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DISCUSSION

Patient narratives 5: providing empathetic care in nursing practice

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Empathy is a complex concept. Patient narratives can help nurses to understand and recognise situations when empathy is required

Abstract

The fifth in our seven-part series on patient narrative explores empathy. We focus on a patient story relevant to all fields of nursing and raise key issues about how health professionals convey empathy to patients.

Citation: Buckley A et al (2016) Patient narratives 5: providing empathetic care in nursing practice. Nursing Times; 112: 15, 22-23.

Authors: Alison Buckley is senior lecturer; Louise Corless is senior lecturer; Steve Mee is associate professor; all at the University of Cumbria.

Introduction

Empathy is a complex concept that demands crucial skills of health professionals: they must not only recognise when it is required but also communicate it to patients. This ability has been a key interpersonal skill in psychotherapy and counselling for many years and is deemed central to humanistic and person-centred practices in health and social care. Rogers (1975) identified empathy as one of the core conditions necessary for the development of a patient-centred therapeutic relationship. He defined being empathic as having the ability:

to perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as if one were the person”.

Nurses need to understand not only the theoretical concepts that inform the development of an empathic relationship but also be committed to developing the attributes, behaviours and communication skills central to it. It is through the use of patient narratives that we begin to understand the importance of empathy. The narrative below is taken from general nursing. After reading it, consider the reflection points that follow.

Narrative: the yellow snake

Grace Sugden* was admitted to a regional neurosurgical unit following a haemorrhagic stroke. During her hospital stay she presented with disturbances in consciousness, acute confusion, florid hallucinations, delusions, dysphasia and dyspraxia. After a long period of rehabilitation, she had recovered sufficiently to be able to give a retrospective account of her experiences while hospitalised. She was particularly able to recall memories from when she was diagnosed with acute confusion.

Following the removal of her nasogastric feeding tube, Mrs Sugden had been asked to feed herself but, because of her dyspraxia and right-sided hemiplegia, she found this difficult. She recalls staff becoming frustrated with her:

“… [I was] like a baby. I was just like a child… I remember the feeding tube being really uncomfortable and not wanting to talk to anyone… when they took it out, they gave me a plate and utensils but I picked up my left hand (my right one wasn’t working) and put the food straight into my mouth like a baby… smearing it over my face

I was embarrassed; I could tell they were annoyed as they had to clean me up.”

Mrs Sugden relates an occasion when she became extremely distressed and tried to pull her urethral catheter out. She describes what she felt about the catheter.

A yellowy thing going into the distance… so frightening… a yellow snake… They kept telling me to leave it alone but I thought it was a snake. I told them to get an electrician to get it out.”

Nursing staff told Mrs Sugden to stop taking the catheter out. She acknowledges that her behaviour must have been particularly challenging for them as she remembers being aggressive and disruptive.

Reflection points

Mrs Sugden had a brain injury, which resulted in her experiencing altered perceptions and interpretations of her environment in an acute phase of her illness. Staff often appeared to reprimand her, challenge her behaviour or try to reassure her that “all is fine”. Nevertheless, her recollection is of her experience at that particular moment in time – she really did believe a snake was coming out of her when she was catheterised.

Reflective point 1

When patients experience altered perceptions it is important not to dismiss them as irrational; they should be taken seriously. Hospital can be a confusing and hectic place for patients who are fully oriented; for those who are confused it must be profoundly disturbing and distressing.

Can you think of patients you have nursed whose diagnosis meant their perception of the environment was very different from yours? What impact did that different perception have on their behaviour? How did you respond to their behaviour? While we cannot always solve the underlying cause of confusion, we can try to provide an environment that is “emotionally safer” and more conducive to recovery. How would your patients describe the environment you provide?

Reflective point 2

Mrs Sugden’s stroke seriously impaired her functioning; she found she was unable to feed herself. Think of a patient you have recently nursed who had reduced functioning due to their condition. Did you demonstrate patience and acceptance of that reduced functioning? How would your patient describe your care?

Reflective point 3

It may be that nurses caring for Mrs Sugden were preoccupied with nursing procedures because she had a life-threatening illness. This focus may have prevented them from seeing the illness from her perspective.

Think of a recent patient you have nursed who had a serious condition. To what extent did you focus on the condition rather than what the patient was experiencing as a result of the condition? To what extent did you stand in their shoes?

Reflective point 4

Mrs Sugden was extremely frightened. Apart from believing that her catheter was a snake, in other parts of her story (not included in this article) she recounted believing being involved in violent scenes that she saw on a television on the ward – namely, that a nurse had deliberately taken her breathing mask to kill her and that she had been strapped to the bed.

Think of a recent patient who may have been frightened. How did their fear affect their behaviour? How did you respond? Would that have been helpful to them?

While it could be argued that nurses cannot wholly empathise with their patients’ experiences of confusion, listening to Mrs Sugden’s story may help us consider whether our nursing actions, in similar situations, might have been therapeutic and reassuring or simply served to compound patient distress. Stories like these highlight the importance of viewing the patient within a diagnosis, rather than simply viewing their actions and behaviours as a result of the illness. Box 1 contains narratives from other fields of nursing.

Conclusion

Francis (2013) highlighted a disturbing lack of empathy on the part of many nurses at Mid Staffordshire Foundation Trust, such as ignoring, even mocking, a patient pleading for help with pain. Similarly, Mrs Sugden was physically incapable of finding her mouth when eating but was criticised by staff for making a mess. The starting point for all nurses should be a acknowledgement that patients such as Mrs Sugden experience confusion, loss, fear, grief and discomfort. This might lead to more compassionate caring.

It is sometimes easier to recognise when an interaction is not empathic rather than when it is. Rarely will patients evaluate their care or experiences using the word “empathy”; they are more likely to describe the actions and behaviours of the nurse as being compassionate or caring. Empathy is central to nursing practice.

  • *The patient’s name has been changed.

Box 1. Narratives illustrating the importance of empathy

  • “I had surgery just before Christmas. On Christmas Day I had a lot of pain. I was thinking about my husband and young daughter at home and was missing them. I love Christmas with my family. I was very tearful. The nurse came over to me and said ‘What are you crying for? It’s Christmas!’”
  • A woman recently had a stoma formed, which leaked in her bed. The nurse responsible was about to go home to a family event and his immediate thought was “I’m going to be late”. He realised from the woman’s response that his facial expression had given away his frustration. She looked distressed at his apparent impatience. The nurse reflected on this afterwards and realised that he needed to be more conscious of his facial responses. This is a good example of empathy after the event. As a result, he changed his nursing practice by becoming more conscious of his responses and presentation.
  • “I regularly have thoughts of wanting to end my life when things become too much for me. One day I was talking to a nurse who kept telling me all the things that were good in my life and how I should be grateful for being financially secure with a wife who has supported me throughout many years of depression. That doesn’t really help when I have been in so much physical pain because of my sailing accident, which has meant I cannot lead the active life I once did.”

Talking points

  • How do you define empathy?
  • What are the key features of empathetic care?
  • Why may patients sometimes experience care that lacks empathy?
  • How could you explore the idea of “standing in your patient’s shoes”?
  • Have you seen health professionals demonstrate a lack of empathy and, if so, what have you done about it?
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