N U R SI N G T H E O R Y A N D C O N C E PT D E V E L O P M E N T O R A N A L Y SI S

Clari®cation of conceptualizations of empathy

Diane Kunyk BScN RN
MN Student, University of Alberta, Edmonton, Alberta, Canada

and Joanne K. Olson PhD RN

Professor, Faculty of Nursing, Edmonton, Alberta, Canada

Submitted for publication 23 October 2000

Accepted for publication 20 April 2001

Correspondence: KUNYK D. & OLSON J.K. (2001) Journal of Advanced Nursing 35(3), 317±325
Diane Kunyk, Clari®cation of conceptualizations of empathy
University of Alberta, Background. If understanding our clients needs, emotions, and circumstances is
47 Westbrook Drive,
fundamental to nursing practice, and empathy is the foundation of that under-
Edmonton,
standing, then a conceptualization of empathy that can be used by nurses is of
Alberta,
Canada T6J 2C8. utmost importance to the profession. In 1992, Morse, Anderson, Bottorff, Yonge,
Email: maranoa@v-wave.com O'Brien, Solberg and McIlveen analysed the concept of empathy in the psycholo-
gical and nursing literature, and suggested the conceptualization of empathy was
incomplete. Since that time, nurse authors have continued to publish conceptual-
izations and research on empathy.
Purpose. The purpose of our analysis was to describe empathy as presented in the
nursing literature between 1992 and 2000.
Method. A concept clari®cation methodology of concept analysis was used because
of the many de®nitions, the rich descriptions, and the application of empathy as a
research variable in the reviewed literature.
Findings. Five conceptualizations of empathy were revealed: empathy as human
trait, empathy as a professional state, empathy as a communication process,
empathy as caring, and empathy as a special relationship.
Conclusions. The literature reviewed contained evidence that the concept is
developing more depth and breadth. Nurse authors are approaching empathy from
a variety of perspectives, time frames, measurements, and outcomes. While all are
important to the development of the concept, further enrichment of the conceptual
work on empathy is needed before a fully mature concept emerges that is fully useful
in nursing practice, research, and education.

Keywords: concept clari®cation, empathy, concept analysis, content analysis,

nurse±client relationship

foundation of nursing practice (Williams 1990, Layton

Clari®cation of conceptualizations of empathy
One of our basic human needs is to be understood. This
understanding forms the foundation upon which relation-
ships are built. In nursing practice, nurses are professionally
interacting with other unique human beings. The relation-
ships that develop between the nurse and clients are the
1994). What attribute is it that gives nurses the ability to
truly understand another person, and thereby promote the
health of that person? Many nurse scholars would argue that
it is empathy that provides nurses with this capability, that
empathy is the essence of all nurse±client communication
(Peplau 1952, Kalisch 1973, Benner & Wrubel 1989).

Ó 2001 Blackwell Science Ltd 317

D. Kunyk and J.K. Olson
Despite years of interest and numerous studies on empathy,
the meaning, outcomes, and nature remain unclear (Gagan
1983, Bennett 1995). Sutherland (1993) claims that empathy
has been termed an ability, an attitude, a feeling, an inter-
personal process, a trait, a state, a sensitivity, and a percep-
tiveness. She argues that this ambiguous use of the concept
contributes to the confusion in the literature. In a review of
the psychological and nursing literature, Morse et al. (1992a)
suggest that the quandary about the meaning and components
of empathy arises from the subjective nature of the concept,
the complexity of the empathic process, as well as the
incomplete conceptualization of empathy in the literature.
Conceptualizations of empathy have been published after
the literature analysed in the Morse et al. (1992a) review
(Alligood 1992, KristjaÂnsdoÂttir 1992, Hudson 1993,
Raudonis 1993, Sutherland 1995, Norman 1996, Smyth
1996, Thompson 1996, Wiseman 1996, Papadatou 1997,
Price & Archbold 1997, White 1997, Dracup & Bryan-Brown
1999, Reynolds & Scott 2000). In addition, empathy has been
the focus of further nursing research (Murphy et al. 1992,
Reid-Ponte 1992, Warner 1992, Bennett & DeMayo 1993,
Sutherland 1993, Kuremyr et al. 1994, Reynolds 1994, Olson
1995, Raudonis 1995, Wheeler 1995, Wilt et al. 1995, Bailey
1996, Baillie 1996, PalssoÊn et al. 1996, Wheeler et al. 1996,
Olson & Hanchett 1997, Evans et al. 1998, Cutliffe &
Cassedy 1999, Omdahl & O'Donnell 1999, Puentes 1999,
Hollinger-Samson & Pearson 2000, May & Alligood 2000).
It was determined that a concept analysis using the nursing
literature from 1992 to 2000 would be appropriate to further
re®ne and clarify the concept, empathy.
Concept analysis
Concept analysis is a term that refers to the process of
unfolding, exploring, and understanding concepts. This crit-
ical assessment can assist in helping concepts mature, thus
increasing the consensus of the meaning of the concept. A
concept is considered to be mature if it meets the following
indicators: (a) is well described with internal characteristics
delineated, (b) there are no competing concepts, (c) the
parameters are clearly de®ned and (d) the concept is oper-
ationalized with quantitative methodology (Morse 1995).
Concept analysis is critical for systematic development of
nursing knowledge.
The Wilson method of concept analysis is commonly used
in nursing literature. It involves an 11-step process that
includes model cases, contrary cases, related cases, borderline
cases, and invented cases (Walker & Avant 1983). Concept
analyses of empathy currently exist in published nursing
literature based on this method (Olsen 1991, Sutherland
318 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(3), 317±325
1995, Wiseman 1996). It was determined that a differing
methodology of concept analysis would be bene®cial to
further analyse the concept, empathy.
Morse (1995) argues that qualitative methods can be used
for concept analysis purposes. Morse et al. (1996) suggest that
the qualitative method of concept clari®cation is appropriate
when there is a large body of literature that includes de®ni-
tions and descriptions, and when the concept has been
measured in research. Empathy meets these requirements for
the concept clari®cation method of concept analysis. Included
in the reviewed articles were numerous explicit and implicit
de®nitions of empathy, rich historical descriptions of empathy
and various quantitative instruments for measuring empathy.
The article by Morse et al. (1990) analysing conceptual-
izations and theories of caring was used as an example of the
method, concept clari®cation. This method includes:
(a) conducting a literature review, (b) analysing the content
of the literature and (c) identifying, describing, comparing,
and contrasting the attributes and the rules of relation for
each category.
This concept clari®cation of empathy includes nursing
articles describing the concept of empathy, or articles that
used empathy as a variable in a research project, from 1992
to the end of 2000. These dates were selected to follow the
last literature review on the concept of empathy by Morse
et al. (1992a), which had concluded that further concept
development was necessary. After analysis of each article in
regards to antecedents, de®nitions, attributes, components,
process, consequences, and outcomes related to empathy, ®ve
conceptualizations of the nature of empathy emerged. Some
authors conceive only one conceptualization of empathy
while others acknowledge the co-existence of more than one
conceptualization.
Conceptualizations of empathy
The ®ve conceptualizations are empathy as a human trait,
empathy as a professional state, empathy as a communication
process, empathy as caring, and ®nally, empathy as a special
relationship (Table 1). Each of these conceptualizations will
be discussed in regard to their characteristics, and the speci®c
author's interpretations of empathy. For purposes of accu-
racy, these descriptions will use the author's own wording.
These conceptualizations are not mutually exclusive nor are
any value judgements intended.
Empathy as a human trait
In this conceptualization, empathy is an innate, natural
ability. Although it is acknowledged that empathy cannot be
 Table 1 De®nitions of empathy classi®ed into ®ve conceptualizations

Author De®nition Consequence Outcome

Empathy as a human trait

Alligood (1992)
Bennett and DeMayo (1993)
Dracup and Bryan-Brown (1999)
KristjaÂnsdoÂttir (1992)
Patient feels understood
The human capacity for perceiving others' feelings Accurate perception Step towards the goal of sympathy
A speci®c emotion that comes as the result of a close Helps nurses deliver care that is
identi®cation and connection with another person attentive and appropriate to the
individual
`An ability or a capacity to share the other person's Communication, Understanding
experience by imaginative constructions of his understanding
attitudes, by anticipation of his behaviour, and/or
by understanding his feelings, needs, perceptions,
Nursing theory and concept development or analysis

and de®nition of the situation, in a state of

emotional readiness'
Morse et al. (1992b) A communication strategy Understanding and communi-
cating that understanding
Norman (1996) A way of being to identify the problem Improved direction of care to
dementia patients
Smyth (1996) Struggle to imagine how another person views Sensitive and individual care
the world

Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(3), 317±325

Empathy as a professional state
Alligood (1992) Patient feels understood
Morse et al. (1992b) A communication strategy Understanding, and
communicating that
understanding
Norman (1996) A way of being to identify the problem Improved direction of care to
dementia patients
Papadatou (1997) The capacity to understand what another person is
experiencing from within that person's frame of
reference
Price and Archbold (1997) The ability to see the world as another person sees it Understanding
Thompson (1996) Ability to access thoughts and feelings of clients Therapeutic phenomena

Empathy as a communication process

Bailey (1996) A central focus and feeling with, and in, another's world Allows the creation of caring
Baillie (1996) Understanding what the other person is experiencing Patient feels understood
and cared for

319
Concept clari®cation
320
Table 1 (Continued)

Author De®nition Consequence Outcome

Olson (1995) Nurse expressed empathy as the skill of Understood As nurse empathy increases, patient
D. Kunyk and J.K. Olson

understanding what a patient is saying distress decreases. As nurse

and feeling, and communicating this empathy increases, patient
understanding verbally to a patient. perceived empathy increases.
Patient perceived empathy is a patient's
feelings of being understood and accepted
by a nurse
Omdahl and O'Donnell (1999) Empathic concern facilitates
communicative responsiveness,
which is the ability to effectively
communicate with others about
sensitive and emotional topics
Reid-Ponte (1992) A communication skill
Reynolds and The ability to perceive and reason, as well as Clients perceive their
Scott (2000) the ability to communicate understanding of situation is understood
the other person's feelings and their attached
meaning
Wheeler (1995) A three phase process The greater the use of empathy,
(1) empathic potential the less distress of patients.
(2) empathy expressed Empathy can be used to effect
(3) empathy perceived overt and measurable changes
in patient outcomes
White (1997) A form of communication Relief from emotional distress
Wiseman (1996) See the world as others see it, understand another's feelings, Patients feel valued and more
nonjudgemental, communicate the understanding' ready to understand themselves
and change

Empathy as caring
Hudson (1993) Empathy is caring, as opposed to curing
Sutherland (1993) Phenomenological empathy is comprised of is patient Patient outcomes improve when
cues, the nurse identifying, interjecting, and intervening empathy is extant in the interaction

Empathy as a special relationship

Raudonis (1995) Helping another know that you care for him as an individual Improvement and maintenance of
patient's physical and emotional
well-being

Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(3), 317±325

Nursing theory and concept development or analysis
taught, it is believed that empathy can be identi®ed, rein-
forced, and re®ned. Other terms used for this conceptu-
alization of empathy are natural, instinctive, emotional,
emotional intelligence, involuntary contagion, and genotypic.
Aesthetics, experience, maturity, self-awareness and cre-
ativity are seen as attributes that help nurses to understand
their clients. The de®nitions used by authors in this category
focus on the accurate perception of other's feelings and
situations, and understanding what this means for the other
person.
Aesthetics, creativity and imagination, as they relate to
empathy, are the focus of Smyth's writing. He suggests that
the antecedents to empathy are imagination and creativity.
He further proposes that not only are there conceptual
bridges between the ®elds of empathy and the aesthetic
experiences, but that the arts can both enrich our under-
standing of empathy and human relationships in general and
possibly enhance our capacity to empathize. According to
Smyth, the process of empathy has two intertwining phases
consisting of (1) resonance and (2) imagination. These
integrated phases are quite different from phases that will
be outlined in the empathy as a communication process
conceptualization.
Some authors recognize more than one conceptualization
of empathy. Alligood (1992), for example, determines that
there are two types of empathy. The ®rst type she labels
`basic empathy'. It is seen as a trait, a human attribute, a
universal human capacity, and is likened to natural, raw,
ordinary, feelings for others. This empathy is involuntary,
and cannot be taught. She does suggest, however, that it can
be identi®ed, reinforced, and re®ned to develop empathic
expertise.
Morse et al. (1992a) propose a communication model
based on two broad characteristics: (a) whether the nurse is
focused on the patient's response or focused on the self,
protecting him/herself from experiencing the patient's
suffering and (b) whether the response is re¯exive and
spontaneous (®rst level) or learned (second level). It is this
second characteristic, the response to the patient, which is
the important characteristic for classifying this model. The
®rst level responses are identi®ed to be re¯exive and
spontaneous. Emotional empathic responses in this model
are seen as culturally conditioned rather than learned, almost
re¯exive or automatic, and are naturally comforting to the
sufferer. The belief that this kind of response cannot be
learned is the identifying characteristic supporting the
empathy as a trait conceptualization. These authors empha-
size that ®rst level responses require more energy than a rote
professional response, but are also seen to be rewarding for
the caregiver.
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(3), 317±325
Concept clari®cation
Empathy as a professional state
Empathy as a professional state is envisioned as a learned
communication skill comprised primarily of cognitive and
behavioural components that are used to convey under-
standing of the clients' reality back to her/him. With this
conceptualization, empathy is a learned phenomenon, where
the nurse cognitively selects the best response. Some examples
of words used to describe this conceptualization of empathy
are deliberate, clinical process, phenotypic, and therapeutic
process. The literature includes discussion of objectivity, the
importance of maintaining client focus, as well as the
inappropriate emotional involvement of the nurse.
The de®nitions of empathy are often the same, or similar,
to the de®nitions used in the conceptualization of empathy as
a human trait. The accurate perception of the clients'
thoughts and feelings, as well as the understanding of the
clients' situation, is emphasized. It is not, therefore, the
de®nition of empathy that distinguishes this conceptualiza-
tion from the empathy as a trait conceptualization.
Thompson (1996) asserts the importance of the nurse being
able to `step outside of this (the empathic experience) in order
to maintain some objectivity so that the communication
remains client focused, and personal emotional exhaustion
and inappropriate emotional involvement of this nurse does
not take place' (p. 24). Self-awareness is discussed as an
important aspect of empathy in the sense that it can clarify
the boundary between self and others. There is a distinction
drawn between the nurse and the client, and an assertion of
appropriateness of professional responses. In this conceptu-
alization, empathy includes emotional distance from the
client, an appropriate professional response, objectivity, and
a therapeutic role.
Kristjansdottir (1992) describes empathy as a therapeutic
phenomenon in nursing care with two interrelated elements:
(a) the intrapsychic constructions and processes and (b) an
interpersonal process. She delineates that empathy includes
not only the accuracy in the therapists' (nurses') perception
but also the ability of the therapist (nurse) to communicate
these perceptions to the client in a supportive way. Consistent
with the trained empathy de®nitions, she believes that
empathy is developed through cognitive development and
personal growth.
Trained empathy is empathy that is learned in relation to
professional practice (Alligood 1992). This conceptualization
of empathy purports that empathy is a deliberate process and
a learned clinical skill. In Alligood's view, trained empathy
includes the cognitive selection of the best response. She
further hypothesizes that this trained response is a skill that
cannot be sustained. She further clari®es that communication
321
D. Kunyk and J.K. Olson
expertise is not a competence in therapeutic empathy that is
based on inherent personal ability (trait empathy). She argues
that therapeutic (state) empathy is a learned phenomena, and
basic (trait) empathy is a natural ability, both unique and
distinct.
Learned empathic responses are labelled second level
empathic responses in the communication model proposed
by Morse et al. (1992b). These authors distinguish two types
of empathic responses: (a) re¯exive and spontaneous (trait)
responses and (b) learned (state), deliberate and conscious,
responses. They identify that learned responses keep the
caregiver somewhat detached, objective and therapeutically
`at arms length' from the client. They further identify that the
primary focus is on understanding the patient's suffering and
developing a repertoire of cognitive and behavioural commu-
nication strategies that can be used. Again, the words
detached, therapeutic, and learned communication response
are used with this conceptualization of empathy as a state.
Empathy as a communication process
The conceptualization of empathy as an exceptional form of
communication breaks empathy into a process whereby the
nurse perceives the client's emotions and situation, then
expresses understanding, and ®nally the client perceives the
understanding of the nurse. The outcome of this process is an
accurate perception of the client, and the client feeling
understood. This conceptualization of empathy does not
imply a predetermined response or, for that matter, that the
response be verbal. However, the communication is a disci-
plined professional response, requiring an empathic attitude,
and the skills necessary to convey this to the client (Olson
1995). This view of empathy usually includes both of the
previous conceptualizations of empathy in the sense that the
process of becoming empathic depends on: (a) innate, natural
abilities, (b) becoming more sensitive and aware of other's
feelings and (c) learned ways of responding helpfully to
people's expression of feelings.
The primary characteristic of this conceptualization of
empathy is the focus on three stages of the process (Table 2).
The ®rst component involves the nurse perceiving the client's
emotions and situation, the second is the nurses' expression
Table 2 Empathy as a communication process
Authors Phase I
Barrett-Lennard (1981) Resonated empathy
La Monica (1981) Helper perception
Olson (1995) Nurse perception
Wheeler (1995) Empathy potential
322 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(3), 317±325
of understanding of the clients' emotions and situation, and
the last is the client perceiving the understanding of the
nurse. Wheeler (1995) describes these stages as: (1) empathy
potential, (2) empathy expressed and (3) empathy received.
Other authors (Reid-Ponte 1992, Kuremyr et al. 1994, Bailey
1996, PalssoÊn et al. 1996) utilize LaMonica's (1981) work,
which includes descriptors of helper perception, helper
communication and client perception. Olson (1995) employs
the words empathic (nurse) perception, nurse expressed
empathy and patient perceived empathy.
Omdahl and O'Donnell (1999) use the term communica-
tion in their research on empathy, however, with a different
approach. Communication is identi®ed as an empathy vari-
able, along with emotional contagion (taking on the emotion
of another person) and empathic concern (a concern for the
well-being of another that does not require sharing of
emotions). This interpretation of empathy does not support
the concept of the communication process of empathy, rather
preferring to treat the identi®ed variables of empathy
discretely.
Empathy as caring
Only two authors conceptualize empathy as an under-
standing that the nurse has of the client's situation and a
compulsion to act because of the experience of understanding
the client (Hudson 1993, Sutherland 1993). This action
component is a critical attribute of empathy in this concep-
tualization. In this conceptualization of empathy, the client
being understood is not considered an outcome of the
empathic process. Rather, the outcome of the empathic
process is clearly designated as nursing interventions that
meet the physical needs of the client and alleviate emotional
suffering.
Sutherland (1993) used qualitative, historical data from the
Civil War period to derive her concept of phenomenological
empathy consisting of four phases: (a) identi®cation,
(b) introjection, (c) detachment (nursing intervention) and
(d) patient response. Identi®cation is seen as a process of
losing consciousness of the self and becoming engrossed in
the experiences and situation of another. Introjection involves
emotionally experiencing what the other person is feeling,
Phase II Phase III
Expressed empathy Perceived empathy
Helper communication Client perception
Nurse expressed empathy Patient perceived empathy
Empathy expressed Empathy received
Nursing theory and concept development or analysis
taking in and resonating emotionally with the meaning that
the experience has for the other person. Intervention is a
nursing action taken on behalf of the patient and based on the
nurse's intense scrutiny of the patient's situation and
emotional responsiveness to the patient's suffering. The
response phase involves the patient having physical needs
met or emotional suffering alleviated.
Hudson (1993) also states that the goal of empathy is
effective nursing as perceived by the patient. She perceives
empathy to be caring, as opposed to curing, and identi®es it
as a feminine trait. The nursing actions described as caring
actions are listening, `being with', comforting, and talking.
Curing elements of nursing are considered to be physical
observation, treatment, and technological maintenance. The
caring actions occur as a result of the empathic experience by
the nurse. Technology and empathy emerge as essential and
equal components in the provision of quality care. Hudson
identi®es that empathy is valuable, but only after the patient's
basic needs are met.
Empathy as a special relationship
This conceptualization of empathy requires a reciprocal
relationship to develop over time between the nurse and the
patient. This element of reciprocity in the relationship
between the nurse and the patient is unique to this perspective
of empathy, a conceptualization only supported by the
writings of Raudonis (1993). The word friendship is used,
in sharp contrast to the conceptualization of empathy as a
state, where a professional distance is purported. Competent
interventions and responses to patient needs are identi®ed as
antecedents to empathy, a reversal when compared with the
conceptualization of empathy as caring whereby competent
interventions and responses to patient needs are identi®ed as
outcomes to the empathy process. Empathy as a special
relationship consists of three sequential phases: (a) initiating,
(b) building and (c) sustaining.
This conceptualization results from a naturalistic ®eld
study (Raudonis 1993) that was designed to explore the
patient's perspective on the nature, meaning, and impact of
empathic relationships with hospice nurses. According to the
hospice patients, an empathic relationship develops through a
process of reciprocal sharing and revealing of personhood
within a context of caring and acceptance. Friendship
emerges as a component and is de®ned as an intense, deep,
and meaningful relationship. A nurses' willingness to spend
time getting to know a patient as an individual, and the
patient's reciprocal sharing, are critical to the development of
empathic relationships between hospice nurses and patients.
The consequence of the empathic relationships between
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 35(3), 317±325
Concept clari®cation
nurses and patients is the improvement and maintenance of
patient's physical and emotional well-being. The empathic
relationships empower patients to cope, and help them
reconcile the needs and issues experienced during this phase
in their lives. As well, these relationships provide the
foundation for patients and nurses to work together to ful®l
the patient's goals.
Discussion
If understanding our clients, their needs, their emotions, and
their circumstances, is fundamental to nursing practice, and
empathy is the foundation of that understanding, then a
conceptualization of empathy that can be used by nurses is of
utmost importance to the profession. This concept clari®ca-
tion methodology revealed ®ve conceptualizations of
empathy that occur in the nursing literature between 1992
and 2000. In 1992, Morse et al. reviewed the psychological
and nursing literature and concluded that the obstacle to
understanding empathy was the almost exclusive attention by
researchers on measuring the observable, objective compo-
nents of empathy while the subjective, nonmeasurable
components were being ignored and devalued. Since 1992,
nursing scholars have taken on this challenge resulting in
more diversity among the conceptualizations of empathy. In
addition to measuring the observable components of
empathy, more subjective, nonmeasurable aspects of empathy
have been considered.
One of the purposes identi®ed for doing this concept
analysis of empathy was to explore empathy for its level of
maturity. A concept is considered to be mature if it there is
consensus about the meaning of the concept (Morse et al.
1996). This process of concept clari®cation indicates that
empathy appears to be a concept that is not yet mature.
Although many de®nitions and rich descriptions of empathy
exist in the reviewed literature, there are many discrepancies.
For example, nursing actions were considered an outcome of
empathy from the caring perspective but an antecedent from
the special relationship conceptualization. Empathy was
likened to a deep friendship in the special relationship
conceptualization yet the state perspective focused on the
importance of maintaining a professional distance, and
skilled therapeutic responses. The parameters of empathy in
these conceptualizations also have discrepancies. The process
is described as linear in the communication, caring, and trait
models, but as an intertwined, complex model by others
(Baillie 1996, Smyth 1996). Empathy has also been identi®ed
as the antecedent to a broader communication model (Morse
et al. 1992b), which contrasts with the conceptualization of
empathy as a communication process (Layton 1994, Olson
323
D. Kunyk and J.K. Olson

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