1. John McKinnon Senior Lecturer in Nursing University of Lincoln UK
In Their Shoes : an ontological perspective on empathy in nursing practice
John McKinnon
Senior Lecturer in Nursing
University of Lincoln UK

2. Defining Empathy
to understand what it is like to be in someone else’s position (what it is like to live that person’s life) or, perhaps less ambitious, (ii) to understand what it is like to experience phenomena as someone else experiences them.
Kirk (2007:239)

3. Defining Empathy
Distinct from Compassion ‘pain in oneself’ (Gilbert and Choden, 2013)
Born of Sound Self Awareness
(Eckroth- Bucher, 2010)
Representational Thinking (Scott, 2000)

4. Defining Empathy Cognitive Empathy Affective Empathy
The Means not an End
The Dorsal Striatum, the Empathic Joy Hypothesis and Intimacy
(Kawamichi ,Tanabe, Takahasi and Sadato, 2013)

5. Research Question
What are the dynamics of empathy as part of nursing ontology?

6. Methodology
Part of a larger study into the commonality of emotion across nursing practice
A purposive sample of 34 nurses talked exhaustively about their experiences with empathy in the context of their relationships with patients and families.
Interviews audio-taped, transcribed verbatim and anonymised
Data was analysed until saturation was reached using a grounded theory method.

7. Background
Interviews took place across 4 NHS Trusts in East Midlands and London
Ethical Approval gained from University of Lincoln Ethics Committee and from NHS Ethics Committee

8. The Sample by Specialism
6 District Nurses
4 Health Visitors
2 School Nurses
5 Nurses in an Acute Adult Surgical Ward
3 Mental Health Nurses
10 Paediatric Hospital Nurses
3 Neonatal Intensive Care Nurses

9. The Sample- Gender and Ethnicity
28 Women and 5 Men
26 White British
3 Black African
3 Black African Caribbean
1 Asian

10. The Sample by Age Grouping
8 nurses aged years
9 nurses aged years
6 nurses aged years
10 nurses aged years

11. Results Four Main Themes Four Clusters of Ten Subthemes
Five Subthemes formed a Process

12. Pursuing Cognitive Empathy- Insight into Behaviour
“I would say, well put yourself in her shoes for 5 minutes, how would you feel living your life in front of every body else knowing that no matter what we do for her son, nothing seems to be working.”
Senior Children’s Nurse

13. Multiple Empathy
“ How do you give hope to someone with no hope? The young girl that I’ve just had is just over twenty who wants to throw herself down the stairs; she can’t go out with friends, she can’t dance, she can’t go to the pub, she can’t drive her car. She is living with parents who are cosseting her, and you can understand why because of the devastation to their lives. Nobody expects a 21 year old daughter will have a severe disability.”
Nurse Specialist for Stroke Patients

14. Empathy for a patient group
“ they have never been in hospital before, they’re frightened, we get young patients here who have stone disease, they might have had their first stone at 18, 19 and they look around and most of the other male patients on the ward are 70 plus, that maybe frightens them. It’s just, they are just bamboozled by what is going on.”
A Senior Renal Ward Sister

15. Tracing the Route of Empathy- Engagement
And for that patient to be open, to tell you experiences and how they are feeling, if you don’t come across as approachable and that you are human… So you engage a little bit and you have to give a bit of yourself. …I often wonder how some colleagues that I see who are very clinical very much I’m here to do this job, and this is what I want to do, and these are the answers I want’ and they give the information and they don’t relax. I don’t know how patients know that you have empathy if you don’t give a little tiny bit.
District Nurse

16. Tracing the Route to Empathy- Artful Listening
“Whereas if you are in a more difficult session things maybe aren’t going so well or the person is telling you some really difficult stuff to hear and it is quite painful then that would be more when you slow down and I guess it is the echoing between where they are at and where you are at so the pace would be maybe very different and slower. “
Nurse Consultant Mental Health

17. Tracing the Route to Empathy- Imagination and Representation
“I can sort of put myself in their shoes in a way. I can imagine, I can try and imagine what it must be like for them.”
A School Nurse

18. The Empathic Process Engagement Listening
An informed Awareness of another’s circumstances
Imagination
Relating the product of the imagination to the self.

19. Biographically Informed
“..she’s been wetting the bed and doing this and doing that and she never used to do it. And I said “it’s all signs of emotional distress. She’s missing what she had. You know, imagine she’s an only child, she had Mum and Dad there, thinking she was the centre of their world and she’s gone to sharing you with another woman and 3 children. So at that age they can’t always tell you how they are feeling. She’s not going to say ‘well I’m fed up because ‘ she’s not going to be that articulate. But the behaviour she is displaying is signs of emotional upset and distress, and that’s what they do. Because she wants you, she wants your attention.”
A School Nurse advising the father of an eight year old girl

20. Biographical Empathy
“you see abuse that they have gone through and they have never had a chance since the day they were born really and you feel sorry for them and you think, if they are self-harming, you know if they are acting in a way that’s out of the norm, if there is such a way then, you can understand why they self-harm you can understand why they would want to be violent towards men because men have abused them from pillar to post.”
A Mental Health Nurse on Women with Personality Disorders

21. Motivation for Practice “It drives me on”
“The fact that I have got this empathy for a lot of the patients does drive me on ..I would probably want to go that extra mile for them whereas I probably wouldn’t have done….You are going to want to see them have some sort of meaningful life. Yes so I guess the empathy thing can play a part there if you channel it in a professional and objective way.”
A Mental Health Nurse

22. The Key to Person Centred Care
“ the fact that if I could put myself in somebody’s shoes, or understand their life history and how it fits into their current way of being, I can work with them a lot better but those that I can’t, I can still work with them, but deep down there is that sense of frustration and that sense of not being able to hook into them as a person because if I don’t understand you as a person I’m not going to be really much good to you on a really deep and meaningful level.”
Mental Health Nurse

23. Struggling to have empathy- “ I can’t imagine”.
“You can only really relate it to how you’d feel yourself can’t you? I just think I can’t imagine that happening, someone taking my children away or me getting to that point in my life where I cant, I wouldn’t be able to cope, you just kind of do it from your own personal experiences, and you just think, God I cant imagine what they must be going through.”
A Health Visitor

24. Empathy from Shared Life Experience- Emotional Kinship
“I know for myself I thought I knew what it would feel like to be bereaved when I visited bereaved patients having done all the courses. I felt that I could empathize with them. But then when I lost my father I felt very different and so my empathy now is different, because I’ve got that lived experience of loss in somebody that you’ve cared about. So I would say that could only come from living through an experience and you can’t learn that from a book. And that’s made me a different person, emotionally, to go and see somebody who is bereaved.”
A District Nurse

25. Empathy from Shared Life Experience- “Emotional Memory Awareness”
I have 3 children of my own and one of my children was diagnosed at the age of 6 months with a very rare condition. To this day, I can still remember those feelings and I can remember what was happening around me and I can remember what TV programme was on. When I am in with families receiving bad news I am always conscious of the fact of how the setting is, about, because I can remember, 18 years on that feeling I got when I was given my bad news and where I was sitting, I can remember I was sitting at home and I can remember what was on the television. It was as if time stood still for that minute, so when I am giving bad news or I am involved in giving bad news to families I always try and be really aware of the setting of where we are.
Senior Ward Sister Children’s Nursing

26. Empathy from Shared Life Experience- Concept Translation
“Having had loss recently I suppose it makes you, although its slightly different, it makes you understand maybe how parents are feeling, though I’ve not lost a child so its different but you know, it makes me realise the support they need… I’ve maybe got a small idea of how they might be feeling and the emotions they’re going through at the time that they perhaps suffer their loss. … I suppose I can make decisions on the next of care or the next step so they feel that we’ve provided or I’ve provided for them what they’ve needed, even if it’s something as simple as holding the baby or making sure they have the opportunity afterwards to properly say goodbye”
Neonatal Intensive Care Nurse

27. Findings A powerful tool for nursing practice
Empathy is a libidinal entity which drives and accurately informs person centred practice
Empathy may simultaneously function singularly or plurally.
Biographical knowledge can substitute for the length of a relationship
Biographical empathy is more likely to reach an affective level than empathy for a phenomenon.
Case Sensitive use of life experience can promote affective empathy through emotional kinship.

28. Implications for Practice and Learning
Self Awareness and Emotional Intelligence must be fostered throughout undergraduate and post graduate study and practice.
Narrative sharing between learners to encourage empathy construction skill.
Service User Participation

29. Empathy ENHANCING FACTORS Knowing The Patient Biography Nurse’s Life
Experience
PROCESS
ENGAGEMENT
LISTENING
INFORMED AWARENESS
IMAGINING
AFFECTIVE EMPATHY
CARE OUTCOME
Evidence of Nurse’s Personal Interest
Patient Perspective Shared and Clarified
Patient feels heard and understood
Nurse uses informed awareness to build emotion picture of patient
Accurately Informed Person Centred Care
Emotional Kinship