@prefix vivo: . @prefix edm: . @prefix ns0: . @prefix dcterms: . @prefix skos: . vivo:departmentOrSchool "Education, Faculty of"@en, "Educational and Counselling Psychology, and Special Education (ECPS), Department of"@en ; edm:dataProvider "DSpace"@en ; ns0:degreeCampus "UBCV"@en ; dcterms:creator "Doyle, Katherine Jane"@en ; dcterms:issued "2010-09-04T00:28:52Z"@en, "1989"@en ; vivo:relatedDegree "Master of Arts - MA"@en ; ns0:degreeGrantor "University of British Columbia"@en ; dcterms:description """The interactive skill of empathy is essential to the practice of nursing. The British Columbia Institute of Technology General Nursing Diploma Program has implemented an interactive skills training program that includes the skill of empathy in order to assist nursing students to acquire this skill. The purpose of this study was to investigate the relationships between the interactive skill of empathy and the developmental variables of level of cognitive development and age and the educational variables of empathy skill training and number of years of post-secondary education in nursing students. Developmentally, the ability most relevant to the cognitive component of empathy is perspective and role-taking which is facilitated by the development of formal operational thinking. The constraints on the development of formal operational thinking consequently are constraints on the development of the cognitive component of empathy. It is this cognitive empathic ability, however, that is considered crucial to nursing. The question therefore arises: To what degree do the cognitive constraints evident in nursing students inhibit or impede their development of empathic interactive skills. Data were collected from two groups of nursing students, one that had experienced the empathy training and the other that had not. The variables of empathic interactive skill and level of cognitive development were measured with Carkhuff's Empathic Understanding in Interpersonal Processes Scale and the Arlin Test of Formal Reasoning respectively. Data on age and number of years of post-secondary education were collected with a Biographical Data Sheet. Hierarchical multiple regression analysis was used to investigate the linear relationship of age, empathy skill training, and cognitive level to the subjects' empathic interactive skill. Two nonparametric tests of chi square were used to examine the degree of independence between empathic interactive skill and the variables of number of years of post-secondary education and the cognitive ability to coordinate multiple frames of reference. The findings of this study indicate that there is a significant linear relationship between empathic interactive skill and empathy skill training. Training accounted for the greatest proportion of variance in empathy scores after age had been removed (53%), F (3, 50) = 30.64, p<.00001. Chi square analysis found that empathic interactive skill was shown to be independent of number of years of post-secondary education and the cognitive ability to coordinate multiple frames of reference. It is recommended that the empathy skill training program be continued with the following suggestions. The contextual, process nature of interaction needs to be emphasized including the constraints and realities of nursing practice that generally are not operating in the counselling paradigm from which the skills program is adopted. Subsequently, more emphasis is required on the facilitative skills, including basic empathy rather than the challenging skills. It is suggested that on-going seminars for faculty to clarify the value and practice of empathy plus a team teaching approach would improve the quality of supervision students receive. Suggestions are made for further research."""@en ; edm:aggregatedCHO "https://circle.library.ubc.ca/rest/handle/2429/28212?expand=metadata"@en ; skos:note "THE RELATIONSHIP OF AGE, EMPATHY SKILL TRAINING AND COGNITIVE DEVELOPMENT TO NURSING STUDENTS * EMPATHIC COMMUNICATION SKILLS By KATHERINE JANE DOYLE B.N., Mc G i l l University, 1973 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS OF THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department of Counselling Psychology We accept this thesis as conforming to the required standard: THE UNIVERSITY OF BRITISH COLUMBIA February 1989 C a t h e r i n e Jane Doyle, 1989 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date INWL Kt \\1 level by 1 level = 43% = 7% Interrater Agreement Interrater compromise Interrater disagreement = 50% = 43% After by 1 level by >1 level, = 7% = 0 * 2 of these responses were rated as 2 or 3 5 of these response were rated as 3 or 4 The investigator averaged them to 2.5 or 3.5 respectively 49 One of the raters was not able to rate subjects' responses from the f i n a l data c o l l e c t i o n i n August. Therefore, a l l the responses from the August data c o l l e c t i o n were rated by the same rater. This rater's ratings of No Training subjects' responses, rated i n May and August, are shown i n Table 8 and 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 other. TABLE 8 C o m p a r i s o n o f R a t e r ' s R a t i n g s o f 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 r a t i n g A u g u s t r a t i n g n M SD n M SD 7 1.6 .4 20 1.4 .5 Cognitive Development. The ATFR was administered to the subjects i n this study under the recommended te s t i n g conditions at the second session. The rooms were comfortable, 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 d i s t r a c t i o n s were kept to a minimum. Scrap paper and pencils were provided. Subjects were read the i n s t r u c t i o n s and t o l d they could have as much time as they needed to complete the t e s t . The subjects' tests were scored by the investigator and nine scores for each subject were obtained, that i s , the o v e r a l l or t o t a l score and a set of eight subtest scores. The subjects' scores on the Frames of Reference subtest were of p a r t i c u l a r i n t e r e s t since i t was argued that i t i s the coordination of two or more frames of reference that i s conceptually linked most c l e a r l y to the construct of empathy. These data were used to test the hypothesis that subjects with high scores on the Frames of Reference subtest would score higher on the Empathic 50 Understanding in Interpersonal Processes Scale than subjects with low scores on the Frames of Reference subtest. Biographical Data. Finally, at the second session, data on subjects' sex, previous work and training, and data on the subjects' ages and their empathy 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 in Interpersonal Processes Scale than subjects with fewer years of post-secondary education. D a t a A n a l y s i s Hypothesis 1 was tested by a hierarchical multiple regression analysis in order to determine the amount of variance in the subjects' empathy scores explained by cognitive level over and above that explained by the other independent variables. The hierarchical order for entry of the predictor variables into the analysis was age, training or no training, and cognitive level. This order was based on assumed causal priority, that i s , \"no variable can be causally affected by one that appears after i t \" (Cohen & Cohen, 1983, p. 121). There is some evidence to suggest that cognitive development in adults may be positively affected by age and education (Kitchener & King, 1981), therefore age and education were entered before cognitive level. Training was a dichotomous variable 51 (Training and No Training) that was coded as a dummy variable and entered as 1 or 0. Hypothesis 2 was analyzed with the non-parametric test of chi square. The scores on the Empathic Understanding i n Interpersonal Processes Scale were categorized into two categories of \"at the mean or greater\" and \"below the mean.\" Those two categories were then analyzed as frequencies comparing subjects with zero to one year of post-secondary education, and two or more years. A s i g n i f i c a n t chi square would imply that the scores on the EUS and the number of years of post-secondary education were not independent. Hypothesis 3 was also analyzed with the non-parametric test of chi square. The EUS scores were categorized as i n Hypothesis 2. They were then analyzed as frequencies comparing subjects with low scores of 0, 1 or 2 and subjects with high scores of 3 or 4 on the Frames of Reference subtest of the A r l i n Test of Formal Reasoning. A s i g n i f i c a n t chi square would imply that the two variables were not independent. Summary This study was designed to investigate the r e l a t i o n s h i p between three predictor var i a b l e s , that i s , nursing students' l e v e l s of cognitive development, t h e i r ages and an empathy s k i l l s program they experience, and the c r i t e r i o n variable of the nursing students' a b i l i t y to i n t e r a c t empathically with patients. A multiple regression analysis was used to determine the degree of variance i n empathic i n t e r a c t i o n accounted for by each of the predictor v a r i a b l e s . Secondarily, an attempt was made to i d e n t i f y i f relationships e x i s t between subjects' empathic communication 52 and two other variables, namely their number of years of post-secondary education and their scores on the Frames of Reference subtest on the Arlin Test of Formal Reasoning. 53 CHAPTER IV FINDINGS AND DISCUSSION The results of the analyses of the data are presented in this chapter under the headings: Characteristics of the Sample; Analyses of the Data in Relation to the Three Hypotheses of the Study; and Evaluation and Discussion of the Findings. C h a r a c t e r i s t i c s o f the Sample The data on the characteristics of the sample were obtained through the Biographical Data Sheet that each participant completed prior to doing the modified Carkhuff Index of Communication and the Arlin Test of Formal Reasoning. Data on age and number of years of post-secondary education were tabulated for both groups of subjects, those with empathy s k i l l s training and those with no empathy s k i l l s training. The data for the two groups were examined by one-way analysis of variance for differences between means. The analyses indicate that there was no s t a t i s t i c a l l y significant difference between the Training group and the No Training group with regard to number of years of post-secondary education but there was a significant difference between the two groups with regard to age, F_ (1, 52) =4.5, p_ <.05. This significant difference was attributed to the fact that two of the subjects in the Training group were outliers with regard to age. A second one-way analysis of variance computed with the outliers removed from the sample revealed no significant difference with regard to age, F_ (1, 50) = 1.9. These data are shown in Table 9. Within the training 54 group, moreover, age had only a low nonsignificant correlation with the dependent variable, empathy scores (r_ = .12). TABLE 9 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 S a m p l e T r a i n i n g No T r a i n i n g V a r i a b l e n M SD n M SD F d f £ Age 22 356.5 91.3 32 306.9 77.8 1.7 1, 52 <.05 (in months) Age 20 336.5 67.7 32 306.9 77.8 1.9 1, 50 (outliers removed) Number of 22 1.0 1.3 32 1.0 1.2 <1 1, 52 years of post-secondary education A n a l y s e s o f t h e D a t a i n R e l a t i o n t o E a c h H y p o t h e s i s Hypothesis 1 states that there is no significant linear relationship between the predictor variables of nursing students' level of cognitive development as measured by the Arlin Test of Formal Reasoning, their age, and training or no training in interactive s k i l l s , and the criterion variable of empathic interaction as measured by Carkhuff's Empathic Understanding in Interpersonal Processes Scale. Descriptive statistics and pairwise correlations are given for a l l variables in Table 10. The correlation between age and empathy was significant, .34. Correlations with the variable of Training were not significant because i t was dichotomous and coded as a dummy variable. 55 Cognitive development showed low relations, less than .2, with the dependent variable and the other independent variables. TABLE 10 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 P e a r s o n I n t e r c o r r e l a t i o n s o f D e p e n d e n t a n d I n d e p e n d e n t V a r i a b l e s ( N = 5 4 ) V a r i a b l e V a r i a b l e M SD 1 2 3 4 1. Empathy 2.03 .84 2. Age 327.1 87.2 .343 3. Training* .4 .4 .793 .281 4. Cognitive ATFR Level 19.7 4.1 .136 .195 .175 * Training or No Training were coded 1 or 0. p_ < .05 = .27 df 50 p_ < .01 = .35 df 50 The multiple regression equation was significant'at F_ (3, 50) = 30.64, p_<.00001 and the predictor variables, in combination accounted for 64.7% of the variance (adjusted = .62^). The null hypothesis was rejected. Table 11 summarizes the findings. After the effect of age was removed, training accounted for the largest proportion of the variance (AR_2 = .52, adjusted = .63) and was positively related to empathy scores. Age accounted for the second largest proportion of variance (AR2 = .11, adjusted R_^ = .10) and also was positively related to empathy scores. The third predictor variable, cognitive level accounted for. a negligible proportion of the variance (4R2 = .0005). 56 TABLE 11 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 o n 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) V a r i a b l e R2 R2 a d j u s t e d i n c r e a s e F t o e n t e r B Age Training Cognitive Level . 117 .647 .647 .100 .117 .633 .529 .626 ,0004 6.93* 76.56** .06 .133 .761 -.022 F (3,50) =. 30.64 p_ < .00001 * p_ < .05 ** p_ < .01 One way analysis of variance indicated a significant difference in the means of the empathy scores for the Training and No Training groups as shown in Table 12. Students in the later terms of the BCIT General Nursing diploma program achieved higher empathy scores than did students at the beginning of the f i r s t term. TABLE 12 C o m p a r i s o n o f M e a n E m p a t h y 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) T r a i n i n g No T r a i n i n g n M SD n M SD F d f p_ 22 2.8 .4 32 1.4 .5 87.6 1, 52 <.00001 57 The distribution of the scores, as shown in Table 13, indicates that 71.2% of the beginning students' responses could be classified as harmful or significantly detracting from the communication of the patient (see Appendix B for descriptions of the levels of the rating scale). In comparison, in the Training group, 63.6% of the responses are neutral and 36.2% are essentially interchangeable with those of the patient and are considered minimally f a c i l i t a t i v e . TABLE 13 D i s t r i b u t i o n o f M e a n E m p a t h y 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 = 5 4 ) T r a i n i n g No T r a i n i n g EUS n % n % Level 1 1.0 to 1.4 0 0 21 65 1.5 to 1.9 0 0 2 6.2 Level 2 2.0 to 2.4 5 22.7 7 21.8 2.5 to 2.9 9 40.9 2 6.2 Level 3 3.0 to 3.4 6 27.2 0 0 3.5 to 3.8 2 9 0 0 EUS: Empathic Understanding in Interpersonal Processes Scale, Carkhuff (1969). Hypothesis 2 states that subjects with more years of post-secondary education would show no significantly greater empathic interaction a b i l i t y as measured by the Empathic Understanding in Interpersonal Processes Scale (Carkhuff, 1969) when compared to subjects with fewer years of post-secondary education. 58 The hypothesis was analyzed by the non-parametric test of chi square. The empathic interaction scores were categorized as below the mean, and at or above the mean and then analyzed as frequencies comparing those subjects with zero to one year of post-secondary education to those with two or more years of post-secondary education. The chi square statistic was not s i g n i f i c a n t , X 2 (1, N_= 54) = <1, and indicated that the two variables are independent of one another. The null hypothesis was accepted. Hypothesis 3 states that subjects with the cognitive a b i l i t y to coordinate multiple frames of reference, as measured by subtest #8 of the Arlin Test of Formal Reasoning, would show no significantly greater empathic interaction a b i l i t y , as measured by the Empathic Understanding in Interpersonal Processes Scale (Carkhuff, 1969), when compared to subjects without the abi 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 in Hypothesis 2 and then analyzed as frequencies comparing those subjects with scores of 3 or 4 on subtest #8 of the ATFR to those with scores of 0, 1, or 2. The chi square stat i s t i c was not s i g n i f i c a n t , X 2 (1, N_ = 54) = <1, indicating that the two variables are independent of one another. The null hypothesis was accepted. E v a l u a t i o n a n d D i s c u s s i o n o f t h e F i n d i n g s The independent variables in question in this study can be classified as developmental, i.e., age and cognitive development, or educational, i.e., empathy training and post-secondary education. Of 59 these, age and empathy training appear to have had a bearing on the dependent variable of empathic communication. This finding is positive and heartening because much time and effort was applied to the training by students and faculty. However, this finding must be considered in the context of the following discussion. Because there was no significant difference between the Training and No Training groups with regard to age and because, within the Training group, age and empathy scores had an insignificant correlation (+.12), the investigator concluded that, regardless of empathy training, the older subjects in this study, scored higher on the measure of empathy than the younger subjects. Additionally, the third independent variable, level of cognitive development, was not related to age. In summary then, i t appears that age had a significant effect on empathy scores and also that i t s effect was not compounded by or related to training or level of cognitive development. The consistency of the implementation of the training program was not measured in this study. The learning materials, that is,, text books, videotapes, self-directed learning modules, and workbooks remained consistent but neither the student/faculty ratio, the teaching strategies nor the faculty who taught the interactive s k i l l s component were monitored. The importance of certain trainer and training characteristics has been described by Carkhuff and Berenson (1967). A greater understanding of the efficacy of the training might be reached i f such variables were explored. Other factors that may have had an effect, either positive or negative, on students' abi 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 significant i n i t i a l differences in the two groups on the criterion variable. The investigator does not believe this was the case in light of the group homogeneity that the BCIT General Nursing diploma program admission requirements fosters, however i t remains an unknown variable. An explanation for the lack of significance of the measure of cognitive development, specifically formal reasoning, as a predictor of empathic interaction relates to by the lack of variance in cognitive development in the sample. The majority of the subjects were formal reasoners as is shown in Table 14. TABLE 14 C o m p a r i s o n o f C o g n i t i v e D e v e l o p m e n t S c o r e s o f 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 M SD F o r m a l N o n - f o r m a l No Training 22 18.9 4.0 71.8% 28.2% Training • 32 21.0 4.6 81.8% 18.1% Total 54 19.7 4.1 75.9% 24.0% 61 As well as the lack of variance in cognitive development in the sample as a methodological limitation, the lack of relationship between measures of the various components of empathy as a conceptual limitation must be addressed. As was discussed in the Literature Review, when operationalized and measured, the components of the multidimensional construct of empathy stand alone and show l i t t l e relationship to each other. If a measure of the cognitive component of empathy specifically, shows l i t t l e relation to a measure of communicative empathy i t is not surprising that a general measure of cognitive development does not show a relationship to communicative empathy. The findings of this study reflect the idea that the components of empathy are distinctly different stages of a process and one cannot be predicted from another. A second explanation for the lack of significance of the Arlin Test of Formal Reasoning (ATFR) as a predictor of empathic interaction relates to i t s appropriateness as a measure of cognitive development in terms of the construct of empathy. In the Literature Review, the investigator drew a theoretical parallel between the cognitive component of empathy, role and perspective taking, and the development of formal operations, specifically the coordination of multiple frames of reference. Perhaps the findings of this study indicate that the relationship is only theoretical or that achievement on the ATFR cannot reflect the relationship. Although Arlin (1984b, p. 2) has stated that the concepts associated with the stage of formal operations \"represent[s] a form of thinking and not necessarily the content of that thinking\" the investigator believes that the ATFR is more suited to the measurement of cognitive development as i t relates to science or mathematics. 62 The scores achieved by the subjects i n the Training group i n t h i s study are comparable to scores reported i n other studies. Lutwak and Hennessy (1981) reported empathy scores (M 2.8, SD .8) for 97 f i r s t year graduate students i n counsellor education or advanced undergraduates taking a graduate l e v e l interview s k i l l s course. Their responses were rated with Carkuff's Empathic Understanding i n Interpersonal Processes Scale (1969). La Monica (1979) reported scores for graduate nursing students and graduate psychology students that also were below the minimally f a c i l i t a t i v e l e v e l . She suggested the following explanations: \"either the undergraduate and graduate c u r r i c u l a f a i l to provide necessary communication s k i l l s content or the instrument f a i l s to detect i t \" (La Monica, 1979). This investigator believes both factors influenced subjects' scores i n t h i s study; the former w i l l be discussed i n the f i n a l chapter, the l a t t e r remains a l i m i t a t i o n of the study both i n terms of the instrument's v a l i d i t y per se and the i n t e r r a t e r r e l i a b i l i t y achieved i n t h i s study and reported e a r l i e r . 63 CHAPTER V SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS Summary a n d C o n c l u s i o n s The a b i l i t y to communicate empathically with patients i s an es s e n t i a l s k i l l i n the practice of nursing. In order to provide nursing students with this s k i l l the nursing f a c u l t y of the BCIT General Nursing diploma program implemented, i n 1985, the systematic, d i d a c t i c -e x p e r i e n t i a l 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 method of Egan (1982a). The s k i l l of empathy i s fundamental i n the Egan model. An o v e r a l l improvement i n students' interpersonal effectiveness has been noted. The implementation of the t r a i n i n g program has provided f a c u l t y with comprehensive, structured framework i n which to teach, t r a i n , observe and give feedback to students about i n t e r a c t i v e s k i l l s . In spite of these benefits, the investigator has observed that the a b i l i t y to communicate empathically i s not well-developed i n some students and that sometimes the processes of projection and stereotyped knowledge are used instead of empathy. These processes are i n d i c a t i v e of a lack of the cognitive developmental task of perspective or role taking. This observation lead to the problem i d e n t i f i c a t i o n of th i s study. The purpose of th i s study was to investigate the predictive r e l a t i o n s h i p of the developmental variables of age and l e v e l of cognitive development and the educational variable of an empathy t r a i n i n g program to nursing students' a b i l i t y to communicate empathically with patients. Secondarily the degree of independence between empathic a b i l i t y and two 64 additional variables — number of years of post-secondary education and the a b i l i t y to co-ordinate multiple frames of reference — w a s examined. Empathy was described i n the L i t e r a t u r e Review as a multidimensional, interdependent construct. The focus of t h i s study was the r e l a t i o n s h i p between the cognitive and communicative components of empathy. I t was thought that the a b i l i t y to communicate one's understanding of another's thoughts, f e e l i n g s and experiences to the other would be dependent to some degree on the a b i l i t y to c o g n i t i v e l y take on the role of that other. The investigator believed that the value of t r a i n i n g and the expectations regarding performance, held by t r a i n e r s , are li m i t e d by and must be tempered by the cognitive developmental constraints existent i n the trainees. The hypotheses of the study were tested by measuring the subjects on the four variables i n question and s t a t i s t i c a l l y examining the relationships among and degree of independence of selected v a r i a b l e s . The findings do not support the idea that cognitive development or the related variables of age and number of years of post-secondary education are important influences on the subjects' a b i l i t y to i n t e r a c t empathically with patients. The empathy s k i l l s t r a i n i n g on the other hand, was s i g n i f i c a n t l y related to greater empathy scores. 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 educa t i on . Empathy has been described, i n t h i s study, as a trained s k i l l that nurses are expected to demonstrate. The r e s u l t s indicate that with t r a i n i n g the nursing students achieved better empathy scores. The 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 reflective of the empirical limitations of the rating scale. An alternative explanation is the lack of f i t between the interactive s k i l l s training program and the remainder of the nursing curriculum. As described earlier the elapsed time from the f i r s t seminar on basic empathy to the one on advanced empathy is approximately 12 months. During this time students are also expected to learn and implement complex psychomotor s k i l l s , nursing assessment and intervention, and related physical and social sciences. They attend c l i n i c a l practica and are assigned to patients with varying degrees of illness for whom they must provide safe competent nursing care. It is a reality that the focus on empathy as a desired nursing s k i l l is sometimes not as sharp as is required to become s k i l l f u l beyond the minimally f a c i l i t a t i v e level. This lack of f i t between the interactive s k i l l s program and the nursing curriculum is most evident in c l i n i c a l practice and this was described in the Literature Review. It is not reasonable given the constraints on communication and the task orientation in most nursing situations for nurses to interact in the manner prescribed by Egan's (1982a) model of helping. The model prescribes using s k i l l s in 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 in many c l i n i c a l situations in which nursing students find themselves is 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 relationship. Looked at in this light, 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 is 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 in this study between cognitive development and empathic ab i l i t y . As suggested in the Literature Review there is a difference between competence and performance with regard to cognitive development. One of the factors that Arlin (1981, 1984) described as affecting the integration of competence and performance is the coordination of actions with appropriate experience. It is suggested that, although the majority of subjects in this study were formal reasoners and many of them achieved positive scores for the eighth schema — the coordination of multiple frames of reference — perhaps they have not had c l i n i c a l learning experiences that facilitated the integration of their competence and performance and that would have resulted in 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 level is reflective of the basic empathy described by Egan (Goldstein & Michaels, 1985) and perhaps that is a more reasonable goal for diploma nursing students, given the constraints referred to above, than the advanced empathy level. It is possible that the introduction in the curriculum of the higher level of empathy, and the expectation that this be implemented by students, is confusing and discouraging for them and leads to feelings of inadequacy or incompetence. It is suggested that advanced empathy continue to be introduced but that factors inhibiting i t s application be explicitly discussed and that the focus c l i n i c a l l y remain on the basic empathy level. In situations where 67 i t might be possible and desirable for students to go beyond the basic level, i t would be incumbent upon the c l i n i c a l nursing instructor to help students move to the advanced level. An example of this would be in the psychiatric nursing experience where the focus for both the patients and students is on interpersonal relationships and communication and the students have more opportunity to develop a helping relationship with their patients. The c l i n i c a l instruction, supervision and role modelling that students receive is c r i t i c a l in helping them to recognize c l i n i c a l situations in which to use specific interactive s k i l l s . Although i t is not possible for nursing students or instructors to entirely overcome the communication restraints 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 interactive s k i l l s more effectively. 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 specifically empathy to the practice of nursing, followed by refresher seminars in the practice of specific s k i l l s . Because most c l i n i c a l situations are complex and instructors have expertise in limited aspects of practice a team teaching approach in c l i n i c a l conferences would allow discussion of diverse facets, for example physical assessment and the interactive dynamics, to be facilitated by instructors with the required expertise. Recommendations for research. This study could be replicated with more controls for differences among subjects by testing the same group of 68 subjects before and a f t e r t r a i n i n g . In t h i s way i n i t i a l differences on the dependent variable and selected independent variables, for example, age could be measured. Another approach to look at the effectiveness of systematic, d i d a c t i c - e x p e r i e n t i a l 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 would be to compare i n t e r a c t i v e effectiveness of subjects from d i f f e r e n t diploma nursing programs, one with 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 as part of the curriculum and one without. A s p e c i f i c s k i l l such as empathy could be the focus or a more general measure of i n t e r a c t i v e effectiveness could be taken. Because the t r a i n i n g appears to have made a difference i n the empathy scores of the subjects i n t h i s study, further research could focus on both i d e n t i f y i n g and maximizing e f f e c t i v e t r a i n i n g implementation str a t e g i e s . An approach to t h i s would be to investigate and compare students' achievement and the teaching strategies used i n d i f f e r e n t nursing programs with s i m i l a r 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 programs. It i s recommended that further research be conducted on the variable of age and i t s e f f e c t on empathy scores. F i r s t , the r e l a t i o n s h i p between age and empathy scores indicated i n t h i s study could be validated. Second, and perhaps more importantly, more s p e c i f i c aspects of the variable of age, for example age-related experiences, and how they e f f e c t empathy could be elucidated. Examining s p e c i f i c variables related to students' c l i n i c a l experience i s another focus for research. Variables such as the amount of time spent with patients, and the kind of patients assigned to students could be investigated. The a p p l i c a t i o n of empathy s k i l l s i s effected by 69 such variables as the severity of illness patients experience, their language, and sociocultural background. Another significant factor related to c l i n i c a l experience is the nature and quality of the c l i n i c a l supervision and 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. Cognitive development beyond the formal operational level could be measured with an instrument such as the Reflective Judgement Index (Kitchener & King, 1981) to test the relationship between more re l a t i v i s t i c thinking and the s k i l l of empathy. 70 REFERENCES Arlin, P.K. (1975). Cognitive development in adulthood: A f i f t h stage? Developmental Psychology, 11, 602-606. Arlin, P.K. (1981a). Performance in time lags in the development of formal operations. 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Toward effective 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 dissertation, Columbia University Teachers College, 1980). Dissertation Abstracts International, 41 1314B. 77 Dear Student: APPENDIX A For my Master's thesis in the Department of Counselling Psychology at U.B.C, I am gathering data about how nursing students learn about the concept of empathy. I am focusing specifically on which developmental factors enhance and/or inhibit the a b i l i t y to understand and'to demonstrate empathy in interaction with patients. Empathy is considered to be an essential element in 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 in beginning nurses. Your participation in this project is important because your experiences can provide valuable insights about how nursing students learn about empathy and they can point to new teaching strategies that 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 participation in this project. This w i l l involve completing: 1. A measure of empathic communication; 2. A Biographical Data Sheet; 3. The Arlin 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 is 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 in the second session. It is a 32 item, multiple-choice 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 . Finally, 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 in 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 in any way. Dates, times and locations for the two sessions w i l l be announced shortly in your nursing class. If you are willing to participate i n the project, please attend the sessions. I realize that your schedule at B.C.I.T. is very busy and I appreciate your interest in this project. A summary of the results of the research w i l l be made available through the office of the Associate Dean of Nursing. 78 APPENDIX A (cont'd...) This study is being conducted under the supervision of Dr. Richard Young of the Department of Counselling Psychology, U.B.C. • Thank you for your time and participation. Sincerely, Kathy Doyle 79 APPENDIX B Empathic Unders tand ing i n I n t e r p e r s o n a l Processes a Sca le f o r Measurement Level 1 The verbal and behavioral expressions of the helper either do not attend to or detract significantly from the verbal and behavioral expressions of the helpee(s) in that they communicate significantly less of the helpee's feelings and experiences than the helpee has communicated himself. Example: The helper communicates no awareness of even the most obvious, expressed surface feelings of the helpee. The helper may be bored or disinterested or simply operating from a preconceived frame of reference which totally excludes that of the helpee(s). In summary, the helper does everything but express that he is listening, understanding, or being sensitive to even the most obvious feelings of the helpee in such a way as to detract significantly from the communications of the helpee. Level 2 While the helper responds to the expressed feelings of the helpee(s), he does so in such a way that he subtracts noticeable affect from the communications of the helpee. Example: The helper may communicate some awareness of obvious, surface feelings of the helpee but his communications drain off a level of the affect and distort the level of meaning. The helper may communicate his own ideas of what may be going on, but these are not congruent with the expressions of the helpee. In summary, the helper tends to respond to other than what the helpee is expressing or indicating. Level 3 The expressions of the helper in response to the expressions of the helpee(s) are essentially interchangeable with those of the helpee in that they express essentially the same affect and meaning. Example: The helper responds with accurate understanding of the .surface feelings of the helpee but may not respond to or may misinterpret the deeper feelings. 80 APPENDIX B (cont'd...) In summary, the helper is responding so as to neither subtract from nor add to the expressions of the helpee. He does not respond accurately to how that person really feels beneath the surface feelings; but he indicates a willingness and openness to do so. Level 3 constitutes the minimal level of 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) in such a way as to express feelings a level deeper than the helpee was able to express himself. Example: The helper communicates his understanding of the expressions of the helpee at a level deeper than they were expressed and thus enables the helpee to experience and/or express feelings he was unable to express previously. In summary, the helper's responses add deeper feeling and meaning to the expressions of the helpee. Level 5 The helper's responses add significantly to the feeling and meaning of the expressions of the helpee(s) in such a way as to accurately express feelings levels below what the helpee himself was able to express or, in the event of on going, deep self-exploration on the helpee's part, to be full y with him in his deepest moments. Example: The helper responds with accuracy to a l l of the helpee's deeper as well as surface feelings. He is \"tuned i n \" on the helpee's wave length. The helper and helpee might proceed together to explore previously unexplored areas of human existence. In summary, the helper is responding with a f u l l awareness of who the other person is and with a comprehensive and accurate empathic understanding of that individual's deepest feelings. Carkhuff, 1969. 81 APPENDIX C D i r e c t i o n s and S c r i p t f o r V ideotape of P a t i e n t S t imu lus Exp ress ions The following vignettes or scenes portray statements or expressions by a patient, of feelings and content related to some aspect of her or hi hospitalization. You may conceive of the patient as a patient to whom you are assigned and to whom you want to be helpful, specifically empathic. An empathic response is one in which you convey to the patient, in way that she or he can understand, your understanding of her or his feelings, thoughts and behaviour. There are 10 vignettes or scenes in this exercise. Your task is to view each scene attentively and then to write an empathic response to the patient. Write your responses in the spaces provided in the response booklet. VIGNETTE 1 The person speaking is this scene is Mrs. Simpson the mother of a 6 year old boy who has been in the hospital for investigation of possible cystic fibrosis. It has been determined that he had pneumonia and he is being discharged today. Mrs. Simpson: \"This is the best news I've had in two weeks. I've been so worried thinking the worst a l l the time. My husband and I tried to be calm about Jim being in hospital but we were getting pretty i r r i t a b l e with one another. It's just so wonderful he's okay and we can go home.\" VIGNETTE 2 In this scene the patient is Mrs. Brown, a woman who is dying from long-standing cardiac and respiratory problems. Mrs. Brown: \"I can understand 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 feels. 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 is the patient in this scene. He is a 28 year old man who has been in the hospital for 2 weeks for investigation and treatment of leukemia. You have just brought his lunch to him. Mr. Martin: \"This place is driving me crazy. I can't stand i t . I feel like a guinea pig. First a bunch of doctors come in and look at me and talk about me. then they give me a student nurse, who looks like she's afraid of me. They 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 in this scene is Mrs. Jones. She is 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 visiting hours are. Mrs. Jones: \"I hope they a l l stay away. I'm always in the middle. The kids complain about my husband and then he complains about them and blames me when he can't manage them. I could walk out on them right now. Who the hell do they think they are?\" VIGNETTE 5 Mrs. Lee is the patient in this scene. She is a 55 year old woman who has been in hospital for 6 weeks because of a stroke. Mrs. Lee \"I'm so excited to be going home. For awhile things weren't looking so good and I didn't know 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 different since I've been sick but i t ' s like a second lease on l i f e . \" 83 APPENDIX C (cont'd...) VIGNETTE 6 The patient you w i l l see in this scene is Mr. Gold. He has arthritis and has been hospitalized for 1 month. He needs assistance with many activities including dressing and getting in and out of bed. You have just answered his 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 in pain most of the time having to wait around ' t i l you can find the time in your busy schedule to help me out. You don't think of me one minute. A l l you can think of is when you're getting off work. Well I'm sick of you and this place. Get out of here.\" VIGNETTE 7 Mr. Sawchuck is the patient in this scene. He has just learned that he has lung cancer. Mr. Sawchuck: \"Why me? Why me? I'm not even that old. And I don't even smoke. Look at me. I thought I had some guts. I'm just a slobbering mess. What are these next months going to be li k e ! \" VIGNETTE 8 The patient in this scene is Mr. Whelan. You have just said 'good morning' to him and told him you'll be his nurse today. Mr. Whelan: \"I'm so happy you're my nurse today. I get the feeling you like your job. You're a good listener and you seem to understand me so well. I feel great when you're on duty.\" 84 APPENDIX C (cont'd...) VIGNETTE 9 The patient you w i l l see in this scene is Miss McLeod. She is a 55 year old woman who is having a breast biopsy the next morning. You have just brought her a sedative to help her sleep. Miss McLeod: I don't know what to expect after the operation. I've never had an operation before and this is even worse than an ordinary operation. The doctor explained a l l the alternatives to me but i t ' s just too much to think about.\" VIGNETTE 10 The person who is speaking in this scene is Mr. Bryant. He is the father of an 11 year old g i r l who was hit by a car. Mr. Bryant: \"I should never have let her go to the movies alone. I don't know what my wife 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 feel as i f I'd broken Karen's arm, not the guy in the car. 85 APPENDIX D CONSENT FORM P r e d i c t o r s o f B n p a t h i c I n t e r a c t i v e S k i l l s I n D i p l o m a N u r s i n g S t u d e n t s The purpose of this research is to investigate the effect of level 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 specific focus of the research is on cognitive developmental factors which enhance and/or inhibit the ab i l i t y to understand and to demonstrate empathy in interactions with patients. Participation in this research requires that subjects complete the following: 1. The Arlin Test of Formal Reasoning (45 minutes); 2. A measure of empathic communication (1 hour); 3. A biographical data sheet (5 minutes). The subjects' responses and scores 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 staff of B.C.I.T. In an effort to ensure that subjects fu l l y understand the purpose and procedures of the research, the investigator w i l l answer subjects' questions prior to participation and w i l l provide opportunity for individual or group discussion following participation. Subjects have the right to refuse to participate or to withdraw from any part of the research at any time; such refusal or withdrawal w i l l not influence subjects' class standing in any way. I consent to participate in the above research and I acknowledge receipt of a copy of this consent form. Investigator: Katherine Doyle M.A. Candidate Department of Counselling Psychology, U.B.C. Date Name Signature 86 A P P E N D I X E B i o g r a p h i c a l D a t a S h e e t Please answer the following questions on the answer sheet provided. Print your name and your birthdate in the space provided on the answer sheet. 1. In which term of the nursing program are you currently registered? a. 1 b. 3 c. 4 2. What sex are you? a. Female b. Male 3. How many f u l l academic years of post-secondary education (exclusive of the BCIT General Nursing program) have you completed? a. 0 c. 2 e. 4 g. 6 b. 1 d. 3 f. 5 h. 7 4. Have you repeated any nursing courses in the BCIT General Nursing program? a. yes b. no 5. Have you trained or worked as a nurse, a nurse aide or a practical nurse for one year or more? a. yes b. no 6. Are you an R.P.N.? a. yes b. no Thank you for participating in this research. 87 "@en ; edm:hasType "Thesis/Dissertation"@en ; edm:isShownAt "10.14288/1.0056014"@en ; dcterms:language "eng"@en ; ns0:degreeDiscipline "Counselling Psychology"@en ; edm:provider "Vancouver : University of British Columbia Library"@en ; dcterms:publisher "University of British Columbia"@en ; dcterms:rights "For non-commercial purposes only, such as research, private study and education. Additional conditions apply, see Terms of Use https://open.library.ubc.ca/terms_of_use."@en ; ns0:scholarLevel "Graduate"@en ; dcterms:title "The relationship of age, empathy skill training and cognitive development to nursing students' empathic communication skills"@en ; dcterms:type "Text"@en ; ns0:identifierURI "http://hdl.handle.net/2429/28212"@en .