Dr. Sorrell is Senior Nurse Researcher, Cleveland Clinic Foundation, Cleveland, Ohio.
The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. The author acknowledges employment at Cleveland Clinic Foundation.
The author acknowledges Carol Santalucia, MBA, Director of Patient Navigation and H.E.A.R.T.™ Service Recovery Programs, and Mary Linda Rivera, RN, ND, Executive Director of the Office of Patient Experience, for their generous contribution of time in interviews for this article.
Address correspondence to Jeanne M. Sorrell, PhD, RN, FAAN, Senior Nurse Researcher, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail: email@example.com.
It was a beautiful autumn day, and I was sitting on the bench outside Cleveland Clinic during my lunch break, waiting for a colleague to finish her purchase at the farmers’ market the Clinic sponsors. A frail man who appeared to be in his late 80s approached me and appeared anxious to talk. He pointed up at the huge building behind us and told me that his wife was there on the seventh floor waiting for surgery after being evaluated over the past several months at two other hospitals. He said he and his wife had raised three children and sent them all to college, but now he worried they might lose their house because he had no idea what his hospital bills would be. As we talked, tears filled his eyes, and he apologized for unburdening himself to me but said that sometimes the worries are too overwhelming and he just needs to talk it out. Before returning to work, I made some suggestions regarding whom the man might contact for help with his worries. He apologized again and thanked me for talking with him: “Sometimes you just need someone to listen to you,” he said.
Later, back in my office, I kept thinking of this man and wondered how many other older adults in the hospital that day, whether patients or family members, were feeling overwhelmed with their health care experience. As health care has become increasingly sophisticated, it seems to have also become increasingly fragmented and impersonal. Hospitals struggle to make the patient experience as satisfying as possible, but this can be difficult because of the many specialists, support personnel, and technology a patient encounters. Nurses may find a renewed focus on empathy to be a way to forge the personal, caring relationship many patients want from their caregivers.
Empathy in Health Care Interactions
Empathy as a therapeutic tool evolved from the work of Carl Rogers, who viewed empathy as a vital component of his person-centered approach to counseling. According to Rogers, empathy can be described as the ability to accurately perceive the internal frame of reference of another person, as if one were with the other person (as cited in Patterson, 1977). It involves a “feeling into” another’s world to comprehend that person’s world and experience (Cowdell, 2010).
Empathy is generally recognized as a positive factor in providing quality care for patients, but what constitutes empathy and how it can be measured has been debated (Yu & Kirk, 2008). Yu and Kirk (2008) conducted a systematic review to identify, critique, and synthesize nursing studies that attempted to measure empathy. Through their review of 30 papers (29 studies), they concluded that there was no consistency in the numerous tools being used to assess empathy.
Pederson (2009) took a similar approach in critically reviewing 206 publications that presented empirical research on empathy in medical students or physicians. He found some interesting commonalities in his review: The term empathy was often not defined; quantitative instruments had a narrow scope that seemed to distance empathy from clinical practice; and very few qualitative research studies could be found. Pederson (2009) recommended that future studies include qualitative approaches and explore the patient’s concrete experiences and interpretations related to empathy.
Integrating Empathy into the Health Care System
To address the need to integrate empathy into the patient experience, the Cleveland Clinic (2010) Office of Patient Experience sponsored a Patient Experience Summit: Transforming Healthcare through Empathy and Innovation in May 2010. The summit featured speakers from a variety of disciplines, including nursing. Patricia Benner, PhD, RN, and Jean Watson, PhD, RN, spoke about interactions with patients who had experienced empathy in health care and those who characterized their health care experiences as impersonal and uncaring. Both Benner and Watson confidently asserted that empathy could—and should—be taught to health care providers. Watson noted:
We’re still in a very medicalized, technical, clinical view of our humanity in the medical world. I feel as though our evolution from a medical treatment orientation to healing and caring is a very different level, it’s an inner process. You can fake empathy through the head, but real empathy comes from the heart.
At the summit, Cleveland Clinic’s Chief Executive Officer and President, Delos M. Cosgrove, MD, told of a pivotal experience he had while addressing a Harvard case study class. During the class, he was confronted by a student whose father had considered going to Cleveland Clinic as a patient but had decided to go to another facility that was considered “more empathetic.” The student asked, “Do you teach empathy? Isn’t that human piece just as important as the medical outcomes, the clinical skill and the technology, and all the bells and whistles?” Dr. Cosgrove describes this as an “aha” moment for him. He set about to change the culture of Cleveland Clinic. An important first step was to create the Office of Patient Experience, one of the first in the country, and to appoint a Chief Experience Officer. “Patients First” became the guiding principle for Cleveland Clinic (2010).
The Office of Patient Experience emphasizes a holistic approach to change the culture of the hospital environment. This is not an easy task with an institution as large as Cleveland Clinic, which has approximately 40,000 employees and one of the highest levels of patient acuity in the country, with intensive care units comprising one third of the hospital (Colvin, 2010). Nurses are an important part of changing the culture to a patients-first focus. To achieve this, nurses have implemented hourly rounding “with purpose” to open lines of communication. When a change in nursing policy/process or a research project is being planned, representatives from the Office of Patient Experience are at the table to consider whether the change is also good for the patients. Currently, a new patient guidebook is being developed, and department members work with patient educators to ensure important elements identified by patients are included. The Patient Service Navigator Program and Healing Services Team deal directly with patients to enhance personal interactions. Voice of the Patient Advisory Councils, which include former Cleveland Clinic patients and some employees, meet regularly at several Cleveland Clinic locations to provide real-time feedback and creative solutions to specific challenges that affect patients and family members.
An interesting question being considered by the Office of Patient Experience is: Do specific hospitalized patient populations, such as older adults, have special needs in terms of patient experience? Older patients often enter the hospital with multiple diagnoses (or sometimes, no diagnosis), multiple medications, complex pain issues, and Medicare as their primary insurance. They may also have fewer external supports than younger patients, and their length of stay in the hospital may be longer. The Office of Patient Experience asserts that it is important to identify what variables have the most impact on the patient experience for each patient.
One important variable appears to be communication. The way in which health care professionals communicate can convey a sense of empathy to patients and family members. Bonvicini et al. (2009) found that communication training made a significant difference in physician empathic expression in patient interactions. Physicians who received formal communication training were more likely to acknowledge patients’ expressed emotion and invite further discussion than those who did not receive the training.
Yu and Kirk (2008) asserted that empathy can be taught as a skill and developed with practice and experience. In a systematic review of nursing literature related to empathy, Brunero, Lamont, and Coates (2010) concluded it is possible to increase nurses’ empathic ability and that the models of education showing the most promise are those using experiential styles of learning. One qualitative study that investigated physicians’ lived experience of patienthood described how their own experiences with illness increased physicians’ depth of understanding and emotional connection with patients (Fox et al., 2009). The development of empathy was one of the most important ways that illness had informed the practice of the physicians in this study. One participant described these changes:
I actually felt I was more involved, as in I…cared more… that sounds a bit, um, nebulous, but actually it did, it made more sense what the people were coming in with…I could see why they were as distressed as they were, I could…relate to it more.
A review of research literature suggests empathy can be taught to health care professionals and that the most effective way may be through experience, rather than formal instruction. Instead of struggling with the precise measurement of such an abstract concept as empathy through quantitative research designs, it may be more valuable to implement qualitative studies to better understand the relation of empathy to the experiences of health care professionals and patients. Because there are currently very few data to help us understand the specific psychosocial needs of older adults during their hospital experiences, future research could provide valuable information to guide health care professionals in integrating empathy into the patient experience for hospitalized older adults.
- Bonvicini, K.A., Perlin, M.J., Bylund, C.L., Carroll, G., Rouse, R.A. & Goldstein, M.G. (2009). Impact of communication training on physician expression of empathy in patient encounters. Patient Education and Counseling, 75, 3–10. doi:10.1016/j.pec.2008.09.007 [CrossRef]
- Brunero, S., Lamont, S. & Coates, M. (2010). A review of empathy education in nursing. Nursing Inquiry, 17, 65–74. doi:10.1111/j.1440-1800.2009.00482.x [CrossRef]
- Cleveland Clinic. (2010). 2010 patient experience summit: Session summaries. Retrieved from http://www.clevelandclinic.org/collective/session_summaries.htm
- Colvin, G. (2010, February18). Cleveland Clinic chief on the business of health. Fortune. Retrieved from the CNN website: http://money.cnn.com/2010/02/17/news/companies/cleveland_clinic_cosgrove.fortune/index.htm
- Cowdell, F. (2010). Care of older people with dementia in an acute hospital setting. Nursing Standard, 24(23), 42–48.
- Fox, F.E., Rodham, K.J, Harris, M.F, Taylor, G.J., Sutton, J. & Scott, J. et al. (2009). Experiencing “the other side”: A study of empathy and empowerment in general practitioners who have been patients. Qualitative Health Research, 19, 1580–1588. doi:10.1177/1049732309350732 [CrossRef]
- Patterson, C.H. (1977). Carl Rogers and humanistic education. In Foundations for a theory of instruction and educational psychology. Retrieved from http://www.sageofasheville.com/pub_downloads/CARL_ROGERS_AND_HUMANISTIC_EDUCATION.pdf
- Pederson, R. (2009). Empirical research on empathy in medicine—A critical review. Patient Education and Counseling, 76, 307–322. doi:10.1016/j.pec.2009.06.012 [CrossRef]
- Yu, J. & Kirk, M. (2008). Measurement of empathy in nursing research: Systematic review. Journal of Advanced Nursing, 64, 440–454. doi:10.1111/j.1365-2648.2008.04831.x [CrossRef]