“ Empathy Equals Match ” : The Meaning of Empathy as It Is Perceived by Greek Nurse Students-A Qualitative Study

Empathy is an integral component of the nurse–patient relationship and is critical to the development of the therapeutic relationship. The focus of this qualitative descriptive study is to explore student nurses’ views on empathy. Student nurses related the concept of empathy, with emotion, conscientiousness, care, communication and support. Empathy for these students was the combination of cognitive, emotional and functional characteristics and skills. Each category, which emerged from the data analysis, contained the concepts of emotion, knowledge and skill. These concepts found to be interrelated and interdependent. This led to the formation of a core category called “Empathy equals Match”.


Introduction
Empathy has been proposed to be the ability to perceive the meaning and feelings of another and to communicate those feelings to the other person (Stein-Parbury, 2005).Empathy as a therapeutic tool has its origins in the work of Rogers (1959) who define empathy as a core of his person-centered approach to counselling.Rogers (1959) describes empathy as: "the state of perceiving the internal frame of reference of another person, with accuracy and with emotional components and meanings that pertain to it, as if one were with the other person, but without the loss of the as-if condition" (Brunero et al., 2010).
Nursing is an art, science, and profession for caring of the patient.The practice of nursing is multidimensional and contains components such as health, illness, care, human and communication.It also contains interdisciplinary skills.Nurses in clinical practice are required on a daily basis to manage properly each of the above components aiming to provide excellent care to the patient.One of the main characteristics of excellent care is empathy and the extent to which nurses provide empathic care.A nurse must understand the patient's feelings in order to be able to help him effectively.That means a nurse needs to have or to develop empathic skills (Tayray, 2009;Ward et al., 2012).
The positive effects of empathy in care are highlighted in several nursing studies, as these show empathy to be effective on health promotion, pain, depression by reducing psychological distress and anxiety in patients and by reducing burnout in nurses (Gerogianni & Gerogianni, 2002;Malikiosi-Loizos, 2003;McCamant, 2006;Derksen et al., 2013;Parvan et al., 2014).
Studies agree about the positive role of empathy in interpersonal relationships in nursing care.In a therapeutic relationship, the health professionals need to focus on understanding the feelings of the patient as if they are in their position.Specifically nurses stated that provision of empathetic care leads to patient satisfaction and to nurses' job satisfaction and professional empowerment (Karlou & Patiraki, 2011).
A review of the literature reveals that there is little agreement about how empathy should be defined (Davis, 1983;Brems, 1989;Bohart & Greenberg, 1997).Consequently, it is argued that there is a need for nurse teachers to define what they mean by empathy.Failure to do so may result in confusion about what is being taught.Furthermore, all teachers should be trained in experiential teaching methods, and that the effects of structured empathy training should be investigated within an experimental research design (Reynolds, 1987;Reynolds et al., 1999;Williams & Stickley, 2010;Fields et al 2011).While nurses agree that empathy is important to nursing, to date, researchers have not studied the "how" nursing students feel and know about empathy using qualitative methods.
There are various views on the nature of empathy.Two key dimensions of empathy reported in the literature: the "cognitive" and the "emotional" (Stalikas & Hamodraka, 2004;Smith, 2010).According to Stalikas and Hamodraka, (2004) the "cognitive" or "understanding dimension" refers to the cognitive understanding of the experience.The person in this case looks and feels from the perspective of the other.The "emotional" or "experiential" dimension refers to the direct experience of the feelings of others.In this sense, a person shares the emotional state or the experience of another person.At a second level two other dimensions of empathy have been identified; the "communicative dimension" and the "empathic understanding".The "communicative dimension" of empathy refers to the sensitively transfer of the understanding of the emotional world of the patient or of the nursing skill to respond adequately to the patients' messages.The "empathic understanding" is taught as a counseling skill and is considered a reliable indicator of the effectiveness of the nurse.It is not only the nurse who feels empathy for the patient, but the patient also develops empathy for the nurse through a mutual exchange of experiences, that called "shared empathy" (Williams, 1990;Fields, 2011;Ward et al., 2009;2012).
The level of education contributes to the development of empathy and affect areas related to the way of communicating the importance of having a job, the way of problem-solving, the adoption of new techniques and methods and the development of different attitudes and beliefs (Malikiosi-Loizos, 2003).The literature reveals that social scientists and health professionals have a higher rating on the empathy in comparison with people involved in business and technology (Malikiosi-Loizos, 2003;Fields, 2004).
Regarding the nursing sector, it is important for the nurse to be able to recognize people who have limited communication abilities and to be able to personalize his/her experience and knowledge in order to achieve proper communication with these people (Morse et al., 1992).Working conditions are also important for the expression of empathy as the literature states that burnout and stress affect the physical, mental and social well-being of nurses, reducing their performance at work, and their ability to provide empathic care (Toukas & Touka, 2011).
Several previous studies have attempted to demonstrate the effectiveness of the use of empathy within health care.Reynolds and Scott (2000), report a positive relationship between empathy and patient responses such as relief from pain, improved pulse and respiratory rates, and clients self-report of worry and distress.Τhey further state that the quality of client's self-disclosure was found to be associated with the level of empathy used by nurses (Reynolds & Scott, 2000).Williams (1979), showed that nurses, who displayed high levels of empathy to institutionalised elderly patients, found that these patients experienced a statistically significant improvement of self-concept, as understood by a reduction in dehumanisation and depersonalisation.La Monica et al., (1987), found less anxiety, depression and hostility in cancer patients being cared for by nurses who show high levels of empathy.Efforts to use empathy skills, understand their influence on patient care and the ability of nurse's to apply these skills would appear warranted.While empathy is commonly accepted as a mutually beneficial aspect of the health provider-patient relationship, evidence suggests that many health profession students are unable to demonstrate this important skill (Fields et al., 2011).

Methodology
The aim of this study was to explore the views of nursing students on the concept of empathy and empathic care.
For the purpose of this study, a qualitative exploratory descriptive design using semi-structured face-to-face interviews was chosen.Qualitative research designs are considered most appropriate for exploring human experiences and opinions.These designs allow the researcher to gain a deeper understanding of the phenomena under study within the real social context in which they occur (Burns & Grove, 2001).For this purpose, a naturalistic approach was considered as the most appropriate to explicate the students' perceptions on empathy within their natural educational setting.Furthermore, exploration of empathy in nursing students is a not well known and a seldom researched area in Greece.To this end, it is essential for nursing practice and education to gain in-depth understanding and knowledge on how nursing students define issues of empathy and empathic care.More specifically, knowledge on how nursing students define empathy may be used by nurse educators to develop appropriate teaching strategies and display existing best practices on empathy and caring.This may foster and promote the nurse -patient relationship and the emotional well -being of patients (Peplau, 1952;Williams & Stickley, 2010;Vanlaere et al., 2010).In this respect, the graduate nurses will be prepared "to respond to clients empathetically, competently and intelligently" (Dearing & Steadman, 2009, p. 174).

Study Setting and Sample
A purposive sample of 13 nursing students, 2 male and 11 female were recruited from the researchers by open invitation.Theoretical sampling was used in selecting the participants, in accordance with the idea that emergent categories dictate the direction and nature of further data collection by allowing the categories that emerged from the early interviews to determine the topics covered in later ones.The researcher proceeded to sample until the data obtained in this study were rich, meaningful, and accurately reflected participants' experiences (Coyne, 1997).The selected participants were all nursing students enrolled in the degree programme taught by the Nursing Department of the Technological Educational Institute of Crete.All participants were in third year of their studies and had successfully completed at least four semesters of hospital-based clinical practice.It was important for the purpose of the study, the proposed participants to have at least four semesters of hospital based clinical experience in order to be able to provide information on empathy and nursing care.Prior to the study, ethical approval was sought and gained from the Nursing Department of the Technological Educational Institute of Crete.

Data Collection and Analysis
Participants were invited, through personal contact, to participate in the study.The researchers provided a full explanation of the study; the nature and the purpose of the study; their rights as participants; and confirmation of ethical approval for the study.Emphasis was placed on voluntary participation and the participants' right to withdrawal at any time without it affecting their studies.Confirmation was given that anonymity will be preserved throughout the course of study and all information collected through the interviews would be used solely for the research project and would be treated confidentially.Informed consent was gained prior to interviews commencing.Semi-structured interviews were conducted with students using a flexible interview schedule.Guide-questions were formulated by the researcher prior to the interview covering the main study areas, namely, exploration of the term empathy, views on empathic care and perceptions of providing empathic care.These guide-questions were used flexibly in order to facilitate the interview process.The interview advantages associated with the wealth of information gathered and the examination of complex emotions and perceptions.Semi-structured interview enables the interviewee to answer freely whilst incorporating the whole range of information to be collected (Denzin and Lincoln 2011).All interviews were conducted by the researcher in a quiet room within the Nursing Department and digitally recorded.Permission was granted prior to each interview for using the tape recorder.Following type recording interviews were transcribed verbatim.Content analysis was used to analyse the data.Qualitative content analysis is one of the several qualitative methods currently available for analyzing data and interpreting its meaning (Schreier, 2012).As a research method, it represents a systematic and objective means of describing and quantifying phenomena (Downe-Wamboldt, 1992;Schreier, 2012).A prerequisite for successful content analysis is that data can be reduced to concepts that describe the research phenomenon (Cavanagh, 1997;Hsieh & Shannon, 2005;Elo & Kyngäs, 2008) by creating categories, concepts, a model, conceptual system, or conceptual map (Weber, 1990;Morgan, 1993;Elo & Kyngäs, 2008).
Content analysis includes specific steps of active reading, assessment, coding and organizing the data (Polit and Beck 2006).Unit of analysis were created from words or phrases of the participants.Themes and common concepts that emerged from analyzing the participants' narrative reports led to the formulation of seven categories (Table 1).The generation of categories led to the formulation of a core category that embraced the emerging concepts and themes and answered the research question.

Establishing Credibility
The strategies used to ensure credibility of findings include critical reflection and engaging with peer researchers to reduce research bias (Polit & Beck 2006).In the data analysis phase of the present study, two peer researchers were engaged in order to eliminate personal bias and to reach consensus on the emerging concepts and themes.Critical reflection was used to evaluate the research process and the effectiveness of the techniques applied throughout the data collection and the data analysis phase.Reflective techniques were employed to monitor the researchers' initial impressions at data collection phase and control personal bias.Reflective notes throughout the study course were crucial to establish credibility of the research (Shenton 2004;Noble and Smith 2015).Caring "To Care"

Findings
Thirteen third-year nursing students participated in the study.Analysis of the data revealed three main themes, entitled, Definition of Empathy, Provision of Empathic Care, Strengthening Empathic Care.Further analysis produced seven categories which conceptualized Greek nursing students' perceptions of empathy.Verbatim quotes are used to highlight the students' views on empathy and empathic care.

Definition of Empathy
At the beginning of the interview participants were asked to reflect on their perceptions about empathy.
Participants' narrative reports focused on how they define empathy and the analysis of relevant data revealed the concepts of "emotion", "consciousness" and "care".All the responses containing these concepts were grouped into three categories: The first category "Emotion and Empathy" explains how students define empathy.The participants felt that empathy is the ability to sense other people's emotions, coupled with the ability to imagine what someone else might be thinking or feeling.Students defined empathy as: "the ability to feel the person who is next to you and the ability to understand a little more of what he feels without being said", also the ability to "put ourselves in his (patient) position ... without doing something imperative, just being able to feel … how he feels" and "the ability of the student to be able to understand how the patient feels, about his health problems" and "having an emotional connection to him and his problems".
Most of the students described empathy as the ability to make emotional connection with the patient and to manage to enter in their mind.They further stated: "not only feeling how the patient accept his situation, but to be able to understand all of the patient's associated feelings", "to understand not only what the patient state as a problem but to understand his inner thoughts, beliefs , worries and wishes".
The second category "Consciousness and Empathy" focused on the fact that empathy is the ability to recognize accurately and understand another's state and to consciously do the right thing.Most students concluded that empathy is fundamental in quality nursing practice.

"Empathetic nurse always tries to understand patients' feelings, to be supportive but always knowing that this is part of her job…she is consciously empathetic … because this is part of the good care she has to offer…"
Finally, the third category called "Caring and Empathy" described empathy as closely linked with a caring process.

"... to understand the physical and the psychological needs of the patient ... and to be able to support the patient" and
"To be able to encourage, and to help the patient to face the problems more effectively".
It became apparent that most of the students believe that with empathy, nurse can make patients feel more valued and respected.When nurses have an understanding of what it is they are going through, and by acknowledging their emotional state and listening attentively, can engage the patients and empower them to be proactive and in charge of their health care.
"Empathic nurses are the ones who help patient feel less alone and understood… (empathic nurses) are bond with patients and help them to get better".

Provision of Empathic Care
Subsequently participants described how they perceive the provision of empathic care.From the participants' narrative reports, the concepts of "communication" and "support" emerged.Responses containing these concepts were grouped into two categories.
The first category is called "Empathic Care and Communication" as most of the participants emphasized that providing empathic care means communicating effectively.Empathy is another component that is essential to a therapeutic nurse-patient relationship.When a nurse shows empathy, she demonstrates that she understands a patient's feelings.
"Being next to the patient and to communicate with him, to encourage patient to tell you whatever he wants in order for him to feel better" Most students also described that communication is a fundamental part of nursing and that the development of a positive nurse-patient relationship is critical for the delivery of quality nursing care.
"(the nurse) to truly understand patient's condition and to be able to find appropriate ways of communication.
To be able to understand how the patient really feels and to do your best for his quick recovery ..." In the second category entitled "Empathic Care and Support" participants stressed that empathic care is related to emotional support.Emotional support appears to be a fundamental form of communication and an important determinant of empathetic relationships.Specifically students stated that empathic care means: "to support…", "... to provide emotional support and... to know what the patient wants so to be able to support patients' aspirations ..." Students underscored that empathic care is closely related to the provision of psychological support to the patient.

"Every patient who receive support and help, feel comfortable and respected…"
"When receiving care, patients tend to be looking for more than the treatment of their disease, they want to receive psychological support." "Patients expect a nurse who will show interest, sympathy, and an understanding of their difficulties, especially their psychological problems."

Strengthening Empathic Care
Furthermore the participants focused on how the provision of empathic care can be enhanced.Analysis of the data at this point revealed the notions of "education" and "personal development".Responses containing these concepts were grouped into two categories.
The first category entitled "Education and Empathic Care", as the participants stressed that the enhancing of empathic care can be achieved by continuing education, and training.
"…through education, and lifelong learning ...", "…with proper training, and attending classes" and "... of course practicing... it's not enough to understand some notions and concepts but to be able to apply these in practice" that is "nurse students need training on the new skills they are learning in order to be able to practice on these".
In this category students stressed that empathy is something that need to be taught by their educators.Students need to be prepared to be more emotionally skilled and experienced in displaying empathy.

"… we need our educator to teach with examples, show to us how to use empathy, explain to us how to do so… in order to increase our empathic ability"
In the second category, entitled "Personal Development and Empathic Care" the participants stated that for enhancing empathic care, students need to develop their personal qualities and attributes.
"…improve our behavior ...", "by searching your inner self ... to understand what exactly some things means, from your own research ... purely through your own motivation ....I believe that we have incentives, we just have to discover them" and "to dare to do things even if it's to do some mistakes ..." Most students agreed that: "...the experience on the work enhances empathy".
"…only if we develop our inner self , we can develop intimacy with ourselves and others".
From the data analysis, empathy understood to be as a combination of cognitive, emotional and functional characteristics and abilities of a person.In each category emerged from the data analysis, the concepts of emotion, knowledge and functional ability are the three basic concepts that define empathy.These concepts found to be interrelated, interdependent and tightly linked, making the existence of each one of these concepts to determine the existence of the others.This resulted in the formation of a core category that embraces all the concepts that the nursing students attributed to empathy.This core category entitled "Empathy equals Match", consists of the concepts associated with the cognitive, emotional and functional abilities that are necessary in order to define and demonstrate empathy.Empathy is defined as the "matching" of all the above abilities and characteristics of the nurse with the respective abilities and characteristics of the patient (Figure 1).

Discussion
The definition of empathy, as shown by the data analysis of this study, is the matching of the cognitive, emotional and functional abilities of two people, the nurse and the patient.Empathy appears to be a complex and multidimensional concept.The participants described empathy as the ability of a person to understand and sense another person's feelings, thoughts and wishes.To be able to understand and to care for the others' emotional state and state of mind was stressed by the participants and associated to the meaning of empathy.
As stated in the literature empathy is the ability to put oneself in the place of others in order to better understand their feelings and experiences (Jahoda, 2005).This concept has two emotional and cognitive components.Emotional component involves listening to the patient's words, gestures, and voice about their feelings.
Cognitive empathy component requires the therapist to precisely observe the patient's behavior and be aware of the meaning by their observations (Parvan et al., 2014).
In addition, sensing the inner self and understanding the experience of the others' were mentioned as essential components to empathy.Participants revealed also the importance of being able to identify in an accurate way the others' needs and aspirations and act accordingly.They also sought the value of these abilities within the course of empathy and empathetic acting.
The study results are supported by other scientists who gave various definitions describing empathy either as emotion or knowledge or evolution.Specifically, Elliot et al., (2011), argued that empathy is a feeling or an experiential process of understanding and gave strong emphasis on the communication of empathic understanding, which they consider absolutely necessary to ensure patient self-awareness.
Participants demonstrated the relation between empathic care and communication.To communicate and to support appeared essential for the delivery of empathetic nursing care.As literature highlights the nurse-patient communication is known as an important factor in quality nursing care.The quality of services will be enhanced if the nurse can establish a good relationship with the patient, family members, physicians, other nurses, and

Empathy = Match
Cognitive Emotional Functional Skills Nurse Patient other health care team members (Derksen et al., 2013).Understanding clients 'needs, feelings, and their situation is the basic nursing task and empathy is the basis for this understanding (Stalikas & Hamodraka, 2004).
Findings from the study associated empathic care to the provision of physical, emotional and psychological support to the patient.This can be achieved by recognizing the feelings, needs and aspirations of the patient.Accordingly education, personal development and lifelong learning may enhance empathetic care.The above findings are supported by other studies.As Reed (2014) argued, to achieve the act of empathy requires knowledge, communication skills, experience and the skill to share and understand the psychological state of the other.Smith (2006) states that the term empathy refers to sensitivity to, and understanding of, the mental states of others.Finally, Bohart and Greenberg (1997) supported that the importance of the role of empathy in a therapeutic relationship depends on the process of dialogue, communication, development, the sharing of new discoveries, knowledge and joint efforts to create new meanings from the patient or the health professional.
Accordingly, theorists and researchers in the area of psychology, referring to the concept of empathy, recognize two main aspects a) the knowledge, and b) the emotional aspect.Brems (1989), Davis (1983) and Hoffman (2000), argued that empathy can either has a cognitive or an emotional nature.Each scientist decides to focus his attention on one of these aspects or a combination of both aspects, which characterize an experience and using a term relating to either adoption or participation describe the process of a person trying to see the world through the other person's eyes (Decety, 2009;Smith, 2010).
Concluding, empathy is defined in this study, as the matching of emotional, cognitive and functional abilities of the nurse and the patient.The interdependence between these concepts leads to the provision of empathic care and highlight the significance of functional abilities as a major component of empathy.

Conclusions
The awareness of the nursing students on the concept of empathy and the provision of empathic care is a key factor in the excellent nursing care.It is important for the nursing students to gain knowledge and ability on understanding the feelings of their patients and to develop cognitive, emotional and functional qualities that enhance the implementation of empathic care.Further study of these issues and especially the exploration of the educational needs of nurses concerning empathy is essential for enhancing empathic skills and applying empathic care.

Limitations of the study and Recommendation for Future Research
This study has some limitations, which might be addressed through further research.
The fact that the study participants consisted of 13 third-year Greek nursing students exerts some limitations on the generalization of the findings and raises questions about the study's transferability to students with different characteristics.Also this study is potentially limited as it was completed in the third year, and, consequently, third year students were still to gain some of their fourth year clinical experience that may have an additional impact on students' understanding of empathy.Second, a sample of nursing students from a particular Greek city was used.Therefore, it is impossible to compare the data of this study with data from other regions of Greece.In order to obtain greater support for these results, it might be necessary to replicate the study with nursing students from different geographic areas of Greece.
Recommendations for future research include longitudinally based designs that monitor empathy levels at each year of nursing students' program in order to explore how this skill develops over time during the course of studies.

"
(empathy) has to do with knowing what I do, and knowing why I do what I do and what exactly is that..." and "(to do) something consciously, by setting yours values, no matter who you are, and what you think, to go on and do the right thing ...".

Table 1 .
Concepts and Units of Analysis per Theme