JAN JOURNAL OF ADVANCED NURSING

ORIGINAL RESEARCH

Empathic accuracy of nurses’ immediate responses to fibromyalgia

patients’ expressions of negative emotions: an evaluation using
interaction analysis
Hilde Eide, Tonje Sibbern & Tone Johannessen

Accepted for publication 18 December 2010

Correspondence to H. Eide: E I D E H . , S I B B E R N T . & J O H A N N E S S E N T . ( 2 0 1 1 ) Empathic accuracy of nurses’

e-mail: hilde.eide@hibu.no immediate responses to fibromyalgia patients’ expressions of negative emotions: an
evaluation using interaction analysis. Journal of Advanced Nursing 67(6), 1242–
Hilde Eide MAPsych PhD RN
1253. doi: 10.1111/j.1365-2648.2010.05579.x
Professor
Clinical Communication and Health
Counseling, Faculty of Health Sciences, Abstract
Buskerud University College, Drammen, Aim. This paper is a report of an observation study designed to describe and
Norway, and evaluate nurses’ immediate responses to fibromyalgia patients’ expressions of neg-
Faculty of Nursing, Oslo University College, ative emotions in first consultations at a pain clinic.
Norway Background. Providing comfort to patients in emotional distress is an important
task for nurses. Empathic accurate perception of patients’ emotions is a precondi-
Tonje Sibbern MA RN
tion for empathic accurate responses.
Assistant Professor
Methods. We analysed 58 videotaped assessment consultations with patients with
Department of Nursing,
Diakonhjemmet University College, fibromyalgia performed from April 2005 to June 2007. Implicit and explicit nega-
Oslo, Norway tive emotional expressions were identified with the Verona Coding Definitions of
Emotional Sequences. Nurses’ responses were coded with the Hierarchical Coding
Tone Johannessen RN System for Sensitivity of Comforting Strategies, with three levels of response to the
Head Nurse person’s perspective: (i) denial, (ii) implicit recognition or approval and (iii) explicit
Department Aker Pain Clinic, recognition of the expressed emotion.
Oslo University Hospital HF,
Results. We identified 801 expressions of negative emotions, 591 implicit and 210
Norway
explicit, on average 14 per consultation. Nurses responded with implicit recogni-
tion, mostly using minimal encouragement, to 75% of emotional expressions, with
explicit recognition to 13% of expressions while 12% of responses were not within
the perspective of the patient. Nurses responded with a higher degree of explicit
recognition (Level 3 responses) to patients’ explicit negative emotional expressions.
Conclusion. The effects of empathic accurate response to implicit and explicit
expressions of negative emotions should be explored further. The combination of
coding systems used appears to be valid and reliable for assessing verbal empathic
accuracy by observers in nursing settings.

Keywords: chronic pain, comfort care, cues and concerns, empathic accuracy,
fibromyalgia, interaction analysis, negative emotion, nurse–patient relations

 2011 The Authors

1242 Journal of Advanced Nursing  2011 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH
Introduction
Empathy, defined as understanding another person’s emo-
tional world, is a crucial competence in all helping relation-
ships (Rogers 1957, Reynolds & Scott 1999), while providing
comfort related to patients’ emotional distress is an important
nursing task (Nightingale 1860, Morse et al. 1992, 2006,
Kolcaba 2001, 2003). However, many studies show that
these core competences are not sufficiently applied in clinical
practice; nurses do not identify patients’ concerns (Heaven &
Maguire 1996, 1997, Farrell et al. 2005) and may not show
much empathy to patients (Reynolds & Scott 2000).
A patient group in special need of receiving comfort is
patients with fibromyalgia syndrome (FMS) as they are
burdened with many disabling symptoms (Bombardier &
Buchwald 1996, Goldenberg et al. 2004, Arnold et al. 2006).
Nurses’ empathy towards patients with FMS is an interna-
tionally relevant research topic because this vulnerable
patient group seems not to be well served in the healthcare
system (Söderberg et al. 1999, Werner & Malterud 2003).
Emotions play a central role in empathic communication
(Ickes et al. 1990). Negative emotions related to health
problems seem to be the key to understanding patient
responses to the actual health condition or medical problem,
its implications and patients’ specific needs in this situation
(Zimmermann et al. 2007, 2010). Patients’ implicit or explicit
expressions of negative emotion in nurse–patient consulta-
tions seem to challenge nurses (Sheldon et al. 2006, 2009).
Sheldon et al. (2009) found that oncology nurses had no
consistent way of relating to patients’ expressions of anger and
sadness. Patients need to handle difficult emotions (negative
emotions) related to their health condition (psychological,
physical, or both) because their emotion regulation through
empathic communication can influence coping, mental health
and quality of life. Suppression of emotion seems to increase
the impact of stress-related negative emotions (Goldin et al.
2008). It is also possible that by letting patients express cues
and concerns, nurses help patients regulate emotional pro-
cessing in the brain (Hariri et al. 2000, Lieberman et al. 2007,
Finset & Mjaaland 2009) and thus create comfort, relief and
well-being. Therefore, it is important that nurses are able to
identify, respond helpfully to and comfort patients’ negative
emotions, which mostly are hinted at and not expressed
explicitly (Suchman et al. 1997, Eide et al. 2004, 2010).
There is no agreement about what constitutes an appro-
priate response to a patient’s expressions of emotion (Del
Piccolo et al. 2010). In several studies, minimal encourage-
ments (like ‘hm’ and ‘yes’) were a common response to
patients’ cues and concerns providing space for further
communication (Eide et al. 2004, Del Piccolo et al. 2007,
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Journal of Advanced Nursing  2011 Blackwell Publishing Ltd
Empathic accuracy of nurses’ immediate responses
Oguchi et al. 2010). Sheldon and Ellington (2008) found that
experienced nurses explore more fully patients’ experiences.
Most observational studies of empathy applying interac-
tion analysis in nursing have been performed related to
cancer patients (Heaven & Maguire 1997, Farrell et al. 2005,
Uitterhoeve et al. 2008). We have not been able to locate any
study investigating how nurses respond to FMS patients’
implicit and explicit expressed negative emotions during an
initial consultation at a pain clinic applying a comfort theory
perspective.
Background
Pain, psychological distress, need for comfort and barriers
Patients with chronic musculoskeletal disorders suffer from
pain and also have complaints such as depression, sleep
problems, loss of employment and economic problems (Bom-
bardier & Buchwald 1996, Goldenberg et al. 2004, Arnold
et al. 2006). A crucial challenge for health personnel, especially
nurses, is the ability to grasp and respond to patients’
expressions of emotions, worries, needs and other topics of
perceived and immediate importance. These are mostly com-
municated implicitly through cues or hints (Levinson et al.
2000, Butow et al. 2002, Zimmermann et al. 2007).
Relating to others’ pain also inflicts pain and distress on the
perceiver (Goubert et al. 2005, 2009, Craig et al. 2010).
Neuropsychological investigation of reactions to observing
others’ pain suggests that pain appears to stimulate avoidance
and a tendency to flight in the observer (Yamada & Decety
2009, Craig et al. 2010). This can be one reason why
healthcare providers are often left with ‘a sinking feeling’
after meeting patients in pain (Alghalyini 2008). Physicians
may also be sceptical towards these patients and often deny
them access to the sick role as chronic pain is not defined as a
disease (Asbring & Narvanen 2003, Page & Wessely 2003,
Goubert et al. 2005). Thus, in addition to the suffering
caused by their condition, patients are often left feeling
dissatisfied with medical consultations because they are
misunderstood, not believed and provided with little or no
support (Söderberg et al. 1999, Werner & Malterud 2003).
Haugli et al. (2004) found that it was of vital importance for
patients ‘to be seen’ and ‘to be believed’ by their provider.
Theoretical framework
The concepts of empathy and empathic accuracy
Empathy is a process by which it is possible to ‘know’
another person’s feelings and thoughts (Gallop & Garfinkel
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H. Eide et al.
1990), and comprises both cognitive and affective processes
(Gallop & Garfinkel 1990, Nerdrum 2000, Neumann et al.
2009). Affective empathy can be defined as the perceiver’s
experience of sharing another’s emotion. Cognitive empathy
is the ability to understand the internal state of another
person. A synonym for cognitive empathy is empathic
accuracy; the degree of correctly identifying another person’s
thoughts and feelings (Ickes et al. 1990, 1997, Zaki et al.
2008). Hall and Schmid Mast (2007) investigated sources of
accuracy, i.e. which communication channels contribute
most to accurate understanding, and found that verbal
information contributes the most, followed by vocal non-
verbal cues. Non-verbal expressions contributed to a lesser
degree. Empathic accuracy seems to have a strong interper-
sonal element; ‘knowing’ another person implies that the
person in question allows thoughts and feelings to be ‘known’
(Zaki et al. 2008).
The concept of empathy is not consistent in the research
literature and several perspectives are presented, both in
nursing and in medicine. Empathy is seen as a human trait, a
professional state, a communication process, as caring and as
a special relationship (Kunyk & Olson 2001). Recently,
authors proposed models of empathy and empathic profes-
sional communication that to a larger degree also take moral
aspects into account (Eide & Eide 2007, Pedersen 2008,
Salmon & Young 2009).
To establish heath care that is continuously empathic,
nurses must always be willing and motivated to show interest
in the patient as a person and care for him or her with dignity
(Gallagher 2004).
The concept of comfort in relation to empathy
There is no consensus on the use of the concept of comfort in
nursing (Malinowski & Stamler 2002). Comfort has been
related to both process and outcomes of nursing (Nightingale
1860, Morse et al. 1992, 2006, Kolcaba 2001, 2003) linked
to states such as ease, well-being and satisfaction (Tutton &
Seers 2003) and is concerned with relief (Kolcaba 2001,
2003, Tutton & Seers 2003). The concept’s position in
nursing has moved from being the essence of nursing to being
a minor strategy within nursing (McIlveen & Morse 1995)
and clarity is needed to distinguish comfort from care or
therapy (Tutton & Seers 2003).
Morse et al. (1992, 2006) linked comfort with the
empathic process within a caring perspective and identified
several strategies leading to comfort. They described a
process based on (i) a spontaneous human way of
responding to suffering and distress, and (ii) professionally
learned strategies. When seeing another person suffering,
1244
one has to perceive this. Morse et al. (1992, 2006) call this
perception empathic insight. The spontaneous and reflexive
response to the perception of the patient’s suffering or
distress can lead to engagement with or withdrawal from
the patient. If it is engagement, the reflexive response is
followed by what Morse et al. (1992, 2006) call a first-level
learned response. This can be viewed as the usual human
expressions in relation to suffering such as pity, sympathy,
consolation, commiseration, compassion and reflexive reas-
surance. These responses can be sufferer-focused or self-
focused (the nurse). Then follows the learned professional
response as therapeutic empathy (patient-focused) or false
reassurance (nurse-focused). The model proposed by Morse
et al. (1992, 2006) is consistent with recent research on
emotional communication and the relationships between the
different brain structures involved (Shamay-Tsoory et al.
2009).
Experiencing another person’s emotion is a rapid process,
and the challenge is to involve higher structures such as the
cortex for conscious handling of emotions and responding
in ways that are analytical and helpful and not defensive.
Suchman et al. (1997) proposed a model suggesting that
encouraging clear expression of an emotion hinted at in a
cue and then reflecting this emotion back will lead to the
patient feeling understood. The evidence for this is not
clear-cut, with studies finding contradictory results (Olson
& Hanchett 1997, Butow et al. 2002, Uitterhoeve et al.
2008). Some evidence shows that the experience of having
another person share an emotion and then verbally
communicate it back reduces physiological activity in the
owner of the emotion, indicating reduced stress (Ono et al.
2009).
In this study, we focus on the immediate response to
expressed negative emotion, what Morse et al. (1992, 2006)
call the first-level learned response. Our hypotheses related to
empathic accurate responding are that (i) the most used
response to implicit expressions of negative emotion will be a
minimal encouragement to explore further, and that (ii)
empathic accurate responses to expressions of explicit neg-
ative emotions would contain more responses reflecting the
specific emotion than only minimal encouragements.
The study
Aim
The aim of this study was to describe and evaluate
nurses’ immediate responses to fibromyalgia patients’
expressions of negative emotion in first consultation at a
pain clinic.
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JAN: ORIGINAL RESEARCH
Design
The study is a descriptive observation study. The setting is the
first assessment consultation at a pain clinic with patients.
The aim of the first assessment consultation is to gain insight
into the patient’s resources, illness burden, understanding of
pain and psychosocial aspects. It is not a counselling session
for teaching the patient to manage pain better or to handle
distressing emotions.
Participants
Fifty-eight patients with FMS were included consecutively as
they were referred to the pain clinic for treatment from April
2005 until June 2007. Five nurses conducted the consulta-
tions. To establish sufficient power in the study, we decided
to include 15 patients per nurse (Reinard 2006). The
analytical unit in this paper is the total amount of cues and
concerns and not the nurse.
Data collection
Videotapes of real-time communication with the nurse were
analysed with two different coding systems.
Verona Coding Definitions of Emotional Sequences
Verona Coding Definitions of Emotional Sequences
(VR-CoDES) was applied to identify and code patients’ explicit
and implicit expressions of emotions (Zimmermann et al.
2009, 2010). A concern is defined as ‘a clear and unambig-
uous expression of an unpleasant current or recent emotion
where the emotion is explicitly verbalized’. A cue is defined as
‘a verbal or non verbal hint which suggests an underlying
unpleasant emotion and would need a clarification from the
health provider’. Seven specifications for different types of
cues are defined to guide the identification process (these are
not applied in the analyses in this study).
Hierarchical Coding System for Sensitivity of Comforting
Strategies
The Hierarchical Coding System for Sensitivity of Comfort-
ing Strategies (HCSSCS) was used to evaluate nurses’ degree
of accurate empathic responding (Applegate 1980, Burleson
1994). Burleson (1994) defines comforting strategies as
‘messages having the goal of alleviating or lessening emo-
tional distress experienced by others’. Applegate (1980)
developed the coding system within a constructivist frame-
work building on Carkhuff’s (1967) empathy scale, socio-
linguistic theory (Bernstein 1975) and structural development
theories (Werner 1957, Piaget 1970,). The assumptions
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Journal of Advanced Nursing  2011 Blackwell Publishing Ltd
Empathic accuracy of nurses’ immediate responses
underlying HCSSCS are that sophisticated messages intend-
ing to comfort another person (i) demonstrate involvement in
the other person, (ii) are evaluatively neutral, (iii) are feeling-
centred, (iv) are more accepting of the other and (v) contain a
cognitively oriented explanation for the experienced feeling
(Burleson 1994, p. 140). Comforting messages describe and
clarify feelings, such as showing understanding and respect,
taking the other seriously, and showing interest in the
patient’s perspective and the situations producing the feelings
(Burleson 1994).
Each statement by nurses following patients’ expressions of
implicit (cue) or explicit unpleasant emotion (concern) was
evaluated with the revised version of the HCSSCS (Burleson
1994). The coding system contains three levels: (i) denial of
the person’s perspective, (ii) implicit recognition or approval
of the person’s perspective and (iii) explicit recognition of the
expressed emotion. Each level has three specified categories.
The nine categories are displayed in Table 1.
Ethical considerations
All patients signed informed consent forms. The study was
approved by the Norwegian Regional Ethical committee.
Data analyses
Coding procedure
First, videotapes were viewed to identify explicit and implicit
emotional expressions (cues and concerns) by applying the
VR-CoDES. These expressions were tabulated together with
the nurse’s subsequent response. The elapsed time was noted
to facilitate retrieval of the specific cue or concern. When all
cues and concerns had been identified, the videotapes were
viewed again and this time, all responses to the identified cues
and concerns were evaluated with the HCSSCS and assigned
codes from 1 to 9. By using also the videos and not only the
transcripts, the paraverbal and non-verbal signs were inte-
grated into the process of assigning the right codes to the
expressions.
Statistical analyses
Descriptive statistics, i.e. frequencies and percentages, were
applied to describe the distribution of responses (SPSS version
17; SPSS, Inc., Chicago, IL, USA). To test hypotheses, cross
tabulations were used and chi square was calculated. To
draw conclusions about the distribution of specific responses
to the explicit and implicit emotional expressions (i.e. to
determine the relative importance of each cell), adjusted
residuals were inspected. An adjusted residual below 3 or
above +3 is regarded as occurring to a greater or lesser degree
1245
H. Eide et al.

Table 1 Comforting strategy coding categories and distribution of nurses’ responses

Frequency %

Level 1. Denial of individual perspective

1.1 The nurse condemns the patient’s feelings. 2 0Æ2
1.2 The nurse challenges the legitimacy of the patient’s feelings. 2 0Æ2
1.3 The nurse ignores the patient’s feelings. 94 11Æ7
Level 2. Implicit recognition of individual perspective
2.4 The nurse attempts to divert the patient’s attention from the distressful situation and the feelings arising from that 111 13Æ9
situation.
2.5 The nurse acknowledges the patient’s feelings, but does not attempt to help the patient understand why those feelings 361 45Æ1
are being experienced or how to cope with them.
2.6 The nurse provides a non-feeling-centred explanation of the situation intended to reduce the patient’s distressed 127 15Æ9
emotional state.
Level 3. Explicit recognition and elaboration of individual perspectives
3.7 The nurse explicitly recognizes and acknowledges the patient’s feelings, but provides only truncated explanations of 73 9Æ1
these feelings.
3.8 The nurse provides an elaborated acknowledgement and explanation of the patient’s feelings. 25 3Æ1
3.9 The nurse helps the patient to gain a perspective on his or her feelings and attempts to help the patient see these feelings 6 0Æ7
in relation to a broader context or the feelings of others.
Total 801

Applied to nursing setting after Burleson (1994).

than determined by chance distribution (Bakeman & Quera
1995).
Validity and reliability
Verona Coding Definitions of Emotional Sequences
The coding system was validated in a patient sample by 12
patients confirming the cues and concerns identified by the
researcher, with a very high degree of sensitivity and speci-
ficity (Eide et al. 2010).
The interrater reliability was 0Æ60 for cues and 0Æ80 for
concerns, measured with Cohen’s kappa (TS coded all
consultations, 10 consultations were used for training
purposes, and then HE coded eight separately for the
calculation of inter-rater reliability). This is characterized as
good and excellent respectively (Altman 1990).
The validity of the coding system HCSSCS in non-clinical
populations is thoroughly established (Burleson 1994). The
HCSSCS has been applied to evaluate standardized patient
consultations performed by medical students (Gillotti &
Applegate 2000), it has been used to examine recently
bereaved adults responses to grief management messages
(Servaty-Seib & Burleson 2007) and a study examined college
students’ evaluations of comforting messages that might be
used by peers to help them cope with one or several upsetting
problems (Burleson 2008) and also in medical consultations
using a revised and adapted version (Bylund & Makoul 2002,
2005). As far as we are aware, this coding system has never
been used in nursing studies.
Results

Hierarchical Coding System for Sensitivity of Comforting
Strategies
As this method was developed for private rather than pro-
fessional settings, we had to apply the specifications in the
categories to nurses’ responses. During a training period, the
first and second authors worked together assigning codes to
responses to reach a preliminary consensus. The second
author (TS) then evaluated all responses. For interrater
reliability calculation, the first author (project leader HE)
coded 261 responses (11 consultations). Intra-class correla-
tion was 0Æ70, which is characterized as good (Sneeuw et al.
1997).
1246
The sample
The sample comprised 58 patients (nine male), all suffering
fibromyalgia for a median of 11 years. Their mean age was
47Æ6 years (SD = 10Æ7); 57Æ4% were married or lived with a
partner and only 17% were working. Using a scale from 0
(no pain) to 10 (worst possible pain), patients reported their
least pain to be 4 with a range of 0–10 and their worst pain as
10 with a range of 7–10.
Five clinical specialist pain nurses [one man, mean age of
41 years (range: 38–51 years)] conducted the consultations
and were responsible for videotaping. Their mean working
time at the pain clinic was 6Æ8 years (range: 3–11 years).
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JAN: ORIGINAL RESEARCH Empathic accuracy of nurses’ immediate responses

Table 2. Nurses’ responses to patients’ explicit and implicit expressions of negative emotion
Provides a non- Explicit
Denial of patient’s Diverts the patient’s Acknowledges the feeling centred recognition
perspective attention patient’s feelings§ explanation– of emotion Total

Explicit negative emotion 21 (2Æ6)§§ 1Æ2–– 26 (3Æ2) 0Æ7 91 (11Æ4) 0Æ6 29 (3Æ6) 0Æ9 43 (5Æ4) 3Æ8 210 (26Æ2)
(concern)
Implicit negative emotion (cue) 77 (9Æ6) 1Æ2 85 (10Æ6) 0Æ7 270 (33Æ7) 0Æ6 98 (12Æ2) 0Æ9 61 (7Æ6) 3Æ8 591 (73Æ8)
Sum 98 (12Æ4) 111 (13Æ6) 361 (45Æ1) 127 (16Æ9) 104 (13Æ0) 801 (100)

Values in parentheses are percentages.


Sum of Hierarchical Coding System for Sensitivity of Comforting Strategies (HCSSCS) categories 1.1–1.3.

HCSSCS category 2.4.
§
HCSSCS category 2.5.
–
HCSSCS category 2.6.

Sum of HCSSCS’ categories 3.7–3.9.

Frequency.
§§
Percentage of total.
––
Adjusted residual.

Nurses’ responses to patients’ expressions of negative recognized or approved the individual perspective of the
emotion patient, but did not help the patient recognize and identify the
specific emotion. Of these responses, 13Æ6% were evaluated as
The mean duration of consultations was 36Æ14 minutes
implicit recognition of the feelings (Level 2.4). The nurses tried
(range: 14Æ25–52Æ30 minutes). A total of 801 responses to
to divert patients’ attention towards another subject and away
591 implicit expressions of negative emotions (cues) and 210
from the one that was emotionally distressing. The nurses used
explicit expressions (concerns) were coded. We present the
the consultation manual to proceed; they focused on the non-
findings as shown in Table 2, from Levels 1 to 3, and give
emotional parts of the same topic, thereby steering the con-
examples of the different responses before testing the
versation, and probably the patient’s attention, away from the
hypotheses.
distressing feeling, as shown in this example of Level 2.4:

Responses not consistent with the patient’s perspective Nurse: I hear that you are searching for what’s wrong with you?
(1.1–1.3)
Patient: Yes, maybe it is some kind of trouble with my heart, I am so
Of responses, 12Æ4% were coded as responses not within the
anxious about what it might be (concern).
perspective of the patient, mostly as ignoring the patient’s
feelings. An example of this kind of response is: Nurse: Have you had an electrocardiogram?

Nurse: I will talk about the things around the pain also. Is it ok for
you if we use the time now for that?
(The patient rises from the chair and walks around in the room)
Patient: Now the pain is so enormous that I have to close everything
around me, it seems like… (cue).
Nurse: But, you live alone, are divorced?
In this example, the nurse completely ignores the patient’s
expression of pain and her feelings. The nurse is not allowing
the patient to finish her sentence, but cuts her off and
continues with questions related to the nurse’s own agenda.
Responses that acknowledge the implicit perspective of the
patient (2.4–2.6)
Most of the responses (75Æ6%) given to the 801 cues and
concerns were coded as responses where nurses implicitly
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Journal of Advanced Nursing  2011 Blackwell Publishing Ltd
In this example, the nurse responded with talking about the
content, the patient’s possible heart problem, thereby engag-
ing the patient and drawing her attention away from her
anxiety. Another example of Level 2.4 is:
Nurse: I see in the questionnaire that you have problems sleeping?
Patient: I get very tired (cue).
Nurse: So are you a little… (shows and points in the manual, while
she reads from it).
In this example, the nurse pointed to the questionnaire the
patient had filled in as a way of sharing, but without
exploring further. This was evaluated as a way of diverting
the patient’s attention away from the distressing experience
of feeling tired.
Of the Level 2 responses, 45Æ1% were evaluated as
acknowledging patients’ feelings (Level 2.5). The nurses
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H. Eide et al.

mostly applied back channel responses to show patients that Testing different nurse responses to the implicit and
they were listening and facilitating patients’ exploration of explicit expressions of negative emotion
the topic. The nurses showed that they were actively listening
Cross tabulation analyses were applied to test the hypotheses
by nodding, using eye contact and saying yes, go on, etc., as
that the nurses responded differently to cues and concerns. As
shown in this example of Level 2.5:
there were few responses at Levels 1 and 3, these were each
Nurse: Is the pain like a, a headache? recoded into single categories, called ‘Denial of patient’s
perspective’ (Level 1) and ‘Explicit recognition of emotion’
Patient: No, it’s not headache. But it feels like you are going to split a
(Level 3). As shown in Table 2, the three categories within
melon in two, and like it’s going to crack. It is a whistling sound. I
Level 2 were retained. We found a significant difference in
have problems with explaining it, I have tried too many doctors, but
responses to implicit and explicit expressions of negative
they don’t understand it (cue).
emotions; chi square test for the whole table was significant
Nurse: Mmm, yes, mmm. I see. (The nurse is nodding). with P = 0Æ01. To determine further which cell contributed
most to this, adjusted residuals were inspected, showing that
In the example, the nurse is actively listening and shows
nurses responded more explicitly to patients’ individual
interest in the patient’s story. The nurse does not help the
perspective and were more likely to recognize distressed
patient to understand why those feelings are being experi-
feelings when patients expressed negative emotions explicitly
enced or how to cope with them.
(adjusted residual = 3Æ8) rather than implicitly (adjusted
In 15Æ9% of responses, the nurses used non-feeling-centred
residual = 3Æ8) (see Table 2).
explanations to reduce patients’ distressed emotional state
Both study hypotheses were confirmed.
(Level 2.6). The nurses summarized what patients had said to
see if they had understood the feelings, as seen in this example:
Discussion
Nurse: With stress, do you mean that you get stressed by working or
other things?
Limitations
Patient: It can be everything, from the relationship with my
We have evaluated nurses’ comforting responses based on a
boyfriend, or how I mentally feel (cue).
criterion of accuracy, comparing a patient’s expression of
Nurse: So, these things affect your stress level? emotion and the corresponding immediate nurse response.
We are not aware if this corresponds to patients’ experience
In this example, the nurse summarizes the patient’s utterance,
of accuracy, nor do we explore the assumption that higher
but does not give explanations of why the patient is emotion-
levels of comforting message strategy as measured with
ally distressed, or that her feelings affect her stress level.
HCSSCS leave patients feeling comforted or less distressed.
As the sample of nurses is small, we are not aware whether
Responses that acknowledge the explicit perspective of the
similar results would be found in larger samples, or with
patient (3.7–3.9)
inexperienced nurses, in other settings or in other patient
Thirteen per cent of responses were evaluated as explicit
populations. This should be explored further in future
recognition and elaboration of individual perspectives. These
studies. This study of nurses’ responses relies on identifica-
strategies included attempts to provide a general under-
tion of patients’ emotional expressions by raters; the
standing of the situation. The nurses tried to reduce patients’
interrater reliability of 0Æ6 (cues) and 0Æ8 (concerns) creates
distressed emotional state with answers to patients’ utter-
some uncertainty about this. We were not able to reach a
ances, for example, a response at Level 3:
higher kappa coefficient for cues. Empathic accuracy
Nurse: So, when you see yourself in the mirror, do you feel that you research shows that trained therapists usually have percep-
look a bit tired? tion accuracy of about 30% when identifying patients’
emotions and thoughts (Marangoni et al. 1995). Another
Patient: Yes, I do that, I feel tired and exhausted (concern).
study of the patients reported in this study (Eide et al. 2010)
Nurse: Yes. It’s not always that what you feel on the inside shows on showed that there was high correspondence between
the outside. patients’ own identified important topics and researchers’
identified cues and concerns. Therefore, we regard our
In the example, the nurse gives a possible explanation for
findings as sufficient to give credible results in this complex
other people’s reaction to the patient’s feelings because they
setting with patients who are suffering to the extent that
do not show on the surface.
 2011 The Authors
1248 Journal of Advanced Nursing  2011 Blackwell Publishing Ltd
JAN: ORIGINAL RESEARCH
What is already known about this topic
• Empathy is regarded as crucial in all helping
relationships.
• Empathic understanding is necessary for nurses to
deliver adequate pain relief.
• Pain in others tends to stimulate protective behaviour in
the receiver.
What this paper adds
• Nurses responded mostly within the perspective of the
patient to expressions of both implicit and explicit
negative emotion, indicating an accurate empathic
response that can contribute to comfort.
• Minimal encouragement was the most frequently used
response to patient’s cues to negative emotion.
• Nurses responded with a higher degree of explicit
recognition (labelling the emotion) to patients’ explicit
negative emotional expressions.
Implications for practice and/or policy
• The Hierarchical Coding System for Sensitivity of
Comforting Strategies could be used in communication
skills training to teach nurses how to respond with
empathic accuracy.
• Observation methods and coding systems seem suitable
for determining degree of observed empathic accurate
response.
• Future studies should explore the relationship between
process and outcome of comforting communication.
patients with fibromyalgia are, taking the limitations into
account.
Empathic accurate responding
As far as are aware, this is the first study to describe nurses’
communication with chronic pain patients at a pain clinic,
using an observer-rated empathic accuracy and comforting
framework. Using the framework of empathic communication
described by Morse et al. (1992, 2006), we have applied
HCSSCS to shed light on how immediate common human
responses are communicated to patients. HCSSCS is a prom-
ising system for assessing empathic accuracy by observers in
nurse–patient relations. In nursing, there has been little use of
empirical research based on interaction analysis to develop
theoretical bases for the relationship between empathy,
 2011 The Authors
Journal of Advanced Nursing  2011 Blackwell Publishing Ltd
Empathic accuracy of nurses’ immediate responses
empathic accuracy and comfort. We have suggested that the
response is called an empathic accurate response. Accuracy is
based on an external evaluation by observers of congruence
between the cues and concerns expressed by patients and the
verbal and/or non-verbal responses given by nurses.
As observed empathic accuracy is our focus, it seems that
the nurses in this study responded to implicit expressions with
responses that were within the perspective of patients. We
regard this as an empathic accurate response, which means
that the emotion expressed is perceived and shared by the
nurse, as evaluated by the HCSSCS. As information about the
exact emotion is missing (that is the nature of a cue), as we see
it, the best response the nurse can give is a response signalling
generalized understanding. Most of the responses were
acknowledging the patients’ perspective by giving minimal
encouragements, which usually have the function of commu-
nicating interest, showing that ‘I listen’ and stimulating the
other to tell more. In the model by Morse et al. (1992, 2006),
first-level responses such as these are described as patient-
focused. Suchman et al. (1997) see such responses as the first
stage in clarifying the situation and the emotion, a potential
empathic opportunity. This is also consistent with the
consultation goal to learn more about the patient and the
patient’s needs and expectations. The nurses in this study were
able to respond accurately to patient’s emotional expressions.
This is can be due to their long experience as Sheldon and
Ellington (2008) describe in their study, but we are not aware
if inexperienced nurses would respond like this.
We found that nurses responded with more sophisticated
responses to explicit expressions of emotion, which indicates a
high degree of empathic accuracy in the response. However, as
we see in Table 2, responses evaluated as Level 1 or 2 were
also given to explicit emotions. We are not aware if these
responses were perceived as less accurate or less understanding
by patients than the responses evaluated as Level 3 responses.
In a recent study exploring empathy in a pain context in
nursing, Campbell-Yeo et al. (2008) called for more research
into the impact of empathically experiencing the pain of
another person, regulating one’s own arousal while at the
same time being able to provide the best pain care manage-
ment. Research shows that labelling an emotion can contrib-
ute to reduced stress in a distressed person (Lieberman et al.
2007, Finset & Mjaaland 2009, Ono et al. 2009). It could be
hypothesized that the labelling of a distressed person’s
feelings, as it occurs with responses categorized as Level 3
in HCSSCS, could also reduce the stress response in the nurse.
Whether this is an effective way of affect regulation in nurses,
in addition to patients, should be tested in future studies.
The HCSSCS appears to provide good descriptions of
different ways of giving verbal messages aimed at comforting
1249
H. Eide et al.
and is also suitable for nursing research. One possible
weakness is the use of the word ‘level’, which could lead to
the misunderstanding that a higher level response is norma-
tively better than a response lower in the hierarchy. The
system evaluates whether the response is within or outside the
patient’s perspective. As first-level responses seem to be
spontaneous human responses rather than specific profes-
sional statements, the scheme appears more suitable than
others based on professional standards. We are not aware
when applying this system whether, for example, first-level
responses are appropriate when taking the whole situation
and the timeframe into account. This could be explored by
applying more descriptive methods and by using rating scales
that specify criteria for quality consultations. These criteria
should be developed in cooperation with patients.
Conclusion
More studies should apply interaction analysis to real clinical
situations, because most research related to empathic com-
munication with pain patients and other patient populations
uses analogue methods for measuring empathy, with doubtful
validity to the real empathic process. Future studies should
explore both process and outcome of comforting communi-
cation to clarify the relationship between the immediate
responses as measured with HCSSCS, productive second-level
responses and short-term and long-term outcomes such as
comfort. Longer sequences of interaction could be analysed
to explore patients’ preferred second level responses or
professional therapeutic strategies leading to desired out-
comes performed.
Future studies should also explore the relationship between
comfort and observed empathic accuracy, integrating both
interaction analyses and patients’ evaluations of accuracy.
Various research strategies could be used to develop under-
standing of how patients experience these responses and how
they contribute to an experience of comfort. Other important
outcome measures are improved quality of life, better
adherence to medical regimens and changes that lead to
reduced risk of lifestyle health problems.
Our findings also have implications for communication
skills training. Studies show that empathic accuracy can be
enhanced by training (Marangoni et al. 1995) and the
findings from this study could be used to develop training
packages.
Acknowledgements
We offer warm thanks to the patients and nurses who
allowed us to study their consultations. This study would not
1250
have been possible without the cooperation of the Aker Pain
Clinic, Oslo University Hospital, which enrolled patients and
undertook data collection. The intellectual work in this study
was stimulated by the collaboration in the Verona Network
on Sequential Analysis, a special interest group within the
European Association for Communication in Health Care,
and we thank all participants. The project is funded partly by
Grant No. 158707 from the Norwegian Research Council
and partly by the Faculty of Nursing, Oslo University
College. Professor Tone Rustøen was responsible for the
NRC grant acquisition – warm thanks to her. A grant from
the Norwegian Fibromyalgia Society contributed to financing
parts of the coding.
Funding
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
HE was responsible for the study conception and design,
and provided statistical expertise. HE, TS and TJ performed
the data collection. HE and TS performed the data analysis
and were responsible for the drafting of the manuscript.
HE, TS and TJ made critical revisions to the paper for
important intellectual content. TJ provided administrative
support.
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