a factor that may  account for some  students' use of projection and stereotyped knowledge instead of empathy, i n spite of their having received empathy t r a i n i n g , i s a general lack of i n t e l l e c t u a l maturity as reflected i n their age and more s p e c i f i c a l l y i n their l e v e l of cognitive development.  The  purpose of this study i s to  investigate the predictive relationship of the variables of age, empathy s k i l l training and cognitive developmental l e v e l to BCIT diploma nursing students' a b i l i t y to communicate empathically  Definition  The  of  with patients.  Terms  terms to be used i n this study are as  Empathy:  follows:  Empathy i s a' multidimensional process including  perceptual/affective, cognitive and communicative components.  The  focus  of this study i s the cognitive component, which i s the a b i l i t y to objectively take the role and perspective  of another.  Conceptual and  operational d e f i n i t i o n s of empathy are reviewed i n Chapter I I .  5  Level of Cognitive Development:  The theoretical framework of this  study i s Piaget's theory of cognitive development which describes four stages i n i n t e l l e c t u a l growth, culminating i n hypothetico-deductive reasoning.  Each stage or l e v e l comprises s p e c i f i c cognitive operations  that one uses to solve problems and understand Interactive S k i l l s Training: systematically-sequenced  the world.  Comprehensive, theoretically-based,  and usually time-limited training methods or  programs designed to enhance the interactive effectiveness of professional helpers (counsellors, s o c i a l workers, nurses, teachers) and lay people i n general (parents, adolescents).  Assumptions  The following basic assumptions underlie this study. 1.  Empathic communication i s 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 r e s t r i c t e d to BCIT diploma nursing students i n order to maintain the homogeneity of the subjects with regard to the program curriculum i n general and the empathy s k i l l s training program specifically.  Other c r i t e r i a that were held constant by r e s t r i c t i n g the  6  study to BCIT were the applicant selection c r i t e r i a  (admission  prerequisites) and the subjects' exposure to d i f f e r e n t faculty. The subjects participated i n the study on a voluntary basis, hence the sample was  not truly representative of the population.  Rosenthal and  Rosnow (1975) have i d e n t i f i e d a number of c h a r a c t e r i s t i c s of volunteers, some of which may  be relevant to the dependent variable of this study,  that i s , empathic communication.  Volunteers  are thought to be higher i n  need for s o c i a l approval, more sociable, more unconventional and less authoritarian than non-volunteers.  These c h a r a c t e r i s t i c s r e f l e c t two of  the four factors that emerged from a factor analysis of Hogan's Empathy Scale, namely Social Self-Confidence Cheek, & Smither, 1983).  1969  and Nonconformity (Johnson,  The independent variables of this study, namely  age and cognitive development are also reflected i n the c h a r a c t e r i s t i c s of volunteers.  Female volunteers  than non-volunteers.  for laboratory research tend to be younger  As well volunteers  tend to be better educated and  more i n t e l l i g e n t , two c h a r a c t e r i s t i c s that might have a positive effect on the variable of cognitive development.  A l l these c h a r a c t e r i s t i c s , except  for the one related to age, are ones that Rosenthal and Rosnow (1975) categorized at the maximum and considerable then, those who  volunteered  confidence  levels.  Perhaps,  i n this study were more empathic, had  higher  cognitive development l e v e l s , and were younger than their counterpart volunteers.  Generalizations therefore, are limited to the  non-  volunteers.  The results of the study are limited by the s e n s i t i v i t y of the psychological measuring instruments to r e f l e c t actual differences i n subjects' cognitive development and their a b i l i t y to communicate empathically.  As well, i t i s recognized 7  that the empathy scores of the  subjects who  have received empathy training may  consistency of the content, delivery method and  have been affected  by  the  teacher competence during  the training program. The  methodology used i n this study presented l i m i t a t i o n s .  l i m i t a t i o n was  the fact that, due  this study, i t was variable,  to the time frames of the curriculum  empathic communication, on the Training  That i s , i n i t i a l differences  between the Training  presented a l i m i t a t i o n .  and  No Training  on the c r i t e r i o n  groups were not known.  It takes approximately one  training  calendar year from the  time students begin to learn about empathy u n t i l they have completed on advanced empathy.  the predictor  and  group prior to their  F i n a l l y , the protracted length of the empathy s k i l l s  section  such  not possible to obtain a measure of the c r i t e r i o n  experiencing the training. variable,  One  variables  c r i t e r i o n variable,  It i s reasonable that variables  of this study could have had  other than  an effect on  empathic communication, i n the Training  the  the  group  subj ects.  Hypotheses 1.  There w i l l be a s i g n i f i c a n t linear relationship predictor  variables  between the  of nursing students' l e v e l of cognitive  development, their age, interactive s k i l l s and  and  training or no  training.in  the c r i t e r i o n variable  of empathic  interaction. 2.  Subjects with more years of post-secondary education w i l l show greater empathic interaction a b i l i t y when compared to subjects with fewer years of post-secondary education. 8  3.  Subjects with the cognitive a b i l i t y to coordinate multiple frames of reference w i l l show greater empathic interaction a b i l i t y when compared to subjects without the cognitive a b i l i t y to coordinate multiple frames of reference.  Description of the Following Chapters A review of selected, relevant l i t e r a t u r e i s presented under the following headings:  i n Chapter II  Conceptual Definitions of Empathy;  Operational Definitions of Empathy; The Development of Empathy; Nursing and Empathy.  The research methodology i s described i n Chapter I I I . It  involves the measurement and analysis of the four variables under question.  Chapter IV presents the findings and Chapter V i s 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 i n conceptual  models of nursing, i s the relationship between the  nurse and the patient (Flaskerud & Halloran, 1980; Riehl & Roy, 1980). The importance of this relationship i s evident i n e t h i c a l codes and practice standards developed by professional nursing associations (Canadian Nurses Association, 1985; Registered Nurses Association of B r i t i s h Columbia, 1984).  Nurse educators, s t r i v i n g to help students and  new graduates to meet these standards, include i n t e r a c t i v e s k i l l s as a component of the nursing curriculum.  The a b i l i t y to demonstrate empathy  is one s k i l l that i s part of that component. the construct of empathy.  Both the conceptual  of empathy w i l l be reviewed.  This review w i l l focus on and operational d e f i n i t i o n s  The section on the development of empathy  w i l l emphasize the cognitive aspect of the construct i n d i f f e r e n t age groups.  The review w i l l then focus on nursing and how knowledge of the  construct of empathy has been applied and investigated i n the f i e l d of nursing.  Conceptual D e f i n i t i o n s of Empathy The construct of empathy i s a subject of interest to various d i s c i p l i n e s within the behavioural  sciences and to professional groups  such as nurses, s o c i a l workers, teachers and counsellors.  I t i s apparent  from the l i t e r a t u r e that empathy - evidence for i t s existence, i t s determinants and i t s effects - i s not a precise or simple construct.  10  S e v e r a l reviews of the c o n s t r u c t (Buchheimer, 1963; Bornstein, Michaels  of empathy have been undertaken  Deutsch & Madle, 1975;  & Silver,  1984;  Smither, 1977).  (1985) reviewed h i s t o r i c a l and  empathy from a conceptual  Katz,  1963;  Recently,  Lichtenberg, Goldstein  and  contemporary d e f i n i t i o n s of  as w e l l as an o p e r a t i o n a l p o i n t of view.  review of d i v e r s e f i e l d s of i n q u i r y - a e s t h e t i c s , s o c i o l o g y and - l e d them to a m u l t i d i m e n s i o n a l ,  comprehensive, conceptual  Their  psychology  d e s c r i p t i o n of  this elusive construct. The  perceptual  d e s c r i b e d by L i p p s " f e e l i n g oneself  and  i n 1897.  He  coined  i n t o , " which was  (Goldstein & Michaels, to the p e r c e p t i o n , but  a f f e c t i v e components of empathy were  1985).  contemplation  the term " E i n f u h l u n g "  Lipps and  initially  o b j e c t s or persons as t a r g e t s , and  (Goldstein & Michaels, The  a f f e c t i v e a p p r e c i a t i o n of an  He  by  could i n v o l v e both  4).  added, to the p e r c e p t u a l  taking.  "Empathy proceeded  through cue-produced shared f e e l i n g s "  to understand the other  perspective  object,  c o n s i s t e d l a r g e l y of heightened  c o g n i t i v e component of empathy was  Mead (1934). ability  p.  as empathy  used the term i n r e l a t i o n  i m i t a t i o n [motor m i m i c r y ] ,  u n d e r s t a n d i n g of the other  to mean  l a t e r t r a n s l a t e d by T i c h e n e r  l a t e r extended the meaning to i n c l u d e people.  means of p r o j e c t i o n and  first  and  introduced  i n the work of  a f f e c t i v e components,  through the process  the  of r o l e t a k i n g or  T h i s component of empathy i s the focus of t h i s  study  and w i l l be expanded upon i n the s e c t i o n on the development of empathy. The  last  sensitively  component of empathy, the a b i l i t y to a c c u r a t e l y  communicate one's p e r c e p t u a l , a f f e c t i v e and  to another, has  c o g n i t i v e empathy  r e c e i v e d most a t t e n t i o n from those i n v o l v e d i n  11  and  psychotherapy and  other  interpersonal helping professions,  nursing,  c o u n s e l l i n g and  s o c i a l work ( C a r k h u f f ,  Authier,  1978;  provides  i n t e r p e r s o n a l evidence of the other  Rogers, 1975;  Truax & Carkhuff,  Reik (1949), Keefe (1976, 1979) proposed v a r i o u s phase conceptions Table  1.  and  1969; 1967).  teaching,  Egan, 1976;  T h i s component  three.  Barrett-Lennard  of empathy.  (1981) have  They are presented  A l l three d e f i n i t i o n s i n c l u d e p e r c e p t u a l , a f f e c t i v e  c o g n i t i v e components and  Keefe (1976, 1979)  i n c l u d e the communicative component.  Ivey &  and  and  Barrett-Lennard  Although s i m i l a r i t i e s  in  (1981)  and  d i f f e r e n c e s are apparent, the e s s e n t i a l p o i n t i s that empathy i s not simple  or p r e c i s e c o n s t r u c t , but  phase c o n c e p t i o n  r a t h e r a complex p r o c e s s .  This  multiple  of empathy i s endorsed by G o l d s t e i n and M i c h a e l s  as a comprehensive c o n c e p t u a l A d i s c u s s i o n and  a  (1985)  d e f i n i t i o n of empathy.  review of l i t e r a t u r e r e l a t e d to o p e r a t i o n a l  d e f i n i t i o n s of empathy f o l l o w s .  Operational Definitions of Empathy Reviews of o p e r a t i o n a l d e f i n i t i o n s of empathy, evidenced i n measurement instruments,  r e v e a l that they are o f t e n something l e s s  the comprehensive c o n c e p t u a l McCain, C a r b o n n e l l ,  definition  & Hagen, 1985;  Feldstein & Gladstein,  1980;  (Barrett-Lennard,  Davis,  1983;  G l a d s t e i n , 1977;  Harman (1986) wrote:  12  1981;  Deutsch & Madle,  Kurtz  than  Chlopan, 1975;  & Grummon, 1972).  TABLE 1 C o m p a r i s o n o f R e i k ' s ( 1 9 4 9 ) , K e e f e ' s ( 1 9 7 6 , 1979) and B a r r e t t - L e o n a r d ' s (1981) C o n c e p t u a l D e f i n i t i o n s o f Empathy Reik  Barrett-Lennard  Keefe  1. I d e n t i f i c a t i o n : Absorption i n contemplating the other person and h i s experiences.  Perception of the feeling state and thoughts of the other by means of the other's overt behavioural cues (both verbal and nonverbal).  Empathic attentional set: Openness to the psychological l i f e of the other.  2. Incorporation: Taking the experience of the other person into oneself by introjection.  A direct feeling response, an " a s - i f " experiencing of the other's affective world.  Empathic resonation: The other's d i r e c t l y or i n d i r e c t l y conveyed experience becomes experientially a l i v e , v i v i d and known to one.  Reverberation: The echoing of the other's experience upon some part of one's own experience. 3. Detachment: Withdrawal from subjective involvement i n order to gain s o c i a l and psychic distance. Objective analysis through reason and scrutiny.  Separating one's own feelings from those perceived and experienced " a s - i f " the other.  4.  Communicating accurate feedback to the other.  Expressed empathy: Communication of a quality of f e l t 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 r e s e a r c h e r s have found l i t t l e  r e l a t i o n among d i f f e r e n t  empathy, as G l a d s t e i n (1985) r e c e n t l y observed,  t e s t s of  i s understandable i n  view o f B a r r e t t - L e n n a r d ' s (1981) a s s e r t i o n that the measures assess different to  stages of a p r o c e s s , and t h e r e f o r e would not be expected  be h i g h l y c o r r e l a t e d ,  Not o n l y i s there l i t t l e  ( p . 371)  r e l a t i o n s h i p amongst the d i f f e r e n t measures, but  t h e r e i s a l s o evidence which q u e s t i o n s the r e l i a b i l i t y individual  and v a l i d i t y of  instruments.  V a r i o u s c l a s s i f i c a t i o n s of measurement instruments have been proposed.  Deutsch  (1985), used  and Madle (1975), as w e l l as G o l d s t e i n and M i c h a e l s  the terms " p r e d i c t i v e " and " s i t u a t i o n a l " to c l a s s i f y  K u r t z and Grummon (1972) d e s c r i b e d two a d d i t i o n a l approaches, r a t i n g s and p e r c e i v e d empathy r a t i n g s .  them.  tape-judged  These l a t t e r were c a l l e d ,  r e s p e c t i v e l y , " o b j e c t i v e " and " s u b j e c t i v e " by F e l d s t e i n and G l a d s t e i n (1980) i n t h e i r comparison of measures of empathy.  Another group o f  instruments a r e those t h a t measure empathy as a p e r s o n a l i t y process or trait  (Hogan, 1969; D a v i s , 1983; Mehrabian & E p s t e i n , 1972).  w i l l be reviewed  The measures  b r i e f l y a c c o r d i n g to the components of the c o n c e p t u a l  d e f i n i t i o n , t h a t i s , the c o g n i t i v e , p e r c e p t u a l / a f f e c t i v e and communicative processes. C o g n i t i v e measures.  The c o g n i t i v e component i s approached w i t h  p r e d i c t i v e measures and w i t h some p e r s o n a l i t y t e s t s .  P r e d i c t i v e measures  are those i n which the s u b j e c t ' s accuracy i n p r e d i c t i n g the s e l f - r a t i n g or p r e f e r e n c e s of another  i s taken as a measure o f the s u b j e c t ' s empathy  (Deutsch & Madle, 1975).  T h i s approach has v e r y l i m i t e d use i n c u r r e n t  empathy r e s e a r c h owing to m e t h o d o l o g i c a l problems i d e n t i f i e d by Cronbach  14  (1955).  Deutsch and  reliability The are  and  Madle (1975) a l s o have d e s c r i b e d  those focused on  t e s t s which measure empathy as a c o g n i t i v e the  subject's  (Hogan, 1969).  The  role taking a b i l i t y , reliability  and  Johnson, Cheek, and  (1983) f a c t o r - a n a l y z e d  self-confidence, are  Smither (1983) and  v a l i d i t y of  construct  Perceptual/affective  measures.  S i t u a t i o n a l measures r e q u i r e  The  that  The  t e s t s t i m u l i have been used and  M i c h a e l s (1985), who  Krathwohl, 1967). reliability not. and  s t a t e that a l s o the  c o n c e p t u a l d e f i n i t i o n of empathy. empathy r e s e a r c h  communicative The  One  are d e s c r i b e d  Deutsch and  by  c o g n i t i v e a n a l y s i s component of such measure that i s used i n  Madle (1975) r e p o r t  i t s convergent and  (Kagan &  that a l t h o u g h i t s  discriminant  validity is  r e l a t i o n s h i p between A f f e c t i v e S e n s i t i v i t y Test  scores  skill.  a f f e c t i v e component of empathy i s a l s o measured by  t e s t s such as  to  these measures draw upon  i s Kagan's A f f e c t i v e S e n s i t i v i t y Test  i s acceptable,  There i s no  i s required  s t i m u l i and/or a f f e c t i v e response  both the a f f e c t i v e component and  current  that  empathic response  subject  portrayed.  the  nonconformity —  the s u b j e c t ' s  contextual  and  social  a l s o w i t h some p e r s o n a l i t y  c o r r e c t l y l a b e l the  Goldstein  Johnson et  a f f e c t i v e component of empathy  be to a person's a f f e c t , s i t u a t i o n , or both.  Several  by  of empathy.  i s approached w i t h s i t u a t i o n a l measures and tests.  reviewed  i d e n t i f i e d four f a c t o r s —  even-temperedness, s e n s i t i v i t y and  r e l a t e d to the  the  Chlopan et a l . (1985).  the s c a l e and  process  such as the Hogan  instrument have been demonstrated i n s e v e r a l s t u d i e s and  al.  the  v a l i d i t y of such measures.  personality  Empathy Scale  problems w i t h  personality  the Q u e s t i o n n a i r e Measure of Emotional Empathy (QMEE,  Mehrabian & E p s t e i n , 1972). v i c a r i o u s l y experience have d i s c u s s e d  the f e e l i n g s of another.  the r e l i a b i l i t y and  be s a t i s f a c t o r y , and  to  Chlopan et a l . (1985)  v a l i d i t y of t h i s measure, found them to  have suggested t h a t the QMEE combined w i t h  Empathy S c a l e p r o v i d e s c o g n i t i v e and  T h i s measures the s u b j e c t ' s a b i l i t y  the Hogan  a b a s i s f o r the measurement of empathy from a  p e r c e p t u a l / a f f e c t i v e p o i n t of view.  T h i s combined p o i n t of view has  been promoted by Davis (1983),  developed the I n t e r p e r s o n a l R e a c t i v i t y Index ( I R I ) .  He  suggested:  Rather than t r e a t i n g empathy as a s i n g l e u n i p o l a r c o n s t r u c t  (i.e.,  as e i t h e r c o g n i t i v e or e m o t i o n a l ) ,  the  the r a t i o n a l e u n d e r l y i n g  i s t h a t empathy can best be c o n s i d e r e d  as a set of  c l e a r l y d i s c r i m i n a b l e from each o t h e r , IRI c o n s i s t s of f o u r s u b s c a l e s  ( F ) , Empathic Concern (EC) and  —  (p.  D i s t r e s s (PD)  t h a t "as d i s p a r a t e as these f o u r c o n s t r u c t s may reflect  the v a r i e t y of r e a c t i o n s to others  r e f e r r e d to as empathy" (p. 114). IRI and empathy.  —  (PT), Fantasy and  Davis s t a t e s  appear, they a c c u r a t e l y  that have at some time been  Davis r e p o r t e d v a l i d i t y t e s t s of  concluded that the r e s u l t s support The  are a l s o  113)  Perspective-taking  Personal  a multidimensional  f o r e g o i n g instruments are o u t l i n e d i n Table  16  IRI  constructs,  r e l a t e d i n t h a t they a l l concern r e s p o n s i v i t y to others but  The  who  2.  the  view of  TABLE 2 R e l i a b i l i t y and V a l i d i t y Reports of C o g n i t i v e and A f f e c t i v e M e a s u r e s o f Empathy Reliability  Validity  Reference  Cognitive  - Predictive Scale f o r the measurement of empathic a b i l i t y (Dymond, 1949)  No  No  Cronbach (1955)  The Empathy Test (Kerr & Speroff, 1954)  No  No  Deutsch & Madle (1975)  Yes  Yes  Johnson, Cheek, & Smither (1983); Chlopan, McCain, Carbonell, & Hagen (1985)  Yes  No  Deutsch & Madle (1975)  Yes  Yes  Chlopan, McCain, Carbonell, & Hagen (1985)  Yes  Yes  Davis (1983)  Personality Empathy Scale (Hogan, 1969)  Affective  Situational Affective S e n s i t i v i t y Test (Kagan, Krathwohl, & Associates, 1967) Personality Questionnaire Measure of Emotional Empathy (Mehrabian & Epstein, 1972)  Cognitive/Affective  Personality Interpersonal Reactivity Index (Davis, 1983)  17  Communicative measures.  Instruments that measure the  aspects of empathy, t h a t i s , one's a b i l i t y communicate one's p e r c e p t u a l , are  the l a s t  tape-judged  ( o b j e c t i v e ) and  F e l d s t e i n and  Gladstein  o b j e c t i v e and  two  to a c c u r a t e l y and s e n s i t i v e l y  a f f e c t i v e and  to be reviewed here.  c o g n i t i v e empathy to another,  These instruments are r e f e r r e d to  perceived  as  ( s u b j e c t i v e ) empathy r a t i n g s .  (1980) analyzed  subjective, according  (1975) t h e o r e t i c a l f o r m u l a t i o n s ,  communicative  f o u r such empathy measures,  two  to s i x c r i t e r i a based on Rogers'  i n order  to determine the  construct  v a l i d i t y of the measures. The (AES,  o b j e c t i v e instruments were the Truax A c c u r a t e Empathy  Truax & C a r k h u f f ,  Interpersonal  1967)  Process Scale  and  (EUS,  Carkhuff's Carkhuff,  instruments were the B a r r e t t - L e n n a r d Barrett-Lennard, Carkhuff,  1962)  1969).  Relationship  the Truax R e l a t i o n s h i p  Gladstein  to meet the same two first  Empathic Understanding i n The  subjective  Inventory  (BLRI,  Inventory (TRI,  Truax &  1967).  F e l d s t e i n and  The  and  Scale  (1980) showed that a l l f o u r measures f a i l e d  c r i t e r i a and  c r i t e r i o n not met  by  thus had  l i m i t e d construct  validity.  the instruments i s A f f e c t i v e Empathy,  a e s t h e t i c s t a t e of unconscious emotional i m i t a t i o n and  identification  counsellors with c l i e n t s .  unobservable  a c t i v a t i o n of the Gladstein,  1980,  I t i n v o l v e s an i n t e r n a l and  counsellor's p.  50).  The  f e e l i n g s and  helpers  authors s t a t e that the instruments (p. 51).  "only  However, the  f a i l u r e of the instruments r e l a t e s to t h e i r i n a b i l i t y  on t h e i r communication of "not  c l i e n t s ' words but  only  of  fantasies" (Feldstein &  h i n t at the a e s t h e t i c e x p e r i e n c e of the h e l p e r " more s e r i o u s  "the  to r a t e  t h e i r u n d e r s t a n d i n g of  a l s o a l l the n o n - v e r b a l a s p e c t s that accompany these  18  words" (p. 50).  This c r i t i c i s m i s consistent with previous c r i t i q u e s  Chinsky and Rappaport (1970) and Rappaport and Chinsky and G l a d s t e i n conclude empathy i n response i n Table  (1972).  that the instruments h o l d promise  to c l i e n t s ' v e r b a l i z a t i o n s o n l y .  by  Feldstein  as measures of  They are summarized  3.  I t i s suggested here that measurement of empathy i s f a r from  precise  and a c c u r a t e and that G l a d s t e i n ' s recommendation to s p e c i f y "which type of empathy i s being measured by which s p e c i f i c type of i n s t r u m e n t " (1977, p. 77) be f o l l o w e d .  Other  recommendations ( F e l d s t e i n & G l a d s t e i n ,  1980)  r e g a r d i n g instruments are that t h e i r l i m i t a t i o n s be c o n s i d e r e d and s e v e r a l instruments may study. was  be used  to tap the empathic  C a r k h u f f ' s Empathic Understanding  dimensions  under  i n I n t e r p e r s o n a l Process S c a l e  used i n t h i s study because the i n v e s t i g a t o r c o n s i d e r e d i t to be  best of the measures of communicative empathy.  words and not t h e i r non-verbal communication, the i n v e s t i g a t o r v i d e o t a p e s of c l i e n t study responded.  Development  The  of  the  To overcome the weakness  i n C a r k h u f f ' s instrument of having h e l p e r s responding to o n l y the  The  that  clients'  developed  s t i m u l u s e x p r e s s i o n s to which the s u b j e c t s i n t h i s instrument i s f u l l y d e s c r i b e d i n Chapter I I I .  Empathy  G o l d s t e i n and M i c h a e l s (1985) s t a t e d : T r a i n i n g i n empathy d u r i n g adulthood probably must b u i l d on a s e t of n a t u r a l l y developing a b i l i t i e s  that begin i n c h i l d h o o d and  continue to emerge a c r o s s the l i f e - s p a n .  19  (p.  61)  that  TABLE  3  C o m p a r i s o n off C o n u r u m i c a t i v e E m p a t h y Empathy C r i t e r i a ( R o g e r s , 1975)  Instruments  Objective AES EUS  Subjective BLRI TRI  Cognitive empathy; empathic understanding; role taking skill.  Yes  Yes  Yes  Yes  Affective empathy; unconscious emotional imitation and i d e n t i f i c a t i o n with c l i e n t s .  No  No  No  No  The temporary suspension of one's belief system.  Yes  Yes  Yes  Yes  Empathy as a process; moment to moment s e n s i t i v i t y to the other; continually evolving behaviour.  Yes  Yes  No  No  The communication of an empathic experience; communication of an understanding of c l i e n t s ' words and the non-verbal aspects accompanying the words; f l e x i b i l i t y i n a l t e r i n g and checking their statements.  No  No  No  No  Additive empathy; the sensing of meanings of which the c l i e n t i s scarcely aware or has chosen not to express.  Yes  Yes  No  Yes  AES: EUS: BLRI: TRI:  Accurate Empathy Scale, Truax & Carkhuff (1967). Empathic Understanding i n Interpersonal Processes Scale, Carkhuff (1969). Barrett-Lennard Relationship Inventory, Barrett-Lennard (1962). Truax Relationship Inventory, Truax & Carkhuff (1967).  20  T h i s statement u n d e r s c o r e s the importance o f a developmental process i n empathy.  The two dimensions o f empathy which have r e c e i v e d the most  a t t e n t i o n i n the c h i l d development a f f e c t i v e dimensions.  l i t e r a t u r e a r e the c o g n i t i v e and  P e r c e p t i o n , communication  and s o c i a l i z a t i o n have  a l s o been s t u d i e d as important i n the development will  focus on c o g n i t i v e development,  o f empathy.  T h i s review  as i t i s the dimension most r e l e v a n t  to t h i s study. Both M a r t i n Hoffman (1976, 1977, 1982) and Norma Feshbach  (1975,  1978) have proposed m u l t i d i m e n s i o n a l models o f empathy development i n c h i l d r e n which, though p r i m a r i l y a f f e c t i v e , have important c o g n i t i v e elements.  Hoffman has i d e n t i f i e d empathic d i s t r e s s as the major mediator  of p r o s o c i a l and a l t r u i s t i c behaviour and has d e s c r i b e d s i x d i f f e r e n t modes through which the v i c a r i o u s a f f e c t i v e response i s aroused. modes f o l l o w a developmental p r o g r e s s i o n and are dependent,  These  i n p a r t , on  c o g n i t i v e p r o c e s s i n g , i n p a r t i c u l a r the c h i l d ' s a b i l i t y to d i f f e r e n t i a t e s e l f from o t h e r s ( G o l d s t e i n & M i c h a e l s , 1985).  Some of the c o g n i t i v e  accomplishments which Hoffman sees as s i g n i f i c a n t i n s e l f - o t h e r d i f f e r e n t i a t i o n are person permanence i n the p h y s i c a l , c o g n i t i v e and a f f e c t i v e realms, r o l e t a k i n g , language development, and comprehension  and an a p p r e c i a t i o n  of the concept o f time and h i s t o r y .  Feshbach's model i s concerned w i t h the development  o f a much wider  range o f empathic e x p e r i e n c e s i n c h i l d r e n than Hoffman's narrower f o c u s on empathic d i s t r e s s o n l y .  The c o g n i t i v e components which Feshbach  describes  as p r e c u r s o r s to the c h i l d ' s emotional r e s p o n s i v e n e s s to the e x p e r i e n c e o f the o t h e r a r e , f i r s t ,  the a b i l i t y t o d i s c r i m i n a t e the emotional s t a t e o f  another and, second, the a b i l i t y  to assume the p e r s p e c t i v e and r o l e of the  21  other.  These two a b i l i t i e s are basic to the broader f i e l d of s o c i a l  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 i n general, and role and perspective taking s p e c i f i c a l l y i n the a f f e c t i v e realm.  Egocentrism i s a  state of fusion or undifferentiation between the self and other people which i s resolved or reversed progressively through s p e c i f i c cognitive developmental stages.  This i s decentration and i t i s the  decentration  during Piaget's formal operational stage of adolescence and young adulthood that i s of most significance to this study.  A more detailed  discussion of this w i l l 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 i s able to see that others may  think and f e e l d i f f e r e n t l y from  oneself, the i n f e r e n t i a l process of role or perspective taking can be used to determine what those differences actually are. process.  It i s a sequential  F l a v e l l ( F l a v e l l , Botkin, Fry, Wright, & J a r v i s , 1968)  proposed a five-step information processing model of role taking.  has Selman  (1980), on the other hand, has proposed a model more i n the Piagetian tradition.  " I t describes a series of f i v e cognitive advances i n the  s e l f ' s understanding and coordination of i t s own (Goldstein & Michaels,  relationship to others"  1985).  It i s important to emphasize that the role-taking models referred to have been developed to address s o c i a l cognition i n several areas.  22  In  order  to understand the c o g n i t i v e component of empathy, one  perspective  t a k i n g i n the a f f e c t i v e realm  must examine  specifically.  In the e a r l y 1970's Helen Borke (1971, 1972), M i c h a e l  Chandler  Stephen Greenspan (1972) engaged i n a seminal debate r e g a r d i n g perspective  t a k i n g i n the a f f e c t i v e realm.  that c h i l d r e n as young as 3 years challenging Piaget's years  o l d precludes  belief  s u b j e c t s was  f e e l i n g s and other  two  r e b u t t a l , incorporated  stereotyped  perspective  age  Greenspan (1972)  and  Chandler and  knowledge i n order  to understand  and  T h i s debate l e d  d e s c r i p t i o n of the process  10 months and  5 years  of  i n which the e m o t i o n a l l y the other  taking  2 months, u s i n g  r e l e v a n t c l u e s were  two evident  i n which p s y c h o l o g i c a l i n f e r e n c e about  s u b j e c t s i s r e q u i r e d to c o r r e c t l y i d e n t i f y the emotions. Michaels  use  others'  (1979) conducted r e s e a r c h on p e r s p e c t i v e  groups, 3 years  i n the s i t u a t i o n and  Greenspan's  taking.  Keating  types of s t o r i e s , one  knowledge.  s t a t e d that young c h i l d r e n may  that t h i s i s a p r e l i m i n a r y form of empathy.  Gove and with  Chandler and  s a i d what Borke c a l l e d empathy i n  investigators into a microanalysis  r o l e and  f e e l i n g s , thus  i n r e a l i t y a form of p r o j e c t i o n or s t e r e o t y p e d  c r i t i c i s m i n t o her h y p o t h e s i s p r o j e c t i o n and  showed  that egocentrism i n c h i l d r e n younger than 7  empathic awareness.  Borke (1972), i n her  and  Borke's (1971) r e s e a r c h  o l d were aware of o t h e r s '  argued a g a i n s t Borke's c o n c l u s i o n and her  role  and  (1985) summarized Gove and  Goldstein  the  and  K e a t i n g ' s (1979) c o n c l u s i o n s :  i n terms of developmental p r o g r e s s i o n ,  emotions are c o n s i d e r e d  to  be  a p a r t of the s i t u a t i o n i t s e l f , w i t h r o l e t a k i n g c o n s i s t i n g of simply  reading  o f f the a f f e c t i v e aspect  of the event.  L a t e r on when  c h i l d r e n understand t h a t f e e l i n g s are p s y c h o l o g i c a l events or  23  processes  they become focused more on the i n t e r n a l s t a t e of the  p a r t i c u l a r s t i m u l u s person, and r o l e t a k i n g becomes the p e r s p e c t i v e t a k i n g d e s c r i b e d i n the developmental  traditional  research,  The development of formal o p e r a t i o n s f u r t h e r d i f f e r e n t i a t e s t h i s and enables  the a d o l e s c e n t and young a d u l t to f o c u s on  c o m p l e x i t i e s and  (p.  25)  ability  increasing  s u b t l e t i e s of the i n t e r n a l s t a t e of the s t i m u l u s  person.  Another m i c r o a n a l y s i s of the s t a g e - l i k e development of p e r s p e c t i v e t a k i n g was  undertaken  by Urburg  and Docherty  (1976).  They d i f f e r e n t i a t e d  between the s t r u c t u r e and content of p a r t i c u l a r r o l e t a k i n g t a s k s . S t r u c t u r e they d e f i n e d as the c o g n i t i v e o p e r a t i o n s necessary to  perform  the t a s k s , such as the number of aspects of a problem to be c o n s i d e r e d whether they can be c o n s i d e r e d s e q u e n t i a l l y or s i m u l t a n e o u s l y . was  Content  d e f i n e d as the p a r t i c u l a r content t h a t the c o g n i t i v e o p e r a t i o n s work  on to produce a s o l u t i o n .  They, l i k e Gove and K e a t i n g (1979), designed  s e r i e s of r o l e t a k i n g t a s k s f o r 3, 4 and  5 year o l d c h i l d r e n .  The  d i f f e r e d i n the complexity of the s t r u c t u r a l component, the primary of  and  the study, w h i l e the a f f e c t i v e content was  Based on t h e i r r e s u l t s , Urburg it  and Docherty  tasks focus  kept simple and c o n s i s t e n t .  (1976)  suggested:  i s p o s s i b l e to d e f i n e c l o s e to an i n f i n i t e number of  developmental  sequences of r o l e t a k i n g s k i l l s . . . R a t h e r  than  c o n s i d e r i n g r o l e t a k i n g as a g l o b a l , u n i d i m e n s i o n a l a b i l i t y , v a r i a b l e s t h a t are known or h y p o t h e s i z e d process should be examined to determine  to a f f e c t  the  the r o l e t a k i n g  the developmental  each as w e l l as the i n t e r a c t i o n s between them. ( p .  course of  203)  T h i s s u g g e s t i o n r e l a t e d to the complexity of c o g n i t i v e development of  a  c h i l d r e n i n P i a g e t ' s p r e o p e r a t i o n a l stage i s a p p l i c a b l e i n d i s c u s s i o n  24  of formal operations and the eventual emergence of less egocentric thought in adolescence and young adulthood.  Theoretically, the development of  formal operations results i n a marked decline i n egocentrism consequently an increase i n perspective taking.  and  This i s oversimplistic,  as a review of the formal operations l i t e r a t u r e shows. Inhelder and Piaget (1958) i d e n t i f i e d 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 l e v e l 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 i t s results can lead the subject to organize a formal combinatorial system" (p. 281). what occurs and i n what order.  They describe the process of t r a n s i t i o n , According to Elkind (1967) i t i s 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 a l l the p o s s i b i l i t i e s i n a system and construct contrary to fact propositions (Inhelder & Piaget, 1958 i n Elkind, 1967), to conceptualize his or her own thought and to conceptualize the of other people.  thought  This l a t t e r i s , according to Elkind, the crux of  adolescent egocentrism.  The adolescent " f a i l s to d i f f e r e n t i a t e 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 a b i l i t y to role take i s most evident i n early adolescence and i s gradually overcome through the development of formal operations.  25  Arlin  (1981a, 1981b, 1984a) c l a r i f i e s  the development of formal and  operations  consequently an i n c r e a s e  r e s u l t s i n a d e c l i n e i n egocentrism  i n r o l e and  d i f f e r e n t i a t i n g between competence and formal  schemata. She  of competence and  described  performance.  the o v e r s i m p l i s t i c view that  perspective  taking  by  performance w i t h r e s p e c t  to  the  three v a r i a b l e s that a f f e c t the i n t e g r a t i o n The  f i r s t v a r i a b l e i s the  manner i n the i n t e g r a t i o n of competence and  phase-like  performance.  The  second  v a r i a b l e i s the p o s s i b i l i t y of a time l a g of approximately f i v e to seven years w i t h r e s p e c t of the formal  schemata.  i n s i s t e n c e on the (Arlin,  coordination So,  she  The  of c o n s t r u c t i o n of the e i g h t  A r l i n s t a t e s that no  of a c t i o n s w i t h a p p r o p r i a t e  enhanced a b i l i t y to take the r o l e and  operations  performance and  are not  perspective  & Adams,  egocentrism l e a d s of another and  operations,  a u n i t a r y concept and  competence i s s u b j e c t  the  e x p e r i e n c e (Kuhn, Ho,  accomplished through the a c q u i s i t i o n of formal that formal  been  well require  r e s o l u t i o n of adolescent  (1953-54)  schemata"  s i m u l t a n e i t y has  concurs that performance may  a l t h o u g h the  performance  t h i r d v a r i a b l e r e l a t e s to " P i a g e t ' s  simultaneity  1981b, p. 5 ) .  i d e n t i f i e d and  1979).  to the development of both competence and  i t is  to  an  this i s evident  the i n t e g r a t i o n of  to numerous complex v a r i a b l e s . i d e n t i f i e d by Urburg  This  complexity i s a r e f l e c t i o n of the  complexity  and  Docherty (1976) i n p r e o p e r a t i o n a l  c h i l d r e n , r e f e r r e d to e a r l i e r i n t h i s  review. Examination of the v a r i a b l e s a f f e c t i n g the a c q u i s i t i o n of the schemata leads perspective  to an a p p r e c i a t i o n of the a d o l e s c e n t ' s  take and  a b i l i t y to r o l e  consequently h i s or her a b i l i t y to be empathic.  schema that r e f l e c t s the concept of empathy most c l e a r l y i s the  26  formal and The'  coordination of two or more systems of reference.  The empathizer  i n an  interpersonal situation must be a f f e c t i v e l y i d e n t i f i e d 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 i n the empathizer's awareness even as they may change moment to moment.  This schema i s one of the last to  develop ( A r l i n , 1981b, 1984a; Neimark, 1975), appearing late i n adolescence, and i s thought to be a necessary but not s u f f i c i e n t condition for role taking (Byrne, 1973; Selman & Byrne, 1974). for this i n other areas as well.  There i s evidence  Studies that look at such cognitive  characteristics as cognitive complexity (Holloway & Walleat, 1980), tolerance for ambiguity  (Jones, 1974) and conceptual l e v e l (Goldberg,  1974; Harvey, Hunt, & Schroder, 1961) indicate that "more cognitively complex, open-minded trainees usually demonstrate greater s k i l l 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, i t might be evident as early as 17 in a precocious adolescent and as late as 21 i n a "late bloomer." might be so, only given the assumption  This  that the adolescent, i n the words  of Inhelder and Piaget (1958), " i s faced with certain kinds of data" (p. 308).  A r l i n views this formal schema as an advanced cognitive concept and  suggests, " I t may be the pivotal concept that marks the t r a n s i t i o n between adolescent and adult thought structures" (1981B, p. 7). She suggests that i t i s what moves the adolescent from a hypothetico-deductive l o g i c a l system into a r e l a t i v i s t i c l o g i c a l system.  27  A r l i n ' s p r o p o s i t i o n regarding adult cognitive research. observation population  and  the e i g h t h formal  I t must, however, be j u x t a p o s e d w i t h another  t h a t i s that only approximately 50%  of the  ever a t t a i n s the P i a g e t i a n s t a t e of formal  (Neimark, 1975). of r e f e r e n c e  As  schema i s seminal i n  important as the c o o r d i n a t i o n  i s f o r r o l e and  perspective  operational  of two  t a k i n g , and  adult thinking  or more frames  hence the  cognitive  component of empathy, that a b i l i t y i s not w e l l developed i n many p e o p l e .  N u r s i n g and Empathy Nursing t h e o r i s t s have d e s c r i b e d (King,  1981;  Orem, 1971;  Rogers, 1970;  C e n t r a l to humanism i s the c o n s t r u c t described  as an empathic and  nursing Roy,  p. 83).  view and it  1974;  of empathy.  Travelbee,  i n s p i t e of F o r s y t h e ' s  "Nursing i s c o n s i s t e n t l y  promotes independence" (Fenton,  "should  (1979, p. 53) be s u b j e c t e d  process of d e s c r i p t i o n , e x p l a n a t i o n ,  suggestion  p r e d i c t i o n and  Nursing r e s e a r c h  regarding  empathy has  empathic communication s k i l l s been i n empathy s k i l l looked  the f i r s t  nursing  tradition.  been d e r i v e d  being  scientific  c o n t r o l , " the  from  h u m a n i s t i c t h e o r e t i c a l framework of C a r l Rogers (1957, 1961). p r i m a r i l y on three a s p e c t s ,  of  t h a t empathy, as  to the s y s t e m a t i c  l i t e r a t u r e r e v e a l s a l e s s than comprehensive r e s e a r c h  has  1966).  In s p i t e of t h i s agreement, from a t h e o r e t i c a l p o i n t  r e l a t e s to n u r s i n g ,  focused  discipline  compassionate i n t e r p e r s o n a l process that  supports dependent needs of p a t i e n t s and 1986,  as a h u m a n i s t i c  the It  has  the d e s c r i p t i o n of  i n nurses.  The  second area of i n t e r e s t has  t r a i n i n g programs.  The  t h i r d area of i n v e s t i g a t i o n  at the r e l a t i o n s h i p of empathy to demographic v a r i a b l e s .  28  1.  Mansfield  (1973) conducted a study to i d e n t i f y verbal and non-  verbal behaviours that f a c i l i t a t e d 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 i d e n t i f i e d .  The behaviour categories were:  introduction to  the patient, head and body positions, verbal behaviour, response to nonverbal cues, f a c i a l expressions, voice tones, and mirror images. a p p l i c a b i l i t y of the study i s minimal because i t was  The  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 i n the study were not the c r i t i c a l factors i n the patients' perceptions empathy.  In f a c t , there was  of  no difference between patient-perceived  empathizers and low empathizers on both positive and  high  negative  communicative behaviours. 2.  Several studies have investigated the effects of empathy s k i l l  training on empathy scores (Clay, 1984; Karshmer & La Monica, 1976; Two  Hrubetz, 1975;  Larabee, 1980;  Law,  1978;  assumptions that underlie these studies are f i r s t  Kalisch,  1971;  Zimmerman, 1980). that empathy can be  learned and second that v i r t u a l l y any nurse can learn i t .  No attention i s  given to the fact that there might be i n d i v i d u a l differences i n s k i l l acquisition.  A l l of the studies support the idea that empathy s k i l l  training i s p o s i t i v e l y related to increased scores on various empathy rating scales.  standard  However, the scales themselves, as discussed  29  e a r l i e r , have questionable r e l i a b i l i t y and v a l i d i t y and consequently  so do  the findings. Clay (1984), i n developing an instrument  to use to both teach and  assess empathic interaction of nursing students, recognized and incorporated the complex and h i e r a r c h i c a l nature of the construct.  She  described a h i e r a r c h i c a l model of the behavioural components of an empathic nurse-patient interaction which r e f l e c t s the perceptual, cognitive and communicative phases of empathy described by Keefe (1979), Reik (1949) and Barrett-Lennard  (1981) and outlined e a r l i e r .  Each  category of Clay's model i s accompanied by a behavioural l i s t of nursing actions that give evidence of the category. were developed  The schedule and guidelines  from videotaped and l i v e nurse-patient interactions i n a  variety of c l i n i c a l practice settings. Their content and c r i t e r i o n related v a l i d i t y were found to be satisfactory i n 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 — behavioural aspects.  the emotional, the cognitive and the  Results showed s i g n i f i c a n t increases i n the f i r s t  two and no difference i n the l a t t e r following the treatment. treatment  The  i n this study was remarkably d i f f e r e n t from the treatments i n  the other studies.  It was e s s e n t i a l l y a semi-structured verbal  interaction group experience, i n which the theme of empathy and the research purpose were disguised to prevent biased responses to the questionnaires.  The treatment  i n the other studies was overtly empathy  s k i l l training.  30  3.  C o r r e l a t i o n a l s t u d i e s of empathy and demographic v a r i a b l e s  comprise the t h i r d area to be reviewed. significant  Collins  (1972) found  no  r e l a t i o n s h i p between dogmatism and empathy as measured by the  Barrett-Lennard  R e l a t i o n s h i p Inventory,  i n 198 b a c c a l a u r e a t e  nursing  s t u d e n t s , however, she d i d r e p o r t a s i g n i f i c a n t d i f f e r e n c e between  empathy  scores of sophomore and s e n i o r students which i n f l u e n c e d f u r t h e r investigation.  Howard  (1975) found  no s i g n i f i c a n t d i f f e r e n c e between  empathy as measured by the Carkhuff  Index of Communication ( C a r k h u f f ,  1969) i n sophomore, j u n i o r and s e n i o r students  i n one n u r s i n g s c h o o l .  T u r n i n g t o nurse p r a c t i t i o n e r s , that i s , s t a f f nurses v a r i o u s medical  s p e c i a l t y a r e a s , Forsythe  and head nurses i n  (1979) i n v e s t i g a t e d the  r e l a t i o n s h i p s between empathy scores as measured by the Hogan Empathy and  v a r i o u s demographics.  I n c r e a s i n g l y higher education  Test  (diploma,  a s s o c i a t e degree or degree) c o r r e l a t e d p o s i t i v e l y w i t h empathy scores and a l s o , had s t a t i s t i c a l l y of  s i g n i f i c a n t p r e d i c t i v e p r o p e r t i e s , as d i d l e n g t h  practice. The l a s t  ability  c o r r e l a t i o n a l study  and e d u c a t i o n a l progress  to be reviewed looked at empathic  of n u r s i n g s t u d e n t s .  Rogers (1986, p.  338) r e p o r t e d that " E d u c a t i o n a l p r o g r e s s i o n was not a s s o c i a t e d w i t h significant  i n c r e a s e s i n the r a t i n g s of sophomores, j u n i o r s and s e n i o r s on  the ECRS [La Monica, 1981] s e l f - r e p o r t and p a t i e n t r a t i n g . " prompted her to r e i t e r a t e q u e s t i o n s baccalaureate fail  programs f a i l  The  r a i s e d by La Monica (1981):  to teach empathy e f f e c t i v e l y or do  Do instruments  to measure the c o n s t r u c t ? As d e s c r i b e d , a l l the c o r r e l a t i o n a l s t u d i e s used d i f f e r e n t  of  results  empathy  ( B a r r e t t - L e n n a r d R e l a t i o n s h i p Inventory,  31  Carkhuff  measures  Index of  Communication, Hogan Empathy S c a l e ) , hence i t i s d i f f i c u l t s t u d i e s o r to r e c o n c i l e the c o n f l i c t i n g r e s u l t s . tape-judged o b j e c t i v e measures r e p o r t e d  review o f the l i t e r a t u r e on n u r s i n g  conceptual  The two s t u d i e s  using  s i m i l a r r e s u l t s , that i s , no  s i g n i f i c a n t d i f f e r e n c e between empathy scores The  to compare the  and e d u c a t i o n a l  progress.  and empathy r e v e a l s many  and m e t h o d o l o g i c a l problems and i t i s suggested that they are  the r e s u l t o f a l a c k o f f i t or a r t i c u l a t i o n of p s y c h o l o g i c a l and communication t h e o r i e s to the theory  and p r a c t i c e of n u r s i n g .  (1984, p. 73) has s t a t e d that a l t h o u g h n u r s i n g  t h e o r i e s make i m p l i c i t  assumptions about the nature o f communication " l i t t l e d i r e c t e d toward e x p l o r i n g d e l i v e r y of n u r s i n g Kasch d e s c r i b e s  Kasch  a t t e n t i o n [has been]  the i n t e r f a c e between communication and the  care." three  conceptual  frameworks that have i n f l u e n c e d  theory  construction i n nursing.  failed  t o develop and a r t i c u l a t e the r e l a t i o n s h i p between communication  and  nursing 1.  therapeutic not  She p o i n t s out how two of them have  and how the t h i r d might provide  a realistic alternative.  The developmental models of n u r s i n g perspective  which "encourages a s t y l e o f communication that i s  e a s i l y a c t u a l i z e d i n many n u r s e - p a t i e n t  p. 7 4 ) . The t h e r a p e u t i c  have been i n f l u e n c e d by the  i n t e r a c t i o n s " (Kasch, 1984,  or c o u n s e l l i n g paradigm "tends t o i g n o r e the  c o n s t r a i n t s on communication i n the h e a l t h care  context  and the i n t e n s e  commitment to task a c t i v i t y t h a t c h a r a c t e r i z e s the d e l i v e r y o f n u r s i n g care"  (Kasch, 1984, p. 7 4 ) . Gagan (1983) a l s o made t h i s p o i n t when she  c a l l e d f o r a "study to determine the p r e c i s e nature and c h a r a c t e r i s t i c s of the empathic process w i t h i n the c o n f i n e s  o f the n u r s e - h o s p i t a l i z e d  r e l a t i o n s h i p " (p. 71). This point i s relevant  -  32  to M a n s f i e l d ' s  patient  (1973) and  Stetler's (1977) studies described e a r l i e r .  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 t y p i c a l i n 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  r e l a t i o n a l dimension —  this includes empathy —  of communication.  In his  l i t e r a t u r e reviews on empathy and counselling outcome, Gladstein (1970, 1977)  made a d i s t i n c t i o n between psychotherapy and counselling,  that i n educational/vocational  concluding  counselling and other non-psychotherapy  processes such as dealing with a developmental task, the need for a highly empathic approach i s l e s s .  I t i s suggested here that nursing i s , for the  most part, a non-psychotherapeutic process.  Of the empathy s k i l l training  studies reviewed, Clay's (1984) i s the most applicable to nursing because i t was developed i n the context of nursing practice. 2.  Systems theory applications i n nursing are seen by Kasch as not  having "contributed much to understanding caregiver-patient interactions i n the delivery of nursing care" (p. 75).  Some c r i t i c i s m s are that a  systems model tends to subordinate the i n d i v i d u a l to the demands of the system; systems concepts are not e a s i l y subjected  to concrete,  empirical  investigation; and the systems perspective does riot provide a foundation for understanding i n d i v i d u a l differences i n communicative functioning. 3.  Kasch (1984) has i d e n t i f i e d an interpersonal competence  perspective as a l i n k between nursing and communication and.states that i t i s consistent with the i n t e r a c t i o n i s t model of nursing i n which "the  33  n u r s i n g p r o c e s s e s s e n t i a l l y i n v o l v e s i n t e r p r e t i n g the meaning of p a t i e n t a c t i o n s and necessary  i n d i c a t i n g or d e f i n i n g f o r the p a t i e n t a p p r o p r i a t e a c t i o n s  to a c h i e v e an o p t i m a l l e v e l of w e l l n e s s " (p. 73).  competence i s comprised  of s o c i a l , c o g n i t i v e , b e h a v i o u r a l , and  r e s o u r c e s of communication t h a t enable process i n t h i s way.  Interpersonal  I t i s broader  the nurse  to use  cultural  the n u r s i n g  than the p s y c h o t h e r a p e u t i c model i n  that i t focuses on more than the h e l p e r - h e l p e e r e l a t i o n s h i p .  I t focuses  on development of the above r e s o u r c e s of communication i n order to facilitate  the a b i l i t y  to a n t i c i p a t e , c o n t r o l and  demands of the s o c i a l environment (Kasch,  f l e x i b l y adapt to the  1984).  S o c i a l c o g n i t i v e competence i s the component of Kasch's model t h a t i s of i n t e r e s t  to t h i s study.  Kasch's (1984) d e s c r i p t i o n of  social  c o g n i t i v e competence i s c o n s i s t e n t w i t h the c o g n i t i v e developmental of p e r s p e c t i v e t a k i n g and d e c e n t r a t i o n d i s c u s s e d e a r l i e r and related  to the c o g n i t i v e aspect of empathy.  A nurse who  view  as such i s  possesses  such a  competence has an expanded "range of a l t e r n a t i v e s or o p t i o n s a v a i l a b l e f o r c o n s t r u c t i n g s t r a t e g i c messages and a d a p t i n g communication to the needs of a p a r t i c u l a r p a t i e n t " (p. Two  79).  q u e s t i o n s f o r n u r s i n g a r i s e from t h i s i n t e r e s t i n s o c i a l  c o g n i t i v e competence and developed?  specific  subsequent empathy.  Who  has  i t and  Instead of a s k i n g , as La Monica (1981) d i d , "do  programs f a i l  to t e a c h empathy e f f e c t i v e l y ? " we  can ask,  how  can i t be  baccalaureate  "To what degree  do the c o g n i t i v e c o n s t r a i n t s e v i d e n t i n a d o l e s c e n t s and young a d u l t s i n h i b i t or impede the development of empathic i n t e r a c t i v e s k i l l s i n n u r s i n g s t u d e n t s ? " As was  seen i n the review of s t u d i e s of empathy  t r a i n i n g programs, the assumptions t h a t empathy can be l e a r n e d and  34  that  anyone, r e g a r d l e s s are p r e v a l e n t .  of t h e i r s o c i a l c o g n i t i v e development, can l e a r n i t ,  Kasch (1984) does not  recommends r e s e a r c h i n t e r p r e t and  understand the v i e w p o i n t of another.  between empathy and  and  various  M i c h a e l s (1985, p. 31)  The  inconsistent  s o c i a l c o g n i t i v e development.  support t h i s .  forms of c o g n i t i v e empathy may  that c a l l  and  fruitful Goldstein  "Understanding the development be important f o r the s e l e c t i o n of  people f o r p r o f e s s i o n a l t r a i n i n g i n psycho-therapy e d u c a t i o n professions  to  that sought to f i n d r e l a t i o n s h i p s  demographic v a r i a b l e s might be more  the independent v a r i a b l e was  of higher  and  i n t o i n d i v i d u a l d i f f e r e n c e s i n people's c a p a c i t y  c o n f l i c t i n g r e s u l t s of those s t u d i e s  if  agree w i t h these assumptions  f o r advanced i n t e r p e r s o n a l  and  other  sensitivity."  SwjHQcUry  It  i s c l e a r from the l i t e r a t u r e that empathy i s not  d i m e n s i o n a l c o n s t r u c t , but has  r a t h e r a complex, m u l t i - f a c e t e d  p e r c e p t u a l / a f f e c t i v e , c o g n i t i v e and  complexity of the  c o n s t r u c t has  i n measurement i n s t r u m e n t s . (Johnson et a l . , 1983)  not  always been g i v e n  Gladstein,  1977;  It The  adequate r e c o g n i t i o n  Recent i n v e s t i g a t i o n s of c o g n i t i v e measures  have shown t h a t separate subscales  Davis,  1983;  Several  or f a c t o r s  can  investigators  Feldstein & Goldstein,  Marks & Tolsma, 1985)  the empathy process and  one-  process.  communicative components.  b e . i d e n t i f i e d i n the c o g n i t i v e component a l o n e . (Chlopan et a l . , 1985;  a simple,  1980;  have emphasized the complexity of recognition  and  Developmental t h e o r i s t s have i n v e s t i g a t e d the development of  the  consideration  various  have recommended that be g i v e n  i n future investigations.  components of empathy.  The  development of the  35  cognitive  component, e s p e c i a l l y i n adolescence and young adulthood, i s central to this study and can be elucidated by a Piagetian framework.  The  operational stage of cognitive development consists of eight operations  formal  formal  schemata and i t i s the eighth schema, the coordination of  multiple frames of reference, that r e f l e c t s the concept of empathy most clearly.  It has been shown, however, that the development of the  operations  formal  schema i s subject to many variables and that they are not  evident i n a large percentage of the adolescent  and adult  population.  This finding i s s i g n i f i c a n t to the study of empathy i n nursing. Empathy i s considered  central to the practice of nursing and i t i s  consistent with and part of Kasch's (1984) communication model of interpersonal competence. resource  Social cognitive competence, a communication  i n the model, i s derived from decentration and perspective  role taking a b i l i t y .  and  This finding highlights the important role that  cognitive development has i n nursing students' a b i l i t y to communicate empathically. training. that may  It i s not a simple matter of providing them with empathy  Nursing educators need to recognize exist i n some students and may  the cognitive constraints  result i n varying levels of  performance of empathic i n t e r a c t i v e s k i l l s . The major purpose of this study i s to investigate the relationship of the independent variables of nursing students' cognitive development, their age, and an empathy s k i l l s t r a i n i n g program that they experience to the dependent variable of their a b i l i t y to communicate empathically patients.  with  Secondarily the study w i l l investigate the relationship of  nursing students' empathic a b i l i t y 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 c o l l e c t i o n and rating procedures, and the data analysis.  37  CHAPTER I I I 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 s k i l l s program that they experience to the nursing students' a b i l i t y to communicate empathically with patients. regression research design was used to determine  A multiple  the extent to which  empathic communication can be predicted from the three variables that are t h e o r e t i c a l l y linked i n this study to empathic communication.  Hypotheses Null form 1.  There w i l l be no s i g n i f i c a n t linear relationship between the  predictor variables of nursing students' l e v e l of cognitive development as measured by the A r l i n Test of Formal Reasoning,  their age, and training or  no training i n interactive s k i l l s , and the c r i t e r i o n variable of empathic interaction as measured by Carkhuff's Empathic Understanding i n Interpersonal Processes Scale. 2.  Subjects with more years of post-secondary education w i l l show  no s i g n i f i c a n t difference i n empathic interaction a b i l i t y as measured by Carkhuff's Empathic Understanding i n Interpersonal Processes Scale when compared to subjects with fewer years of post-secondary education. 3.  Subjects with the cognitive a b i l i t y to coordinate multiple  frames of reference as measured by subtest #8 of the A r l i n Test of Formal Reasoning w i l l show no s i g n i f i c a n t difference i n empathic interaction 38  a b i l i t y as measured by C a r k h u f f s Empathic Understanding i n Interpersonal Processes  Scale when compared to subjects without  the cognitive a b i l i t y to  coordinate multiple frames of reference.  Asstujupti-OIILS  The hypotheses are based on the following assumptions.  The findings  of the study must be considered i n the l i g h t of these assumptions because the degree of their accuracy both allows and l i m i t s the conclusions that can be drawn from the findings. 1.  That the instruments  used, that i s the A r l i n Test of Formal  Reasoning and the Empathic Understanding i n Interpersonal Processes  Scale  used to rate subjects' responses to the patient stimulus expressions are adequately  sensitive to r e f l e c t actual differences i n subjects' cognitive  development and empathic communication. 2.  That the implementation of the interactive s k i l l s component of  the General Nursing program at BCIT i s s u f f i c i e n t l y consistent as to content, delivery method and teacher competence to ensure that subjects have had similar empathy s k i l l s training.  Subjects  The subjects i n this study were students i n the B r i t i s h Columbia Institute of Technology diploma nursing program (leading to R.N.). They were s o l i c i t e d by l e t t e r and were volunteers.  Appendix A.  The subjects were recruited on the basis of whether or not they had experienced  the empathy s k i l l training component of the curriculum.  It  begins i n the tenth week of Term 1 and i s completed i n the fourteenth week 39  of Term 3.  (Each Term i s 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 i n order to reduce the confounding effects of i n i t i a l 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 i s evidence to suggest  s i g n i f i c a n t differences between men's and women's cognitive development ( G i l l i g a n , 1982).  Some of these differences relate to role and  perspective taking and interpersonal orientation.  The under-  representation of men i n 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 p o s i t i v e l y or negatively, their scores on the c r i t e r i o n variable, empathic  communication.  A l l of the Registered  Psychiatric Nurses i n the BCIT diploma nursing program have experienced a communication s k i l l s training program including empathy s k i l l s i n their R.P.N, program and, as stated i n the Literature Review, these programs are p o s i t i v e l y related to increased scores on various standard empathy rating scales.  Conversely, Mynatt (1985) found a s i g n i f i c a n t l y low negative  correlation between students' l e v e l of empathy and amount of work experience i n nursing.  For these reasons the Registered Psychiatric  Nurses were excluded from the study. 40  Two participants, one i n the Training group and one i n the No Training group did not complete the A r l i n Test of Formal Reasoning.  One dropped  out of the nursing program between testing sessions and the other said she could not do the A r l i n Test of Formal Reasoning. A possible explanation for the low number of volunteers i n the Training group recruited i n A p r i l (column 5) i s that they were recruited at the end of the term one week before their f i n a l examinations.  This  was  done i n order to test them as soon after the empathy t r a i n i n g , as possible.  However, the investigator believes  the r e c r u i t s ' enthusiasm and  energy for additional work was low and hence resulted i n a low volunteer rate. The f i n a l sample consisted of 54 subjects.  Data on recruitment,  p a r t i c i p a t i o n and deletion from the study are shown i n Table 4.  41  TABLE 4 Recruitment,  P a r t i c i p a t i o n and D e l e t i o n Ho  Training Total  Jan.  AUK.  Recruited  40  48  88  50  Volunteered (percentage o f recruits)  16  23  39  21  (40)  Deleted (percentage o f volunteers)  (47.9) (44.3)  3  3  (18.7)  1 Did not complete (percentage o f (6.2) volunteers) Included i n study (percentage o f recruits)  12 (33.3)  The method analysis. Cohen  Jan.  (13) 0  Subjects  Training Apr.  (42)  6  of  Total  Grand Total  46  96  184  7  28  67  (14.5)  2  (15.3)  (9.5)  1  1  (0)  (2.5)  20  32  3  18 (27.7)  (42.8)  According  to methods d e s c r i b e d  by Cohen  11  (17.8)  (16.4) 2  1  (0)  (3.5)  4  22  (8.6)  of a n a l y s i s f o r h y p o t h e s i s 1 was m u l t i p l e  (36.4)  5  0  (4.76)  (41.6) (36.3)  (29.1)  (2.9)  54  (22.9)  (29.3)  regression  (1977) and Cohen and  (1983), the sample s i z e of 54 was s u f f i c i e n t l y l a r g e t o achieve a .5  power l e v e l f o r d e t e c t i n g a minimum of .10 R  2  when the alpha  level  equals  .05.  The P r e d i c t o r  and C r i t e r i o n  Variables  An argument was made i n the L i t e r a t u r e Review that r o l e and perspective ability  taking a b i l i t y i s required  to be empathic and that  that  i s dependent upon a c e r t a i n - l e v e l of c o g n i t i v e development.  was f u r t h e r argued that the s p e c i f i c  It  c o g n i t i v e concepts n e c e s s a r y f o r r o l e 42  and p e r s p e c t i v e t a k i n g are not apparent a d o l e s c e n t s and a d u l t s . w i t h development.  i n a l a r g e percentage of  Age, the second  p r e d i c t o r v a r i a b l e , i s confounded  The p o s i t i v e r e l a t i o n s h i p of age to the c o n s t r u c t of  empathy, e s p e c i a l l y the c o g n i t i v e component of empathy, i s well-documented i n the c h i l d and a d o l e s c e n t developmental Chapter  II.  clear.  Although p o s t - f o r m a l developmental  l i t e r a t u r e , as was reviewed i n  In the a d u l t p o p u l a t i o n , however, t h i s r e l a t i o n s h i p i s not as  c o g n i t i v e developmental Kitchener & King,  researchers describe a  sequence i n a d u l t s (Basseches,  1980; Brabek, 1983;  1981), many a d u l t s appear to reach a peak l e v e l of  c o g n i t i v e development not beyond the P i a g e t i a n formal o p e r a t i o n s yet It  the passage of time and the a c q u i s i t i o n of l i f e e x p e r i e n c e s  level, continue.  i s t h i s aspect of age, t h a t i s , time and e x p e r i e n c e , on empathic  communication t h a t i s of i n t e r e s t Empathy s k i l l s study.  to t h i s  t r a i n i n g was the t h i r d p r e d i c t o r v a r i a b l e i n t h i s  The t r a i n i n g method used  i n the diploma  was d e s c r i b e d i n d e t a i l i n Chapter has observed  study.  n u r s i n g program a t BCIT  I and as s t a t e d t h e r e , the i n v e s t i g a t o r  t h a t some students seem not to b e n e f i t from the t r a i n i n g .  That i s , they do not a c h i e v e s a t i s f a c t o r y l e v e l s o f understanding or communication of empathy. empathy s k i l l s completed,  training.  There i s a confounding  v a r i a b l e r e l a t e d to the  By the time the empathy s k i l l s  the student has a l s o completed  t r a i n i n g has been  12 months of the other  components of the c u r r i c u l u m t h a t c o u l d i n f l u e n c e , e i t h e r p o s i t i v e l y or n e g a t i v e l y , the s t u d e n t ' s a b i l i t y  to i n t e r a c t e m p a t h i c a l l y w i t h  patients.  T h i s should not be confused w i t h simple c h r o n o l o g i c a l age, because students begin the program a t d i f f e r i n g ages. process i n g e n e r a l , i n c l u d i n g c l i n i c a l  43  I t i s the e d u c a t i o n a l  e x p e r i e n c e , t h a t may be i n f l u e n c i n g  empathic communication.  This w i l l be discussed i n Chapter  IV, the  analysis and evaluation of the findings. The c r i t e r i o n variable of empathic communication was measured by the Empathic Understanding  i n Interpersonal Processes Scale (Carkhuff, 1969).  It i s described i n d e t a i l later i n this chapter.  Empathic communication  i s described as the a b i l i t y to adopt a patient's frame of reference i n order to understand  his or her feelings, thoughts and/or behaviour and the  a b i l i t y to convey that understanding to the patient i n a way he can understand.  that she or  One's understanding can be based on the patient's  verbal or non-verbal behaviour that i s conveyed either d i r e c t l y or i n d i r e c t l y , that i s , implied. The fundamental question for this study was which of the above three predictor variables, either singly or i n combination,  is/are the best  predictor(s) of empathic communication with patients.  Instrumentation  Empathic Communication.  The c r i t e r i o n variable, empathic  communication, was measured with an adaptation of Carkhuff's Index of Discrimination (1969) and rated with C a r k h u f f s Empathic Understanding i n Interpersonal Processes Scale (EUS).  The scale ranges from one  to.five  with the midpoint, three, being the minimal l e v e l of f a c i l i t a t i v e empathy (Carkhuff, 1969, Vol. 1, p. 175).  Appendix B.  Ten patient stimulus expressions were used.  They are adaptations of  client expressions i n C a r k h u f f s Index of Discrimination (1969, Vol. 1, pp. 115-123) and Egan's Exercises i n Helping S k i l l s (1982b).  Appendix C.  A l l of them are t y p i c a l and r e a l i s t i c verbal expressions of patients  44  and/or family/friends i n general acute medical/surgical nursing units to which nursing students would be expected to respond empathically.  The  following i s 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 i s even worse than an ordinary operation.  The doctor explained a l l the alternatives to me  but i t ' s just too much to think about" (adapted from Egan, 1982b, p. 42). The content and face v a l i d i t y of the patient stimulus expressions were ascertained by reference to the professional judgement of a group of s i x nurse educators and p r a c t i t i o n e r s .  They i d e n t i f i e d the primary affect  evident i n each patient stimulus expression and made a judgement about the relevance and realism of each one. Only those patient stimulus expressions i n which the affect i s clear and unambiguous and which are relevant and r e a l i s t i c 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 f e e l i n g with different problem areas. —  The problem area i n 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 i n 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.  45  This was done to control for  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 i n Table 5.  There was  no s i g n i f i c a n t differences between the means for responses to Tape A or Tape B for either group. TABLE 5 C o m p a r i s o n o f S c o r e s o n Two O r d e r s of P a t i e n t Stimulus Expressions Tape A  •M  n  Tape B SB  n  M  SD  F  df  Training  18  2.8  .4  4  2.8  1.3  <1  1, 20  No Training  12  1.5  .5  20  1.4  .5  <1  1, 30  Cognitive Development.  The independent  variable of cognitive  development was measured with the A r l i n Test of Formal Reasoning.  It i s 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'" ( A r l i n , 1984b, p. 1). It i s based on Inhelder and Piaget's-(1958) theoretical framework which includes eight s p e c i f i c 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 m u l t i - t r a i t , multi-method v a l i d i t y study of the ATFR was ( A r l i n , 1982).  conducted  The study indicated that the ATFR i s a v a l i d and r e l i a b l e  measure of formal operations.  The r e l i a b i l i t y measures were as follows: 46  Test-Retest  .76 to .89  Hoyt  .71 to .89  Cronbach Alpha  .60 to .73  Data C o l l e c t i o n  and R a t i n g Procedures  Each subject participated i n two data c o l l e c t i o n sessions.  The Data  Collection Schedule i s described i n Table 6. TABLE 6 Data C o l l e c t i o n  Schedule No T r a i n i n g  Jan/88 Term 1  SESSION 1  Training  Aug/88 Term 1  Jan/88 Term 4  Apr/88 Term 3  Week 3  Week 1  Week 3  Week 15  Week 5  Week 1  Week 3  Week 15  Empathic Understanding  SESSION 2 - A r l i n Test of Formal Reasoning - Biographical Data Sheet  Empathic Communication.  The subjects were asked, at the f i r s t  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, i n writing, i n the response booklet given to them.  These instructions plus a description of what an empathic response 47  c o n s i s t s o f , were repeated a t the b e g i n n i n g o f the v i d e o t a p e . There was a 3-minute pause between each p a t i e n t stimulus s u b j e c t s were t o l d lengthened.  Appendix C.  e x p r e s s i o n and  that i f they needed more time the pause would be  There were no requests  f o r more time i n any of the f o u r  showings of the v i d e o t a p e s . The  s u b j e c t s ' responses were r a t e d by two t r a i n e d r a t e r s .  r a t e r s were f a c u l t y members i n the BCIT diploma n u r s i n g responsible  f o r the . i n t e r a c t i v e s k i l l s  undertaken e x t e n s i v e  training.  interactive skills  training.  The  program who are  They have a l s o A d d i t i o n a l l y , before  doing any r a t i n g s they experienced f i v e hours of d i d a c t i c d i s c r i m i n a t i o n t r a i n i n g by the i n v e s t i g a t o r , a c c o r d i n g  to c r i t e r i a d e s c r i b e d  by Carkhuff  (1969, V o l . 1, pp. 169-173). I t was agreed by the r a t e r s and the i n v e s t i g a t o r t h a t , a l t h o u g h the r a t i n g s c a l e c o n s i s t s of f i v e l e v e l s , discriminate  l e v e l s 1, 2, and 3.  the r a t e r s c o u l d o n l y  accurately  T h i s was based on C a r k h u f f ' s  description  of the l e v e l s (1969, V o l . 1, p. 173-176) t h a t i n d i c a t e s that i n order t o a c c u r a t e l y d i s c r i m i n a t e between l e v e l s 4 and 5 "a minimum of a h e l p e e helper-helpee  i n t e r a c t i o n " (p. 176) i s r e q u i r e d .  study, thought a s u b j e c t ' s it  simply  as 3+.  gave a v a l u e had  When the r a t e r s , i n t h i s  response was b e t t e r than a l e v e l 3 they r a t e d  When the data were analyzed  of 4 t o responses r a t e d as 3+.  the i n v e s t i g a t o r a r b i t r a r i l y In summary then, the r a t e r s  to d i s c r i m i n a t e amongst only f o u r l e v e l s o f performance. The  r a t e r s ' i n t e r r a t e r r e l i a b i l i t y was determined f o l l o w i n g the  January and A p r i l , 10 p a t i e n t stimulus  1988 data c o l l e c t i o n s , on 10 s u b j e c t s ' responses t o a l l expressions.  The 10 s u b j e c t s ' responses were randomly  s e l e c t e d from among those of 44 s u b j e c t s .  48  Four were from the group w i t h  no training and 6 were from the group with t r a i n i n g .  The  subjects'  responses were given to the raters i n random order and the raters were not informed which group the subjects were i n , for both the determination of i n t e r r a t e r r e l i a b i l i t y and the rating of a l l remaining responses. Table 7 summarizes the interrater r e l i a b i l i t y ratings. i n t e r r a t e r r e l i a b i l i t y correlation was +.62 agreement was  50%.  The  and the percentage of  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 t r a i n i n g .  TABLE 7 Interrater Reliability on 100 Subject Responses Before and After Discussion  Before  Interrater Interrater Interrater by 1 by >1  r e l i a b i l i t y correlation agreement disagreement level level  After  Interrater Interrater Interrater by 1 by >1  Agreement compromise disagreement level level,  r = .62 = 50% = 43% = 7% = 50% = 43% = =  * 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  49  respectively  7% 0  One  of the r a t e r s was  not able to r a t e s u b j e c t s ' responses from the  f i n a l data c o l l e c t i o n i n August.  T h e r e f o r e , a l l the responses from the  August data c o l l e c t i o n were r a t e d by the same r a t e r . of No T r a i n i n g s u b j e c t s ' responses, Table  8 and  r a t e d i n May  This r a t e r ' s ratings  and August, are shown i n  appear to be not s i g n i f i c a n t l y d i f f e r e n t  from each o t h e r .  TABLE 8 Comparison of R a t e r ' s R a t i n g s of No T r a i n i n g S u b j e c t ' s R e s p o n s e s May n 7  rating M SD 1.6  August n  .4  C o g n i t i v e Development.  The  20  ATFR was  rating M  SD  1.4  .5  administered  to the s u b j e c t s i n  t h i s study under the recommended t e s t i n g c o n d i t i o n s at the second s e s s i o n . The  rooms were c o m f o r t a b l e ,  d i s t r a c t i o n s were kept provided.  w e l l - l i g h t e d and w e l l - v e n t i l a t e d and  to a minimum.  Scrap  S u b j e c t s were read the i n s t r u c t i o n s and  much time as they needed to complete the The  paper and  p e n c i l s were  told  they c o u l d have as  test.  s u b j e c t s ' t e s t s were scored by the i n v e s t i g a t o r and nine  f o r each s u b j e c t were o b t a i n e d , set of e i g h t s u b t e s t s c o r e s .  that i s , the o v e r a l l or t o t a l score and  The  a  s u b j e c t s ' s c o r e s on the Frames of  Reference s u b t e s t were of p a r t i c u l a r i n t e r e s t i s the c o o r d i n a t i o n of two  scores  s i n c e i t was  argued that i t  or more frames of r e f e r e n c e that i s  c o n c e p t u a l l y l i n k e d most c l e a r l y to the c o n s t r u c t of empathy. were used to t e s t the h y p o t h e s i s  These data  t h a t s u b j e c t s w i t h h i g h scores on  Frames of Reference s u b t e s t would score h i g h e r on the Empathic 50  the  Understanding i n Interpersonal Processes Scale than subjects with low scores on the Frames of Reference subtest. Biographical Data.  F i n a l l y , at the second session, data on  subjects' sex, previous work and t r a i n i n g , and data on the subjects' ages and their empathy s k i l l s 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 f u l l 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 i n Interpersonal Processes Scale than subjects with fewer years of post-secondary education.  Data A n a l y s i s  Hypothesis  1 was  tested by a h i e r a r c h i c a l multiple regression  analysis i n order to determine  the amount of variance i n the subjects'  empathy scores explained by cognitive l e v e l over and above that explained by the other independent  variables.  The h i e r a r c h i c a l order for entry of  the predictor variables into the analysis was age, training or no training, and cognitive l e v e l .  This order was based on assumed causal  p r i o r i t y , that i s , "no variable can be causally affected by one that appears after i t " (Cohen & Cohen, 1983, p. 121).  There i s some evidence  to suggest that cognitive development i n adults may be p o s i t i v e l y affected by age and education (Kitchener & King, 1981), therefore age and education were entered before cognitive l e v e l .  51  Training was a dichotomous variable  ( T r a i n i n g and No T r a i n i n g ) t h a t was as 1 or  coded as a dummy v a r i a b l e and  entered  0.  Hypothesis square. Processes  The  2 was  analyzed w i t h the non-parametric  scores on the Empathic Understanding  S c a l e were c a t e g o r i z e d i n t o two  g r e a t e r " and  "below the mean."  Those two  t e s t of c h i  i n Interpersonal  c a t e g o r i e s of "at the mean or c a t e g o r i e s were then analyzed  f r e q u e n c i e s comparing s u b j e c t s with zero to one year of e d u c a t i o n , and  two  or more y e a r s .  that the s c o r e s on the EUS e d u c a t i o n were not Hypothesis square.  The EUS  and  A significant  post-secondary  c h i square would  the number of years of  imply  post-secondary  independent.  3 was  a l s o analyzed w i t h the non-parametric  s c o r e s were c a t e g o r i z e d as i n Hypothesis  t e s t of c h i  2.  They were  then analyzed as f r e q u e n c i e s comparing s u b j e c t s w i t h low s c o r e s of 0, 2 and  as  s u b j e c t s w i t h h i g h s c o r e s of 3 or 4 on the Frames of  s u b t e s t of the A r l i n Test of Formal Reasoning. would imply t h a t the two v a r i a b l e s were not  1 or  Reference  A significant  c h i square  independent.  Summary T h i s study was  designed  three p r e d i c t o r v a r i a b l e s ,  to i n v e s t i g a t e the r e l a t i o n s h i p between  t h a t i s , n u r s i n g s t u d e n t s ' l e v e l s of c o g n i t i v e  development, t h e i r ages and an empathy s k i l l s program they e x p e r i e n c e ,  and  the c r i t e r i o n v a r i a b l e of the n u r s i n g s t u d e n t s ' a b i l i t y to i n t e r a c t empathically with p a t i e n t s . determine  A m u l t i p l e r e g r e s s i o n a n a l y s i s was  used  the degree of v a r i a n c e i n empathic i n t e r a c t i o n accounted  each of the p r e d i c t o r v a r i a b l e s .  S e c o n d a r i l y , an attempt  i d e n t i f y i f r e l a t i o n s h i p s e x i s t between s u b j e c t s ' empathic  52  was  to  f o r by  made to  communication  and two other variables,  namely their number of years of post-secondary  education and their scores on the Frames of Reference subtest on the A r l i n Test of Formal Reasoning.  53  CHAPTER IV FINDINGS AND DISCUSSION  The results of the analyses of the data are presented i n this chapter under the headings:  Characteristics of the Sample; Analyses of  the Data i n Relation to the Three Hypotheses of the Study; and Evaluation and Discussion of the Findings.  C h a r a c t e r i s t i c s 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 A r l i n 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 s k i l l s training and those with no empathy s k i l l s t r a i n i n g .  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  s i g n i f i c a n t difference between the Training group and the No Training group with regard to number of years of post-secondary education but there was a s i g n i f i c a n t difference between the two groups with regard to age, F_ (1,  52) =4.5,  p_ <.05.  This s i g n i f i c a n t difference was attributed to the fact that two of the subjects i n the Training group were o u t l i e r s with regard to age.  A  second one-way analysis of variance computed with the o u t l i e r s removed from the sample revealed no s i g n i f i c a n t difference with regard to age, F_ (1,  50) = 1.9.  These data are shown i n Table 9.  54  Within the training  group, moreover, age had only a low nonsignificant correlation with the dependent variable, empathy scores  (r_ = .12).  TABLE 9 M e a n s , S t a n d a r d D e v i a t i o n s a n d One—Way A n a l y s i s o f V a r i a n c e o f C h a r a c t e r i s t i c s o f t h e Sample  Variable  n  Training M  SD  No n  Training M SD  F  df  £  Age (in months)  22  356.5  91.3  32  306.9  77.8  1.7  1, 52 <.05  Age (outliers removed)  20  336.5  67.7  32  306.9  77.8  1.9  1, 50  Number of years of post-secondary education  22  1.0  1.3  32  1.0  1.2  Analyses of  <1  1, 52  the Data i n R e l a t i o n to Each Hypothesis  Hypothesis 1 states that there i s no s i g n i f i c a n t l i n e a r relationship between the predictor variables of nursing students' l e v e l of cognitive development as measured by the A r l i n Test of Formal Reasoning, their age, and t r a i n i n g or no t r a i n i n g i n i n t e r a c t i v e s k i l l s , and the c r i t e r i o n variable of empathic i n t e r a c t i o n as measured by Carkhuff's Empathic Understanding i n Interpersonal  Processes Scale.  Descriptive s t a t i s t i c s and pairwise correlations are given for a l l variables i n Table 10. s i g n i f i c a n t , .34.  The correlation between age and empathy was  Correlations with the variable of Training were not  s i g n i f i c a n t because i t was dichotomous and coded as a dummy variable. 55  Cognitive development showed low r e l a t i o n s , less than .2, with the dependent variable and the other independent variables.  TABLE  10  M e a n s , S t a n d a r d D e v i a t i o n s and P e a r s o n I n t e r c o r r e l a t i o n s of Dependent and I n d e p e n d e n t V a r i a b l e s (N = 54) Variable  SD  Variable  M  1.  Empathy  2.03  2.  Age  3.  Training*  4.  Cognitive ATFR Level  327.1  1  2  4  3  .84 87.2  .343  .4  .4  .793  .281  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  s i g n i f i c a n t ' a t F_ (3, 50) =  30.64, p_<.00001 and the predictor variables, i n combination accounted for 64.7%  of the variance  rejected.  (adjusted  = .62^).  Table 11 summarizes the findings.  The n u l l hypothesis  was  After the effect of age  was  removed, training accounted for the largest proportion of the variance ( R_2 A  = .52, adjusted  scores.  = .63) and was  Age accounted for the second largest proportion of variance  = .11, adjusted R_^ = .10) and also was scores.  p o s i t i v e l y related to empathy (AR2  p o s i t i v e l y related to empathy  The third predictor variable, cognitive l e v e l accounted for. a  negligible proportion of the variance (4R2 = .0005). 56  TABLE 11 H i e r a r c h i c a l M u l t i p l e Regression A n a l y s i s on E m p a t h y S c o r e s o f N u r s i n g S t u d e n t s (N =54)  R2  R2 adjusted increase  Variable  F to enter  B  Age  . 117  .100  .117  6.93*  .133  Training  .647  .633  .529  76.56**  .761  Cognitive Level  .647  .626  ,0004  .06  -.022  F (3,50) =. 30.64 p_ < .00001 * p_ < .05 ** p_ < .01  One way analysis of variance indicated a s i g n i f i c a n t difference i n the means of the empathy scores for the Training and No Training groups as shown i n Table 12. Students i n the later terms of the BCIT General Nursing diploma program achieved higher empathy scores than did students at the beginning of the f i r s t term. TABLE 12 C o m p a r i s o n o f Mean Empathy S c o r e s f o r T r a i n i n g a n d No T r a i n i n g G r o u p s ( N = 54)  n  Training M  SD  n  No  22  2.8  .4  32  Training M SD  1.4  .5  57  F  87.6  df  1, 52  p_  <.00001  The d i s t r i b u t i o n of the scores, as shown i n Table 13, indicates that 71.2% of the beginning students' responses could be c l a s s i f i e d as harmful or s i g n i f i c a n t l y detracting from the communication of the patient (see Appendix B for descriptions of the levels of the rating scale). comparison,  In  i n the Training group, 63.6% of the responses are neutral and  36.2% are e s s e n t i a l l y interchangeable with those of the patient and are considered minimally f a c i l i t a t i v e . TABLE  for  D i s t r i b u t i o n o f Mean Empathy S c o r e s T r a i n i n g a n d No T r a i n i n g G r o u p s (N =  Training n %  EUS  No n  Level 1  1.0 to 1.4 1.5 to 1.9  0 0  0 0  Level 2  2.0 to 2.4 2.5 to 2.9  5 9  Level 3  3.0 to 3.4 3.5 to 3.8  6 2  EUS:  13  Empathic Understanding (1969).  54)  Training %  21 2  65 6.2  22.7 40.9  7 2  21.8 6.2  27.2 9  0 0  0 0  i n Interpersonal Processes Scale, Carkhuff  Hypothesis 2 states that subjects with more years of post-secondary education would show no s i g n i f i c a n t l y greater empathic interaction a b i l i t y as measured by the Empathic Understanding  i n Interpersonal Processes Scale  (Carkhuff, 1969) when compared to subjects with fewer years of postsecondary education.  58  The hypothesis was analyzed by the non-parametric square.  test of chi  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. s t a t i s t i c was not s i g n i f i c a n t , X two variables are independent  2  (1, N_=  The chi square  54) = <1, and indicated that the  of one another.  The n u l l hypothesis was  accepted. Hypothesis 3 states that subjects with the cognitive a b i l i t y to coordinate multiple frames of reference, as measured by subtest #8 of the A r l i n Test of Formal Reasoning, would show no s i g n i f i c a n t l y greater empathic interaction a b i l i t y , as measured by the Empathic Understanding i n Interpersonal Processes Scale (Carkhuff, 1969), when compared to subjects without the a b i l i t y to coordinate multiple frames of reference. The test of chi square was used to analyze the hypothesis.  The  empathic interaction scores were categorized as i n 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. s t a t i s t i c was not s i g n i f i c a n t , X two variables are independent  2  The chi square  (1, N_ = 54) = <1, indicating that the  of one another.  The n u l l hypothesis was  accepted.  E v a l u a t i o n and  D i s c u s s i o n of  The independent  the  Findings  variables i n question i n this study can be  c l a s s i f i e d as developmental,  i . e . , age and cognitive development, or  educational, i . e . , empathy training and post-secondary education. 59  Of  these, age  and empathy training appear to have had  dependent variable of empathic communication. and heartening because much time and e f f o r t was students and  faculty.  Because there was  investigator  This finding i s positive applied  to the training by  discussion. no s i g n i f i c a n t difference  No Training groups with regard to age and  the  However, this finding must be considered i n the  context of the following  group, age  a bearing on  empathy scores had  and  between the Training  because, within the  and  Training  an i n s i g n i f i c a n t correlation (+.12), the  concluded that, regardless of empathy training, the older  subjects in this study, scored higher on the measure of empathy than the younger subjects. cognitive  development, was  appears that age i t s effect was cognitive The  Additionally,  had  the t h i r d independent variable,  not related to age.  l e v e l of  In summary then, i t  a s i g n i f i c a n t effect on empathy scores and also  that  not compounded by or related to training or l e v e l of  development. consistency of the implementation of the training program  not measured i n this study.  The  was  learning materials, that is,, text books,  videotapes, self-directed learning modules, and workbooks remained consistent nor  the faculty who  monitored. has  but neither the student/faculty r a t i o , the teaching  The  taught the  strategies  interactive s k i l l s component were  importance of certain trainer and  training  been described by Carkhuff and Berenson (1967).  characteristics  A greater  understanding of the e f f i c a c y of the training might be reached i f such variables were explored. Other factors that may  have had  an e f f e c t , either positive or  negative, on students' a b i l i t y 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' c l i n i c a l 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 s i g n i f i c a n t i n i t i a l differences in the two groups on the c r i t e r i o n variable. believe this was  The investigator does not  the case i n light of the group homogeneity that the BCIT  General Nursing diploma program admission requirements  fosters, however i t  remains an unknown variable. An explanation for the lack of significance of the measure of cognitive development, s p e c i f i c a l l y formal reasoning, as a predictor of empathic interaction relates to by the lack of variance i n cognitive development i n the sample.  The majority of the subjects were formal  reasoners as i s shown i n Table  14.  TABLE  14  Comparison of C o g n i t i v e Development Scores No T r a i n i n g a n d T r a i n i n g G r o u p s  n  No Training Training Total  •  M  SD  Formal  of  Non-formal  22  18.9  4.0  71.8%  28.2%  32  21.0  4.6  81.8%  18.1%  54  19.7  4.1  75.9%  24.0%  61  As well as the lack of variance i n cognitive development i n the sample as a methodological l i m i t a t i o n , the lack of relationship between measures of the various components of empathy as a conceptual must be addressed.  As was  limitation  discussed i n the Literature Review, when  operationalized and measured, the components of the  multidimensional  construct of empathy stand alone and show l i t t l e relationship to each other.  If a measure of the cognitive component of empathy s p e c i f i c a l l y ,  shows l i t t l e r e l a t i o n to a measure of communicative empathy i t i s not surprising that a general measure of cognitive development does not show a relationship to communicative empathy.  The findings of this study r e f l e c t  the idea that the components of empathy are d i s t i n c t l y d i f f e r e n t stages of a process and one cannot be predicted from another. A second explanation  for the lack of significance of the A r l i n Test  of Formal Reasoning (ATFR) as a predictor of empathic interaction relates to i t s appropriateness  as a measure of cognitive development i n terms of  the construct of empathy.  In the Literature Review, the investigator drew  a theoretical p a r a l l e l between the cognitive component of empathy, role and perspective taking, and the development of formal  operations,  s p e c i f i c a l l y the coordination of multiple frames of reference.  Perhaps  the findings of this study indicate that the relationship i s only theoretical or that achievement on the ATFR cannot r e f l e c t relationship.  the  Although A r l i n (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 i s more suited to the measurement of cognitive development as i t relates to science or mathematics. 62  The  scores achieved  by the s u b j e c t s i n the T r a i n i n g group i n t h i s  study are comparable to s c o r e s r e p o r t e d i n other s t u d i e s . Hennessy (1981) r e p o r t e d empathy scores graduate  (M 2.8,  l e v e l i n t e r v i e w s k i l l s course.  r a t e d w i t h C a r k u f f ' s Empathic Understanding (1969).  psychology  minimally f a c i l i t a t i v e l e v e l . " e i t h e r the undergraduate and communication s k i l l s Monica, 1979).  content  year  i n Interpersonal  Processes nursing  students t h a t a l s o were below the  She  suggested  graduate  the f o l l o w i n g e x p l a n a t i o n s :  curricula  or the instrument  fail  to p r o v i d e  necessary  f a i l s to d e t e c t i t " (La  study; the former w i l l be d i s c u s s e d i n the  the l a t t e r remains a l i m i t a t i o n v a l i d i t y per se and  t h i s study and  were  T h i s i n v e s t i g a t o r b e l i e v e s both f a c t o r s i n f l u e n c e d  s u b j e c t s ' scores i n t h i s  instrument's  T h e i r responses  La Monica (1979) r e p o r t e d s c o r e s f o r graduate  students and graduate  chapter,  .8) f o r 97 f i r s t  students i n c o u n s e l l o r e d u c a t i o n or advanced undergraduates  t a k i n g a graduate  Scale  SD  Lutwak and  of the study both i n terms of the  the i n t e r r a t e r  reported e a r l i e r .  63  final  r e l i a b i l i t y achieved i n  CHAPTER V SUMMARY,  Summary  and  CONCLUSIONS,  AND  RECOMMENDATIONS  Conclusions  The a b i l i t y t o communicate e m p a t h i c a l l y w i t h p a t i e n t s i s an essential s k i l l  i n the p r a c t i c e of n u r s i n g .  students w i t h t h i s s k i l l diploma  the n u r s i n g f a c u l t y of the BCIT General  Nursing  program implemented, i n 1985, the s y s t e m a t i c , d i d a c t i c -  experiential interactive s k i l l s skill  In order t o p r o v i d e n u r s i n g  t r a i n i n g method of Egan (1982a).  The  of empathy i s fundamental i n the Egan model. An o v e r a l l improvement i n s t u d e n t s ' i n t e r p e r s o n a l e f f e c t i v e n e s s has  been noted.  The implementation  of the t r a i n i n g program has p r o v i d e d  f a c u l t y w i t h comprehensive, s t r u c t u r e d framework i n which t o teach, observe of  and g i v e feedback  t o students about i n t e r a c t i v e s k i l l s .  these b e n e f i t s , the i n v e s t i g a t o r has observed  communicate e m p a t h i c a l l y i s not w e l l - d e v e l o p e d  train,  In spite  t h a t the a b i l i t y to  i n some students and that  sometimes the processes of p r o j e c t i o n and s t e r e o t y p e d knowledge a r e used i n s t e a d of empathy.  These processes a r e i n d i c a t i v e of a l a c k of the  c o g n i t i v e developmental  task of p e r s p e c t i v e or r o l e t a k i n g .  o b s e r v a t i o n l e a d t o the problem i d e n t i f i c a t i o n of t h i s The  This  study.  purpose of t h i s study was to i n v e s t i g a t e the p r e d i c t i v e  r e l a t i o n s h i p of the developmental  v a r i a b l e s of age and l e v e l of c o g n i t i v e  development and the e d u c a t i o n a l v a r i a b l e of an empathy t r a i n i n g program to n u r s i n g s t u d e n t s ' a b i l i t y t o communicate e m p a t h i c a l l y w i t h p a t i e n t s . S e c o n d a r i l y the degree of independence between empathic a b i l i t y and two  64  additional variables — the a b i l i t y  number of years of post-secondary  to c o - o r d i n a t e m u l t i p l e frames of r e f e r e n c e — w a s  Empathy was  construct.  the r e l a t i o n s h i p between the c o g n i t i v e and I t was  understanding  thought  t h a t the a b i l i t y  of another's  thoughts,  The  the r o l e of that o t h e r .  The  focus of t h i s study  to communicate one's  f e e l i n g s and e x p e r i e n c e s  to the other  to c o g n i t i v e l y take  are  constraints  trainees.  hypotheses of the study were t e s t e d by measuring the s u b j e c t s on  the f o u r v a r i a b l e s i n q u e s t i o n and  statistically  examining the  r e l a t i o n s h i p s among and  degree of independence of s e l e c t e d v a r i a b l e s .  f i n d i n g s do not support  the i d e a t h a t c o g n i t i v e development or the  v a r i a b l e s of age  and number of y e a r s of post-secondary  i n f l u e n c e s on the s u b j e c t s ' a b i l i t y  with p a t i e n t s . significantly  D i s c u s s i o n and  The  empathy s k i l l s  The  related  e d u c a t i o n are  to i n t e r a c t  empathically  t r a i n i n g on the other hand,  was  r e l a t e d to g r e a t e r empathy s c o r e s .  Recommendations  Empathy t r a i n i n g i n  nursing education.  i n t h i s study, as a t r a i n e d s k i l l The  on  i n v e s t i g a t o r b e l i e v e d t h a t the v a l u e of  must be tempered by the c o g n i t i v e developmental  e x i s t e n t i n the  important  was  the e x p e c t a t i o n s r e g a r d i n g performance, h e l d by t r a i n e r s ,  l i m i t e d by and  The  examined.  communicative components of  would be dependent to some degree on the a b i l i t y  t r a i n i n g and  and  d e s c r i b e d i n the L i t e r a t u r e Review as a  multidimensional, interdependent  empathy.  education  t h a t nurses  Empathy has been d e s c r i b e d , are expected  to demonstrate.  r e s u l t s i n d i c a t e t h a t w i t h t r a i n i n g the n u r s i n g students  b e t t e r empathy s c o r e s .  The  achieved  t r a i n i n g moved the students from making  65  harmful responses to making neutral or minimally f a c i l i t a t i v e  responses.  This questionable progress could be r e f l e c t i v e of the empirical limitations of the rating scale.  An alternative explanation i s the lack  of f i t between the interactive s k i l l s t r a i n i n g program and the remainder of the nursing curriculum.  As described e a r l i e r the elapsed time from the  f i r s t seminar on basic empathy to the one on advanced empathy i s approximately  12 months.  During this time students are also expected to  learn and implement complex psychomotor s k i l l s , nursing assessment and intervention, and related physical and s o c i a l sciences.  They attend  c l i n i c a l practica and are assigned to patients with varying degrees of i l l n e s s for whom they must provide safe competent nursing care.  It i s a  r e a l i t y that the focus on empathy as a desired nursing s k i l l i s sometimes not as sharp as i s required to become s k i l l f u l beyond the minimally facilitative level.  This lack of f i t between the interactive s k i l l s  program and the nursing curriculum i s most evident i n c l i n i c a l practice and this was  described i n the Literature Review.  It i s not  reasonable  given the constraints on communication and the task orientation i n most nursing situations for nurses to interact i n the manner prescribed by Egan's (1982a) model of helping.  The model prescribes using s k i l l s i n  order to help the patient thoroughly explore his or her situation, set r e a l i s t i c goals and determine actions to achieve those goals.  In other  words, the s k i l l s are to be used within the context of a helping relationship.  The best that can be achieved i n many c l i n i c a l situations  in which nursing students find themselves i s the isolated use of a particular s k i l l or s k i l l s out of context of a patient-centred, goal directed r e l a t i o n s h i p . Looked at i n this l i g h t , the subjects' progress  66  from predominantly harmful responses to either neutral or  minimally  f a c i l i t a t i v e ones i s positive. The decontextualization of empathic interaction and the competing demands of the curriculum and c l i n i c a l experience provide additional explanation  for the lack of relationship i n this study between cognitive  development and empathic a b i l i t y .  As suggested i n the Literature Review  there i s a difference between competence and performance with regard to cognitive development.  One  of the factors that A r l i n (1981,  1984)  described as a f f e c t i n g the integration of competence and performance i s the coordination of actions with appropriate  experience.  It i s suggested  that, although the majority of subjects i n 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 c l i n i c a l learning experiences that f a c i l i t a t e d the integration of their competence and performance and that would have resulted i n highly f a c i l i t a t i v e empathic responses. The minimally  f a c i l i t a t i v e l e v e l i s r e f l e c t i v e of the basic empathy  described by Egan (Goldstein & Michaels,  1985)  and perhaps that i s a more  reasonable goal for diploma nursing students, given the constraints referred to above, than the advanced empathy l e v e l .  It i s possible that  the introduction i n the curriculum of the higher l e v e l of empathy, and expectation that this be implemented by students, discouraging  i s confusing  the  and  for them and leads to feelings of inadequacy or incompetence.  It i s suggested that advanced empathy continue to be introduced but that factors i n h i b i t i n g i t s application be e x p l i c i t l y discussed and that the focus c l i n i c a l l y remain on the basic empathy l e v e l . 67  In situations where  i t might be possible and desirable for students to go beyond the basic l e v e l , i t would be incumbent upon the c l i n i c a l nursing instructor to help students move to the advanced l e v e l .  An example of this would be i n the  psychiatric nursing experience where the focus for both the patients and students i s on interpersonal relationships and communication and the students have more opportunity  to develop a helping relationship with  their patients. The c l i n i c a l i n s t r u c t i o n , supervision and role modelling students receive i s c r i t i c a l i n helping them to recognize situations i n which to use s p e c i f i c i n t e r a c t i v e s k i l l s .  that  clinical Although i t i s  not possible for nursing students or instructors to e n t i r e l y overcome the communication r e s t r a i n t s and task orientation of many c l i n i c a l situations, the investigator believes that a focus on c l i n i c a l supervision could help students to apply i n t e r a c t i v e s k i l l s more e f f e c t i v e l y .  One such approach  would be professional development seminars for faculty to renew and clarify  the value of caring, interactive s k i l l s and s p e c i f i c a l l y empathy  to the practice of nursing, followed by refresher seminars i n the practice of s p e c i f i c s k i l l s . Because most c l i n i c a l situations are complex and instructors have expertise i n limited aspects of practice a team teaching approach i n c l i n i c a l conferences would allow discussion of diverse facets, for example physical assessment and the i n t e r a c t i v e dynamics, to be f a c i l i t a t e d by instructors with the required expertise.  Recommendations f o r research.  This study could be replicated with  more controls for differences among subjects by testing the same group of 68  s u b j e c t s before  and  after training.  the dependent v a r i a b l e and age  In t h i s way  initial  d i f f e r e n c e s on  s e l e c t e d independent v a r i a b l e s , f o r example,  c o u l d be measured. Another approach to look at the e f f e c t i v e n e s s of  didactic-experiential interactive s k i l l s  systematic,  t r a i n i n g would be to compare  i n t e r a c t i v e e f f e c t i v e n e s s of s u b j e c t s from d i f f e r e n t diploma n u r s i n g programs, one w i t h an i n t e r a c t i v e s k i l l s c u r r i c u l u m and  one w i t h o u t .  t r a i n i n g program as p a r t of  A specific s k i l l  the  such as empathy c o u l d be  focus or a more g e n e r a l measure of i n t e r a c t i v e e f f e c t i v e n e s s c o u l d  the  be  taken. Because the t r a i n i n g appears to have made a d i f f e r e n c e i n the empathy scores of the s u b j e c t s i n t h i s study, on both i d e n t i f y i n g and strategies.  further research could  maximizing e f f e c t i v e t r a i n i n g  of age age  t r a i n i n g programs.  i s recommended t h a t f u r t h e r r e s e a r c h be conducted on the v a r i a b l e  and  and  compare  the t e a c h i n g s t r a t e g i e s used i n d i f f e r e n t  n u r s i n g programs w i t h s i m i l a r i n t e r a c t i v e s k i l l s It  implementation  An approach to t h i s would be to i n v e s t i g a t e and  s t u d e n t s ' achievement and  focus  i t s e f f e c t on empathy s c o r e s .  empathy scores  Second, and  First,  i n d i c a t e d i n t h i s study  the r e l a t i o n s h i p between  could be v a l i d a t e d .  perhaps more i m p o r t a n t l y , more s p e c i f i c aspects  v a r i a b l e of age,  f o r example a g e - r e l a t e d e x p e r i e n c e s ,  and  of  how  the they  effect  empathy c o u l d be e l u c i d a t e d . Examining s p e c i f i c v a r i a b l e s r e l a t e d to s t u d e n t s ' experience  i s another focus f o r r e s e a r c h .  time spent  w i t h p a t i e n t s , and  c o u l d be i n v e s t i g a t e d .  The  clinical  V a r i a b l e s such as the amount of  the k i n d of p a t i e n t s assigned  a p p l i c a t i o n of empathy s k i l l s  69  to  students  i s e f f e c t e d by  such variables as the severity of i l l n e s s patients experience, their language, and  sociocultural background.  Another s i g n i f i c a n t factor  related to c l i n i c a l experience i s the nature and quality of the supervision  and  clinical  role modelling of instructors and nursing personnel that  students experience. The  relationship of cognitive development and empathic s k i l l could  be pursued.  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Unpublished manuscript, University of Massachusetts, Amherst. Kasch, CR. (1984). Interpersonal competence and communication i n the delivery of nursing care. Advances i n Nursing Science, January. Katz, R.L.  (1963).  Keefe, T. (1976).  Empathy: Empathy:  Its nature and uses. The c r i t i c a l s k i l l .  Keefe, T. (1979). The development for Social Work, 15, 30-37.  New York:  Free Press.  Social Work, 21, 10-14.  of empathic s k i l l .  Journal of Education  Kerr, W.A., & Speroff, B.G. (1954). Validation and evaluation of the empathy test. Journal of General Psychology, 50, 369-376. King, I. (1981). A theory for' nursing: New York: Wiley.  Systems, concepts and process.  Kitchener, K.S., & King, P.M. (1981). Reflective judgement: Concepts of j u s t i f i c a t i o n and their relationship to age and education. Journal of Applied Developmental Psychology, 2_, 89-116. Kuhn, D., Ho, V., & Adams, C. (1979). Formal reasoning among pre- and late adolescents. Child Development, 50, 1128-1135. Kurtz, R.R., & Grummon, D.L. (1972). Different approaches to the measurement of therapist empathy and their relationship to therapy outcomes. Journal of Consulting and C l i n i c a l Psychology, 39, 106115.  75  La Monica, E. (1981). Construct v a l i d i t y of an empathy instrument. Research i n Nursing and Health, 4_, 389-400. La Monica, E. (1979). V a l i d i t y of Carkhuff's index of communication. Group & Organization Studies, 4, 377-382. Larabee, D. (1980). Effects of a modified theme-centred interactional method on r a i s i n g empathy i n psychiatric nurses and patient care assistants (Doctoral d i s s e r t a t i o n , University of Pittsburgh, 1980). Dissertation Abstracts International, 41, 2454A. Law, E. (1978). Toward the teaching and measurement of s t a f f nurses (Doctoral d i s s e r t a t i o n , Brigham Young University, 1978). Dissertation Abstracts International, 39, 779A. Lichtenberg, J . , Bornstein, M., & S i l v e r , D. (1984). H i l l s d a l e , NJ: Analytic Press.  Empathy I I .  Lutwak, N., & Hennessy, J . J . (1981). Conceptual systems functioning as a mediating factor i n the development of counseling s k i l l s . Journal of Counseling Psychology, 29, 256-260. Mansfield, E. (1973). Empathy: Concept and i d e n t i f i e d psychiatric nursing behaviour. Nursing Research, 22 (6), 525-530. Marks, S.E., & Tolsma, R.J. (1985). Empathy research: Some methodological considerations. Unpublished manuscript, University of B r i t i s h Columbia, Vancouver, B.C. Mead, G.H. (1934). Mind, s e l f and society. Chicago Press.  Chicago:  University of  Mehrabian, A., & Epstein, N.A. (1972). A measure of emotional empathy. Journal of Personality, 40, 525-543. Mynatt, S. (1985). Empathy i n faculty and students i n different types of nursing preparation programs. Western Journal of Nursing Research, 7_ (3), 333-348. Neimark, E.D. (1975). I n t e l l e c t u a l development during adolescence. In F.D. Horowitz (Ed.), Review of c h i l d development research (Vol. 4) (pp. ). Chicago: University of Chicago Press. Orem, D. (1970). An introduction to the theoretical basis for nursing. Philadelphia: F.A. Davis. Rappaport, J . , & Chinsky, J.M. (1972). Accurate empathy: construct. Psychological B u l l e t i n , 77, 400-404.  Confusion of a  Registered Nurses' Association of B r i t i s h Columbia (1984). Standards for nursing practice i n B r i t i s h Columbia. Vancouver, B.C.: Author. 76  Reik, T. (1949).  Listening with the t h i r d ear.  New York:  Farrar, Straus.  Riehl, J.P., & Roy, C. (1980). Conceptual models for nursing practice (2nd Ed.). New York: Appleton-Century-Crofts. Rogers, C. (1957). The necessary and s u f f i c i e n t conditions of therapeutic personality change. Journal of Counseling Psychology, 21, 95-103. Rogers, C. (1961).  On becoming a person.  Boston:  Houghton M i f f l i n .  Rogers, C. (1975). Empathic: An unappreciated way of being. Counseling Psychologist, 5, 2-10.  The  Rogers, I.A. (1986). The effects of undergraduate nursing education on empathy. Western Journal of Nursing Research, 8_(3), 329-342. Rosenthal, R., & Rosnow, R.L. Wiley.  (1975).  The volunteer subject.  New  York:  Roy, C. (1974). The Roy adaptation model. In J.P. Riehl and C. Roy (Eds.), Conceptual models for nursing practice (pp. ). New York: Appleton-Century-Crof ts. Selman, R. (1980). The growth of interpersonal understanding. Academic Press.  New  York:  Selman, R.L., & Byrne, D.F. (1974). A structural-developmental analysis of levels of role-taking i n middle childhood. Child Development, 45, 803-806. Shantz, C. (1983). Social cognition. In P.H. Mussen (Ed.), Carmichael's manual of child psychology, 4th ed. (pp. 495-555). New York: Wiley. Smither, S. (1977). A reconsideration of the developmental study of empathy. Human Development, 20, 253-276. S t e t l e r , C.B. (1977). Relationship of perceived empathy to nurses' communication. Nursing Research, 26 (6), 432-438. Travelbee, J . (1966). F.A. Davis.  Interpersonal aspects of nursing.  Philadelphia:  Truax, C.B., & Carkhuff, R.R. (1967). Toward e f f e c t i v e counseling and psychotherapy. Chicago: Aldine. Urburg, K.A., & Docherty, E.M. (1976). Development of role-taking s k i l l s in young children. Developmental Psychology, 12, 198-203. Zimmerman, B. (1980) . Teaching empathy to baccalaureate nursing students (Doctorial d i s s e r t a t i o n , Columbia University Teachers College, 1980). Dissertation Abstracts International, 41 1314B. 77  Dear Student:  APPENDIX A  For my Master's thesis i n 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 s p e c i f i c a l l y on which developmental factors enhance and/or i n h i b i t the a b i l i t y to understand and'to demonstrate empathy i n interaction with patients. Empathy i s considered to be an essential element i n nurse-patient relationships, yet very l i t t l e has been written about what factors f a c i l i t a t e empathy i n beginning nurses. Your p a r t i c i p a t i o n i n this project i s important because your experiences can provide valuable insights about how nursing students learn about empathy and they can point to new teaching strategies that w i l l f a c i l i t a t e this learning. The Associate Dean of Nursing has given me permission to approach you regarding p a r t i c i p a t i o n i n this project. This w i l l involve completing: 1. 2. 3.  A measure of empathic communication; A Biographical Data Sheet; The A r l i n Test of Formal Reasoning (ATFR).  In the f i r s t session you w i l l view a videotape of 10.different patient statements. Your task i s to write an empathic response to each one of them. This w i l l take approximately 1 hour for you to complete. The ATFR w i l l be done i n the second session. It i s a 32 item, multiplechoice paper and pencil test that measures your reasoning and problem solving a b i l i t y . It w i l l take approximately 45 minutes for you to complete i t . F i n a l l y , you w i l l be asked to complete a Biographical Data Sheet which w i l l allow me to ensure that the subjects i n the study are as similar to each other as possible. This w i l l take less than 5 minutes to complete. Your responses on a l l the variables w i l l be kept confidential. No information about your scores or responses w i l l 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 w i l l not influence your class standing i n any way. Dates, times and locations for the two sessions w i l l be announced shortly i n your nursing class. If you are w i l l i n g to participate i n the project, please attend the sessions. I realize that your schedule at B.C.I.T. i s very busy and I appreciate your interest i n this project. A summary of the results of the research w i l l be made available through the o f f i c e of the Associate Dean of Nursing.  78  APPENDIX A (cont'd...)  This study i s being conducted under the supervision of Dr. Richard Young of the Department of Counselling Psychology, U.B.C. • Thank you for your time and p a r t i c i p a t i o n . Sincerely, Kathy Doyle  79  APPENDIX B Empathic Understanding i n I n t e r p e r s o n a l Processes a S c a l e f o r Measurement  Level 1 The verbal and behavioral expressions of the helper either do not attend to or detract s i g n i f i c a n t l y from the verbal and behavioral expressions of the helpee(s) i n that they communicate s i g n i f i c a n t l y 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 t o t a l l y excludes that of the helpee(s). In summary, the helper does everything but express that he i s l i s t e n i n g , understanding, or being sensitive to even the most obvious feelings of the helpee i n such a way as to detract s i g n i f i c a n t l y from the communications of the helpee. Level 2 While the helper responds to the expressed feelings of the helpee(s), he does so i n 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 l e v e l of the affect and d i s t o r t the l e v e l 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 i s expressing or indicating. Level 3 The expressions of the helper i n response to the expressions of the helpee(s) are e s s e n t i a l l y interchangeable with those of the helpee i n that they express e s s e n t i a l l y 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 f e e l i n g s .  80  APPENDIX B (cont'd...)  In summary, the helper i s responding so as to neither subtract from nor add to the expressions of the helpee. He does not respond accurately to how that person r e a l l y feels beneath the surface feelings; but he indicates a willingness and openness to do so. Level 3 constitutes the minimal l e v e l of f a c i l i t a t i v e interpersonal functioning. Level 4 The responses of the helper add noticeably to the expressions of the helpee(s) i n such a way as to express feelings a l e v e l deeper than the helpee was able to express himself. The helper communicates his understanding of the expressions of the helpee at a l e v e l deeper than they were expressed and thus enables the helpee to experience and/or express feelings he was unable to express previously.  Example:  In summary, the helper's responses add deeper feeling and meaning to the expressions of the helpee. Level 5 The helper's responses add s i g n i f i c a n t l y to the feeling and meaning of the expressions of the helpee(s) i n such a way as to accurately express feelings levels below what the helpee himself was able to express or, i n the event of on going, deep self-exploration on the helpee's part, to be f u l l y with him i n his deepest moments. The helper responds with accuracy to a l l of the helpee's deeper as well as surface feelings. He i s "tuned i n " on the helpee's wave length. The helper and helpee might proceed together to explore previously unexplored areas of human existence.  Example:  In summary, the helper i s responding with a f u l l awareness of who the other person i s and with a comprehensive and accurate empathic understanding of that individual's deepest feelings. Carkhuff, 1969.  81  APPENDIX C D i r e c t i o n s and S c r i p t f o r V i d e o t a p e Patient Stimulus Expressions  of  The following vignettes or scenes portray statements or expressions by a patient, of feelings and content related to some aspect of her or h i hospitalization. You may conceive of the patient as a patient to whom you are assigned and to whom you want to be h e l p f u l , s p e c i f i c a l l y empathic. An empathic response i s one i n which you convey to the patient, i n way that she or he can understand, your understanding of her or his feelings, thoughts and behaviour. There are 10 vignettes or scenes i n this exercise. Your task i s to view each scene attentively and then to write an empathic response to the patient. Write your responses i n the spaces provided i n the response booklet.  VIGNETTE 1 The person speaking i s this scene i s Mrs. Simpson the mother of a 6 year old boy who has been i n the hospital for investigation of possible c y s t i c f i b r o s i s . I t has been determined that he had pneumonia and he i s being discharged today. Mrs. Simpson: "This i s the best news I've had i n two weeks. I've been so worried thinking the worst a l l the time. My husband and I tried to be calm about Jim being i n hospital but we were getting pretty i r r i t a b l e with one another. I t ' s just so wonderful he's okay and we can go home." VIGNETTE 2 In this scene the patient i s Mrs. Brown, a woman who i s dying from long-standing cardiac and respiratory problems. Mrs. Brown: "I can understand i t 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 f e e l s . We never talk about my dying. I know he's trying to protect me but i t ' s so unreal. I don't t e l l 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 i s the patient i n this scene. He i s a 28 year old man who has been i n the hospital for 2 weeks for investigation and treatment of leukemia. You have just brought his lunch to him. Mr. Martin: "This place i s driving me crazy. I can't stand i t . I feel l i k e a guinea pig. F i r s t a bunch of doctors come i n and look at me and talk about me. then they give me a student nurse, who looks l i k e she's a f r a i d of me. They a l l pretend they know so much but they don't know anything about me. They don't want to." VIGNETTE 4 The patient i n this scene i s Mrs. Jones. She i s 42 years old and has been admitted to the hospital today for treatment of ulcerative c o l i t i s . You have just told her when v i s i t i n g hours are. Mrs. Jones: "I hope they a l l stay away. I'm always kids complain about my husband and then them and blames me when he can't manage out on them right now. Who the h e l l do  i n the middle. The he complains about them. I could walk they think they are?"  VIGNETTE 5 Mrs. Lee i s the patient i n this scene. She i s a 55 year old woman who has been i n 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 i f I'd ever get home. Being able to get a homemaker has made a l l the difference. I know things w i l l be d i f f e r e n t since I've been sick but i t ' s l i k e a second lease on l i f e . "  83  APPENDIX C (cont'd...) VIGNETTE 6 The patient you w i l l see i n this scene i s Mr. Gold. He has a r t h r i t i s and has been hospitalized f o r 1 month. He needs assistance with many a c t i v i t i e s including dressing and getting i n and out of bed. You have just answered his c a l l b e l l . Mr. Gold: "Who do you think you are! You c a l l yourself a nurse? Here I am i n pain most of the time having to wait around ' t i l you can find the time i n your busy schedule to help me out. You don't think of me one minute. A l l you can think of i s when you're getting off work. Well I'm sick of you and this place. Get out of here." VIGNETTE 7 Mr. Sawchuck i s the patient i n this scene. he has lung cancer.  He has just learned that  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 i n this scene i s Mr. Whelan. You have just said 'good morning' to him and told him y o u ' l l be h i s nurse today. Mr. Whelan: "I'm so happy you're my nurse today. I get the f e e l i n g you l i k e your job. You're a good l i s t e n e r and you seem to understand me so well. I f e e l great when you're on duty."  84  APPENDIX C (cont'd...) VIGNETTE 9 The patient you w i l l see i n this scene i s Miss McLeod. She i s a 55 year old woman who i s 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 i s even worse than an ordinary operation. The doctor explained a l l the alternatives to me but i t ' s just too much to think about." VIGNETTE 10 The person who i s speaking i n this scene i s Mr. Bryant. father of an 11 year old g i r l who was h i t by a car.  He i s the  Mr. Bryant: "I should never have l e t her go to the movies alone. I don't know what my wife w i l l say when she gets here. She says I'm careless - but being careless with the kids - that's something else! I almost f e e l as i f I'd broken Karen's arm, not the guy i n the car.  85  APPENDIX D CONSENT FORM Predictors of Bnpathic Interactive S k i l l s  Investigator:  I n Diploma Nursing  Students  Katherine Doyle M.A. Candidate Department of Counselling Psychology, U.B.C.  The purpose of this research i s to investigate the effect of l e v e l of cognitive development, age, and an interactive s k i l l s training program on nursing" students' a b i l i t y to interact empathically. The s p e c i f i c focus of the research i s on cognitive developmental factors which enhance and/or i n h i b i t the a b i l i t y to understand and to demonstrate empathy i n interactions with patients. Participation i n this research requires that subjects complete the following: 1. 2. 3.  The A r l i n Test of Formal Reasoning (45 minutes); A measure of empathic communication (1 hour); A biographical data sheet (5 minutes).  The subjects' responses and scores w i l l be kept confidential. Subjects' responses and scores w i l l be rated and recorded by number and not name. No information about individual responses or scores w i l l be given to faculty or s t a f f of B.C.I.T. In an e f f o r t to ensure that subjects f u l l y understand the purpose and procedures of the research, the investigator w i l l answer subjects' questions prior to p a r t i c i p a t i o n and w i l l provide opportunity for individual or group discussion following p a r t i c i p a t i o n . Subjects have the right to refuse to participate or to withdraw from any part of the research at any time; such refusal or withdrawal w i l l not influence subjects' class standing i n any way.  I consent to participate i n the above research and I acknowledge receipt of a copy of this consent form.  Date  Signature  Name  86  APPENDIX  Biographical  E  Data  Sheet  Please answer the following questions on the answer sheet provided. Print your name and your birthdate i n the space provided on the answer sheet. 1.  In which term of the nursing program are you currently registered? a.  2.  4  Female  b.  Male  0 1  c. d.  2 3  e. f.  4 5  g. h.  6 7  yes  b.  no  Have you trained or worked as a nurse, a nurse aide or a p r a c t i c a l nurse for one year or more? a.  6.  c.  Have you repeated any nursing courses i n the BCIT General Nursing program? a.  5.  3  How many f u l l academic years of post-secondary education (exclusive of the BCIT General Nursing program) have you completed? a. b.  4.  b.  What sex are you? a.  3.  1  yes  b.  no  b.  no  Are you an R.P.N.? a.  yes  Thank you for p a r t i c i p a t i n g i n this research.  87  

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