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Empathy vs. Emotional Reasoning in Nursing

What can a nurse do to truly be empathetic to patients?

Mr. Jones, a 26-year-old male, has been diagnosed with testicular cancer. Upon hearing this, a nurse on his unit immediately requests a psychiatric consultation for depression.

The psychiatrist goes to see Mr. Jones who expresses surprise at his being seen as depressed. In fact, his mood had been rather upbeat after his physician informed him that his tumor was localized, had not spread beyond the initial site and his prognosis is excellent. (In his case, a 5-year survival rate of 99.5 percent for localized cancer.1)

After the psychiatric consultant left, Mr. Jones began to doubt his positive feeling about his cancer. "Maybe it's more serious than I thought, if they think I'm depressed," he thinks to himself.

Decision Analysis

Was the nurse right in putting in for a psychiatric consultation?

Mr. Jones did not express any feelings of being depressed. He was eating well, sleeping, had maintained an active interest in his job and hobbies. He had no suicidal ideations. And he was positive he could overcome his illness.

While initially shocked to hear the diagnosis and showed concern about his future, he was immediately relieved when given education about his type of cancer and good prognosis.

When the nurse on the unit was asked why she felt a consult was necessary, she replied, "It is a very serious disease. I'd be depressed if I were diagnosed with cancer. I was being empathetic."

Despite her good intention, the psychiatric consultation was not helpful and may turn into a self-fulfilling prophecy. Mr. Jones is now worried and anxious about the cancer and is having difficulty sleeping.

The nurse mistook emotional reasoning for empathy.

Separate Definitions 

Empathy is defined as the ability to understand another person's circumstances, point of view, thoughts and feelings. When experiencing empathy, one should be able to understand someone else's internal experiences.2

Empathy involves communication. Trying to understand what another person is experiencing without communication leads to interpretation without meaning. It becomes a mechanism of internal thought processes rather than an understanding of another's point of view or feelings.

The nurse inferred the patient was depressed based on her feeling: "I'd be depressed so he must be too."

She didn't attempt to verify his thoughts or feelings as similar to hers or attempt to understand what he might be experiencing. This was a cognitive distortion on the part of the nurse. It is mind reading when one person proposes to know what another person is thinking or feeling.

Emotional reasoning is defined as "a cognitive error whereby a person who is nervous or anxious resorts to emotional reactions to determine a course of action."3

In this scenario, the nurse's own anxiety is projected upon the patient who is then subjected to an unnecessary assessment. It becomes harmful to him as he now may think, "I not only have cancer but I have depression too - a double whammy!"

Being Empathetic

Remember empathy without communication is mind reading. Listen to patients; provide education, but don't give advice.

What can a nurse do to truly be empathetic to patients?4

· Remember empathy without communication is mind reading
· Listen to patients and allow them to express their feelings
· Reflect back what you hear so they can clarify their thoughts
· Don't be judgmental
· Don't say, "I know how you feel"
· Make eye contact
· Provide education, but don't give advice
· Be knowledgeable about their illness
· Acknowledge their right to feel as they do. This is an essential step in showing you are trying to understand

If a patient voices depressed feelings or meets the established criteria for a depression or a depression-related disorder  tell him you would to like to request a psychiatric consultation as you are concerned about how his mood could interfere in rehabilitation or recovery. This suggests concern.

What are the Criteria for Depression?5

· Can't sleep enough or sleeps too much 
· Lack of concentration or finds previously easy tasks now difficult
· Feelings of worthlessness and hopelessness
· No control over negative thoughts
· Loss of appetite or can't stop eating
· Constantly irritable, or becomes enraged even at small things
· Thoughts that life is not worth living, or having a suicide plan

Nursing can be an emotional profession. One can see the ravages of disease or the wonder of cure. Whatever the outcome, nurses best help patients when care is based on communication, scientific research and intellect rather than emotion that results in faulty cognitions.

References for this article can be accessed by clicking here

Michael C. LaFerney is a psychiatric clinical nurse specialist who works at Arbour SeniorCare, Rockland, MA.

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I appreciate the points Lauren Johnson, RN, Clinical Educator,makes. However and unfortunately, in my state in long-term care settings many patients have a standing order for psych services and psych consults are routinely suggested by nurses and carried out. OR they are suggested to the physician by a nurses who gives the OK.The majority of Psych consults in long-term care are initiated by nursing.
I would dispute her assertion "that nurse on the unit does not simply hear about a patient and order medical consults because of her feelings. It is so important to provide realistic scenarios so that nurses internalize the message. Nurses must be empowered to make changes, not shamed by dramatic examples that cannot be found within the profession."
In evidence based practice one sees emotional reasoning used frequently and my example is not so dramatic or non-existent. As one who has does numerous psych consults emotional reasoning has been a consistent and common theme.Nurses have suggested and had many psych consults done exactly in the manner described above. It is not shameful to think in this way.- it is a common cognitive distortion pattern seen in people. The purpose of the article is to bring this negative distortion into awareness so treatment based on communication and scientific research can be given. Awareness will empower nursing to change this.
I'd be interested in what other nurses have observed-does this happen or is it non-existent and not found in our profession?

Michael C. LaFerney,  RNCS,  ASCJuly 19, 2009
Rockand, MA

I loved the advice about empathy, especially the part about not being a mind reader. This section will be a valuable teaching tool.

However, it is not within the nurse's scope of practice to order a psych consult. It would be more realistic for the nurse to consult a nurse cancer specialist to provide resources for this patient.

The point came across, but at what cost? A nurse on the unit does not simply hear about a patient and order medical consults because of her feelings. It is so important to provide realistic scenarios so that nurses internalize the message. Nurses must be empowered to make changes, not shamed by dramatic examples that cannot be found within the profession.

I will share this article with my staff, but only the part about being empathic.

Lauren Johnson,  RN, Clinical Educator,  Washington County HospitalJuly 16, 2009
Hagerstown, MD

Indeed a great example of how to practice with empathy and not emotion. Good listening skills are a basic and necessary tool.Our interpretation of what
is communicated to us is vital to good practice.

Jeanine Post,  RNCHPN ,  Hospice of Union CountyJuly 13, 2009
Monroe, NC

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