Humanistic Nursing, Interpersonal Relations Theory,

and the Empathy-Altruism Hypothesis

Karen L. McCamant, RN; MSN

University of Delaware School of Nursing, Newark, Delaware

The purpose of this paper is to illuminate the relevance and applicability of theory for nursing research and prac-
tice. Following a brief explanation of the four levels of theoretical abstraction recognized by nursing, Paterson and
Zderad’s humanistic nursing theory and Peplau’s theory of interpersonal relations are described. In addition, one
social psychology theory, the empathy-altruism hypothesis, is also explained. The value and implications of the
three theories for nursing research and practice are discussed, and several research questions are proposed.

O ften the study of theory, espe-

cially as it relates to the social
sciences, is viewed as burdensome, or
worse, needless. Indeed, social science
theory has actually been described as a
necessary evil (Becker, 1993). More-
over, many authors fail to identify a
theoretical framework for their research
studies. Yet, for people who work in
the human services, including nursing,
psychology, and education, theoretical
frameworks inform professional prac-
tice. Consequently, an understanding
not only of nursing theory, but also of
theories emerging from other social
sciences, must underpin nursing prac-
tice. In this paper the author describes
two nursing theories and one social
psychology theory in terms of their
application to nursing research. Specif-
ically, humanistic nursing theory and
interpersonal relations theory are dis-
cussed, while the empathy-altruism
hypothesis is also explored. An expla-
nation of the hierarchical taxonomy
of nursing theories is offered to pro-
vide a contextual basis for theoretical
discussion.
Levels of Nursing Theory
Before describing individual
theories, it is important to note that
many nurse scholars recognize four
levels of theoretical abstraction, which
Nursing Science Quarterly, Vol. 19 No. 4,
October 2006, 334-338
DOI: 10.1177/0894318406292823
© 2006 Sage Publications
are meta-theory, grand theory, middle
range theory, and practice theory (Van
Sell & Kalofissudis, 2002). Meta-
theory describes nursing in its most
abstract, least measurable terms.
Nursing meta-theories illuminate the
actual process of nursing, rather than
specific concepts or steps within nurs-
ing practice. The constructs developed
in meta-theories lend support to less
abstract nursing concepts. By contrast,
grand theories describe the practice of
nursing within its global context,
including concepts that are applicable
even across cultures. Because middle-
range nursing theories pertain specifi-
cally to details within nursing practice,
they are less abstract than grand or
meta-theories (Alligood & Tomey,
2002). Middle-range theories relate to
a limited scope within the larger nurs-
ing experience, and are easily under-
stood and adapted to practice (Walker
& Avant, 2005). Alligood and Tomey
(2002) believe that Kolcaba’s comfort
theory and Mishel’s uncertainty in ill-
ness theory are examples of middle
range theories. Practice theories are
the least abstract, and pertain to very
specific nursing situations (Walker &
Avant, 2005). Some important terms
used when discussing nursing theory
include conceptual models, concep-
tual frameworks, or paradigms. These
terms describe the broad frame of ref-
erence from which any phenomena,
including nursing, are approached and
studied (Alligood & Tomey, 2002).
The leveling of nursing theories is not
clear-cut, nor is it without controversy.
Kleiman (2004), a noted scholar of
Paterson and Zderad’s (1976/1988)
humanistic nursing theory, stated that
the terms used to describe levels of
theories were derived from sociology,
and often carry pejorative connotations.
For example, while the actual founders
of the humanistic nursing theory
described it as a meta-theory, Kleiman
(2004) noted that it can arguably be
described as both a grand and a middle
range theory, depending on the situa-
tion to which it is being applied. This
apparent discrepancy actually reflects
the idea that meta-theories can be
understood to contain all of the con-
structs of the lower-level theories.
Humanistic Nursing
Paterson and Zderad (1976/1988)
developed humanistic nursing in the
early 1960s, but continued to refine it,
with assistance from their students,
during the next 2 decades. These theo-
rists describe nursing not in terms of a
profession, or even a calling, but as a
human response by one person to
another person in need (Decker-Brown,
2003). Because humanistic theory
expresses the total nursing experience
in any and all contexts, it can be con-
sidered a nursing meta-theory. More-
over, within the construct of humanistic
theory, the act of nursing is understood
in terms of both the nurse and the
patient, and has even been described
Keywords: Batson, Paterson, Peplau,
nursing research, nursing theory, Zderad

as a kind of call and response relation-
ship (Decker-Brown, 2003). This dual-
istic, interrelational aspect of the
humanistic model clearly reflects the
earlier, seminal work of Peplau
(1952/1991), whose theory explained
the interpersonal dynamics that natu-
rally occur between the nurse and the
patient. Consistent with Peplau and in
a more contemporary context, an
assumption of the nursing social con-
tract states that, “The relationship
between nurse and patient involves
both in the process of care” (American
Nurses Association, 2003, p. 3)
In humanistic nursing, the act of
nursing is described as a lived dialogue
between the nurse and the patient, as
they exist together in the larger world
(Kleiman, 2004). The interaction
between the nurse and the patient is
both universal and unique, and it can
arise from an array of contexts. Within
the lived dialogue of the nursing act,
the needs of the patient are paramount,
but it is only through that nurse-patient
relationship that the qualities of being a
nurse can actually be experienced.
While it is happening, the nurse-patient
relationship becomes the center of the
universe, but this relationship also
exists within and is influenced by the
external world. For example, a nurse’s
ability to be fully present in the nursing
act may be detrimentally affected by
poor working conditions, or even per-
sonal distractions, such as family prob-
lems. Furthermore, like all human
interactions, the nursing relationship
exists as a dyad in which the patient’s
ability to receive care is as influential
as the nurse’s ability to render it. Thus,
the quality of the relationship between
the nurse and the patient, as well as the
subjective experience of each person
individually, is informed by the
authenticity and integrity that each
brings to the interaction.
As a meta-theory, the model pre-
sented in humanistic nursing (Paterson
& Zderad, 1976/1988) describes the
universality of the act of nursing itself,
whether it occurs in the context of the
highly technical Western medical cen-
ter, or in what Western civilization
might consider very primitive societies.
The constructs and assumptions of this
theory draw from the almost boundless
diversity of human experience, and its
breadth encompasses the full nature of
nursing as a human interaction. The act
of nursing involves both being and
doing, and the quality of the experience
reflects the values of those involved.
Similarly, this author has often described
being a nurse, not as what I do, but as
who I am. In the humanistic nursing
model, the relationship is as natural and
spontaneous as any other human
response to the need of another, such as
mothers caring for children, even
though this theory has necessarily been
developed and refined to fit the health-
care needs of a modern world.
Humanistic Nursing
and Nursing Research
Phenomenology provides the philo-
sophical basis for humanistic nursing
(Decker-Brown, 2003). As a philoso-
phy, phenomenology presupposes that
an integral relationship exists between
the self and the environment, or the
self and others, and that the experience
of that relationship as it is lived can be
described (Burns & Grove, 2005).
Humanistic nursing relies on phenom-
enological expression to describe the
nature of the nurse-patient relation-
ship (Kleiman, 2004). Thus, even as a
meta-theory, the tenets put forth by
humanistic theorists can be evaluated
through research. Furthermore, vari-
ous research methodologies can be
applied to the study of Paterson and
Zderad’s (1976/1988) humanistic nurs-
ing. Researchers that consider the
lived experience of the nurse-patient
relationship from either perspective
may integrate humanistic nursing as a
framework. For example, a recent
study (McCabe, 2004) in Ireland
examined patients’ experiences of how
nurses communicate with them.
Similarly, another phenomenological
study explored how nurse case man-
agers describe their experience as
patient advocates (Hellwig, Yam, &
DiGuilo, 2003).
Humanistic nursing can be applied
to the examination of the nurse-patient
relationship as experienced by the nurse
Theory Analysis 335
in those situations where patients are
especially vulnerable, even if they are
essentially noninteractive. For example,
patients who are anesthetized for
surgery or other invasive procedures,
or who are otherwise unresponsive
due to their health condition, are not
able to describe the subjective experi-
ence of the nurse-patient relationship.
Nurses, however, often describe these
types of patient care scenarios as their
most professionally gratifying, and
families are often most appreciative of
the nurse in this context, as well. Of
course, in these circumstances, the
caregiving role of the nurse often
expands to encompass not only the
patient, but also his or her significant
others. Examples can be found among
the studies that have examined the
subjective experience of nurses when
family remains present during code
blue situations (Clark et al., 2005;
Moreland, 2005).
Paterson and Zderad’s (1976/1988)
humanistic nursing, as a meta-theory,
describes the totality of the nurse-
patient experience as a lived dialogue,
regardless of how communication
between the participants occurs. Essen-
tially, there is really no nursing experi-
ence that cannot be considered in
terms of this theory. Table 1 presents
examples of potential nursing research
questions that reflect Paterson and
Zderad’s humanistic nursing theory as
it can be applied in the clinical setting.
Interpersonal Relations Theory
In contrast to Paterson and Zderad’s
(1976/1988) humanistic nursing
theory, Peplau’s (1952/1991) theory of
interpersonal relations in nursing is
considered by some to be a middle-
range nursing theory (Howk, 2002).
Specifically, middle-range theories are
less abstract, and their concepts are
more readily applied to practice
(Alligood & Tomey, 2002). Further-
more, the concepts presented in
Peplau’s earlier work can certainly be
recognized as smaller, more precise
elements expressed within the Paterson
and Zderad’s humanistic meta-theory.
For example, Peplau was the first
336 Nursing Science Quarterly, 19:4, October 2006

Table 1
Research Questions Framed by the Humanistic Nursing,
Interpersonal Relations, and Empathy-Altruism Theories
Theory Research Questions

Humanistic nursing theory
Interpersonal relations theory
Empathy-altruism theory
How do patients describe the experience of being cared for by nurses in various clinical settings?
How do nurses describe the experience of the nursing profession at its most and least gratifying?
What nursing qualities do patients perceive as most important in generating a positive nurse-patient experience?
How do patients perceive and prioritize their needs over the course of a given healthcare encounter?
How do nurses describe the experience of being part of the nursing profession over the course of the healthcare encounter?
Do nurses working in settings with a varied patient population describe differences in feelings of compassion and
empathy between different patient groups? (Elderly cataract patients versus young adult patients with chronic pain?
Gynecological patients versus male urological patients? Patients with known infectious diseases? Morbidly obese
patients? And others?)
Based on the assumption that empathetic response occurs more readily in people of similar experience, are nurses more
likely to respond to requests for pain medication from patients who have undergone procedures that the nurse has
also undergone himself or herself?

theorist to articulate the idea that the
work of nursing is inextricable from the
patient’s experience of receiving care.
While Paterson and Zderad’s humanis-
tic theory describes the nature of the
nurse-patient relationship, Peplau’s
interpersonal relations theory focuses
on the specific components that actu-
ally comprise that relationship. As the
first psychiatric clinical nurse specialist
and a certified psychoanalyst, Peplau
developed her theory as a reflection
of Sullivan’s (1953) interpersonal
psychology that was evolving during
the middle of the 20th century. Like
Sullivan, Peplau had been trained in
traditional Freudian psychoanalytic
theory, which focuses on intrapsychic
conflicts, but she rejected that view for
one that emphasizes interpersonal or
relational dynamics. Thus, given her
scholarly background, the fact that she
focused on the fundamentals of the
relationship between the nurse and
patient is hardly surprising.
Peplau (as cited in Deloughery,
1998) summarized her model by
explaining that nursing is an interper-
sonal process that must deal with the
client’s felt [perceived] needs (p.49).
Peplau was probably the first person to
describe the nursing role in terms of a
process, a paradigm now fully inte-
grated into contemporary nursing
theory. Distinct from a simple itemized
list of nursing activities, the term
process implies not only organization
and structure, but also fluidity that
allows for the application of critical
thinking and modification by the nurse.
According to Peplau’s (1952/1991)
interpersonal relations theory of nurs-
ing, the phases of the nurse-patient
process unfold in a way that is both
ordered and predictable. Furthermore,
Peplau described the elements of this
relationship in terms of four distinct,
ordinal phases. The first phase, orien-
tation, occurs when the patient ini-
tially accesses the healthcare setting.
During that time the nurse is responsi-
ble for helping the patient to relax, so
that anxiety about the unfamiliar situ-
ation does not impede the patient’s
ability to benefit from care. Phase
two, identification, occurs when the
patient is able to recognize the need to
receive care. Often characterized by
ambivalence exacerbated by anxiety,
this phase requires the nurse to con-
tinue providing reassurance, while
adding prospective education and
clarification of expectations. Despite
the negative semantic connotations of
the term, the third phase is referred to
as exploitation, and it describes the
acknowledgement by the patient of
the need for care, as well as the recog-
nition that the nurse is uniquely able
to provide it. The final phase, resolu-
tion, happens when the patient recov-
ers, and progresses to being able to
separate from dependency on nursing
care (Peplau, 1952/1991). Clearly,
Peplau’s theory was predicated on the
recognition that nurses have more
actual direct patient contact than any
other healthcare professional.
Interpersonal Relations Theory
and Nursing Research
Everything emerges from the con-
text of its time, including nursing
theories. It is well recognized that
Peplau (1952/1991) theorized about
nursing care during an era when the
average length of stay in the hospital
was 2.5 weeks, often including pre-
and postoperative days. The keynote
speaker at the annual meeting of the
American Society of Perianesthesia
Nursing stated that the average length
of stay for all surgical procedures in
2003 was 4.5 hours (Porter-O’Grady,
2004). Given that dramatic develop-
ment, is Peplau’s model of the nurse-
patient relationship still relevant
today? This author would argue that
even amid the fast pace of the contem-
porary surgical setting or emergency
department, nurses continue to
observe that each phase described in
Peplau’s theory occurs precisely in the
expected order, despite the abbrevi-
ated interactive time available between
the patient and the nurse.
Pelpau’s (1952/1991) interpersonal
relations theory of nursing can pro-
vide the theoretical framework for
research that seeks to examine the
nurse-patient interaction within any
given healthcare encounter, regardless
of the length of that encounter. For
example, one study compared nurses’

and patients’ perceptions of patient
needs in the emergency department
(Hostutler, Taft, & Snyder, 1999). This
study employed both quantitative and
qualitative methodology, and the
results were expected to directly
impact practice by identifying discrep-
ancies between nursing and patient
perceived care priorities. This study
would certainly lend itself well to
replication in the ambulatory surgery
setting, as well as in other healthcare
venues. Furthermore, the design might
be expanded to compare patients’ per-
ceived needs during different phases
of the healthcare encounter with those
presented by Peplau. Examples of
potential research questions applying
Pelpau’s theoretical framework are
proposed in Table 1.
The Empathy-Altruism
Hypothesis
Like the interpersonal relations and
humanistic theorists discussed above,
social psychologists also seek to
explain the nature of human interac-
tions, particularly within the context
of helping. Since Batson (1990) first
proposed the empathy-altruism hypoth-
esis in the late 1980s, he has written
extensively on this social psychology
theory, and his research has been
published primarily in the highly
respected, peer-reviewed Journal of
Personality and Social Psychology.
Specifically, Batson described the
underlying motivation of helping rela-
tionships, and the applicability of his
ideas to the nursing role is obvious.
Indeed, the American Association of
Colleges of Nursing has included
altruism as one of the five core values
of professional nursing (Fahrenwald
et al., 2005). Altruism describes the
nature of behavior that is not ostensi-
bly self-serving, while empathy refers
to the intrinsic emotional response that
allows one person to identify with the
psychological experiences of another.
According to the empathy-altruism
hypothesis, purely altruistic behavior
occurs regularly and frequently in
human interaction, but it requires an
empathetic emotional response within
the potential helper (Batson, 1990).
Defined as “an emotional reaction
characterized by such feelings as com-
passion, tenderness, soft-heartedness,
and sympathy” (Cialdini, Brown,
Lewis, Luce, & Neuberg, 1997,
p. 481), empathy is further described
in this social psychology theory as the
primary motivation for altruistic
behavior (Batson, Turk, Shaw, &
Klein, 1995; Cialdini et al., 1997).
Altruism, according to Batson (1990),
is prosocial behavior that occurs in
direct response to the emotional expe-
rience of empathy. In this conceptual
model, there is no doubt that a rela-
tionship exists between empathy and
altruism, but Batson admitted that
there is ongoing debate about why this
relationship exists (Batson, 1990;
Batson et al., 1991).
The primary theoretical question
raised by the empathy-altruism
hypothesis, therefore, is whether or
not the helper experiences personal
psychological and emotional gain
from the act of helping. Traditional
evolutionary psychologists argue that
therein lies the true, albeit hidden,
motivation for helping, and that altru-
ism is essentially hedonistic (Cialdini,
Baumann, & Kendrick, 1981; Cialdini
et al., 1997). Batson’s critics propose
that the gratification derived from
helping others results primarily from
the positive, endorphin-like response
enjoyed by the helper. By contrast,
supporters of the empathy-altruism
hypothesis propose that satisfaction
with helping can be derived purely
from having benefited the person in
need (Batson et al., 1991). These ques-
tions really reflect a deeply philosoph-
ical argument, reminiscent of the
prophetic words of the spiritual poet,
Rabindranath Tagore (as cited in
Brown, 1994), who wrote:
I slept and dreamt that life was only joy.
I awoke, and saw that life is only service.
I served—and behold—all service is joy!
(p. 70)
In essence, Batson and his colleagues
(as well as his critics) were attempting
to define the true source of the joy
experienced through helping. Batson
Theory Analysis 337
staunchly defended the notion that
human beings clearly value the welfare
of others. Other researchers have argued
that altruism is ultimately self-serving,
generating a counterhypothesis, the
empathic-joy hypothesis, which has
even been tested against Batson’s theory
(Batson et al., 1991; Cialdini et al.,
1997).
The Empathy-Altruism Hypothesis
and Nursing Research
Had Batson’s (1990) theory emerged
from the discipline of nursing, it might
be described as a meta-theory in that
it serves to explain deep, underlying
qualities of human nature, as well as
the intrinsic motivation for complex
human behavior. But even though
social psychology gave rise to this
hypothesis, the implications for nurs-
ing are not only clear, but also com-
prehensive enough to encompass all
aspects of the profession. For example,
nurse educators at South Dakota State
University have recently suggested
including a study of the construct of
altruism in their nursing baccalaureate
curriculum (Fahrenwald et al., 2005).
Furthermore, nurse researchers inter-
ested in recruitment and retention issues
might apply the empathy-altruism
hypothesis when considering the rela-
tionship between empathetic personal-
ity styles and the desire to join or remain
in the nursing work force. Beyond
that, researchers might also study sex
differences in empathetic emotional
response as it relates to altruistic
behavior, possibly generating sugges-
tions as to why nursing remains a
female-dominated profession. Human
resource specialists and nurse recruiters
might refer to this theory when consid-
ering how experienced nurses behave
toward their newly licensed colleagues.
Finally, researchers might explore why
different nurses are drawn to specific
patient populations. For instance, are
certain types of patients more or less
likely to engender empathy in certain
types of nurses?
The empathy-altruism hypothesis
could certainly provide the theoretical
framework for a plethora of nursing
studies. The concepts of empathy and
338 Nursing Science Quarterly, 19:4, October 2006
altruism clearly inform not only the
nurse-patient relationship, but also the
interaction between nurses and their
managers and colleagues. Additional
research questions based on this theory
that could be applied in the clinical set-
ting are presented in Table 1.
Conclusion
While the concept of theory itself
may seem intimidating and abstract,
especially to nurses who often must
focus on life’s most tangible realities,
the contribution of theorists must not
be disregarded. Whether considering
the nursing process against the back-
drop of the broadest meta-theory, or
testing the ideas presented in middle-
range theories, nurses can attain a
deeper understanding of their own
practice through the study of nursing
theory. Furthermore, theoretical con-
tributions from other social sciences
have much to offer nursing, as well.
Clearly the empathy-altruism hypothe-
sis stands as an example of a social
psychology theory with broad applica-
bility to nursing practice. As the world
in which the work of nurses increases
in its complexity and also in its chal-
lenges, sound knowledge of nursing
and other social theory provides an
invaluable means though which prac-
tice can be both understood and
improved.
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