Empathy in the nurse–patient relationship in geriatric care: An integrative review

Abstract

Introduction:

Empathy is a complex human experience that involves the subjective intersection of different individuals. In the context of nursing care in the geriatric setting, the benefits of empathetic relationships are directly related to the quality of the practice of nursing.

Objective:

Analyze scientific production on the benefits of empathy in the nurse–patient relationship in the geriatric care setting.

Methods:

An integrative review of the literature was performed using the PubMed, Cochrane, CINAHL, Scopus, PsycINFO, and Web of Science databases. The articles retrieved were organized, evaluated, and classified based on the level of scientific evidence.

Results:

Relationships of empathy between nurses and older people were analyzed in quasi-experimental studies using different assessment tools, the majority of which had moderate levels of validity and reliability. Studies with a qualitative approach discussed the meaning of empathy in terms of the quality of care offered, compassion, and vulnerability.

Discussion:

Levels of empathy increase when activities are developed with the aim of teaching, sensitization, and training for relational care between nursing staff and older people. The analysis of empathetic relationships is important to the evaluation of the quality of care provided to older people.

Conclusion:

Empathy in the nurse–patient relationship in the geriatric care setting is an important ethical aspect that contributes to the quality of the practice of nursing. The present findings indicate the need for more robust assessment tools with adequate psychometric properties and the descriptive analysis of empathy.

Keywords

Empathy geriatric nursing nurse–patient relations nursing care older people

Introduction

The issue of empathy emerged in the nursing literature after the 1950s.¹ It is likely that researchers in the field began their studies inspired by the work of Rogers² on empathetic understanding in the therapeutic relationship in psychology. However, the use of this concept in issues of interactions between nurses and patients and in clinical nursing practice only emerged in the mid 1970s. Up to the 1990s, the literature considered empathy to be appropriate, desirable, and therapeutic as well as a useful component of nurse–patient interactions.³ Subsequently, empathy emerged in the 21st century in educational strategies and the programs of healthcare institutions as an important means of improving the quality of nursing care.⁴

There is little agreement in the literature on the concept of empathy. A classic concept, which is still used by researchers in the health field, considers empathy to be the ability to feel the private world of another person as if it were one’s own, but without losing the “as if it were” aspect.⁵ A recent review study pursued the issue further in the context of nursing, breaking down empathy into four components: (1) emotive: empathy is the subjective ability to experience and share another’s psychological state or intrinsic feelings; (2) moral: there is a strong altruistic inner force that motivates the practice of empathy; (3) cognitive: empathy is the intellectual ability to identify and understand the feelings and perspectives of another person from an objective standpoint; (4) behavioral: empathy is a communicative response that transmits the perspective of another.³

For a broader, multi-faceted, more complex definition, it is necessary to consider the etymological root of the term. Empathy partially originated from the German word Einfühlung, from ein meaning “within” and fühlen meaning “to feel,” conceived in German psychology and philosophy as a shared understanding between separate individuals of each other and their experiences.⁶ The term has its roots in Greek, from em meaning “in” and pathos meaning “passion.” In Greek art, empathy is a human experience or representation that evokes pain, compassion, melancholy, sadness, or tenderness.⁷ Therefore, empathy in the present study is considered a complex human experience involving the subjective intersection of different individuals.

The experience of empathy between nursing staff and older people has important peculiarities. Such relationships are affected by the aging process, which involves coping with the losses resulting from the progressive decline in the ability to adapt as well as changes imposed by chronic diseases. An investigation involving older people in Europe found that approximately 35% of individuals up to 75 years of age will continue up to their deaths in a situation of frailty and the need for assistance on some activities, with increasing vulnerability and being unable to act as rapidly as before. Moreover, approximately 15% of this population will live for years in a situation of dependence, requiring the assistance of others for one or more essential activities of daily living.⁸

Whether in the context of frailty or dependence, nursing care provided to older people should be established in an empathetic manner. Care is needed to ensure consent and respect for autonomy, even in situations of disease, insufficiency, and communication compromised by the aging process. For geriatric nursing, resources of holistic care are essential to meeting the biological, psychological, social, and spiritual needs of individuals.⁹ In the same manner as human care, empathy is a profoundly relational experience.¹⁰ Empathetic interventions and non-pharmacological treatment strategies can improve the quality of life of older people.^11,12 Thus, there is a need for more in-depth studies on empathy in the context of interpersonal relationships between nurses and older people.

The importance of studies in this field was referenced in the World Report on Aging and Health of the World Health Organization published in 2015.¹³ The report stressed the fact that the health needs of older people tend to become more chronic and complex, and that care must encompass the multidimensional requirements of this population in an integrated fashion. The report also demonstrated that it is necessary to provide integral person-centered care, and that the experience of empathy is essential to achieving this goal.

Few studies have been conducted on empathetic relationships in the field of geriatric nursing. This article discusses the effects and benefits of empathetic relationships. Technological advances in the health field have led to important changes in the relationship between health professionals and their patients. One perceives a very large number of therapeutic interventions and the experience of empathy runs the risk of losing its value among the intensity of interventionist practices.

A literature review could contribute to decision-making in the clinical practice of nursing and assist in the establishment of theoretical, empirical, and educational bases for returning the value of empathetic relationships to the field. The importance of empathy is directly related to the quality of the nursing practice. It is therefore necessary to determine the current state of the art on this issue. Thus, the aim of the present review was to analyze scientific production on the nurse–patient relationship in the geriatric care setting in light of the issue of empathy.

Methods

The integrative review method proposed by Ganong¹⁴ was used, which consists of the following steps: (1) formulation of the guiding question based on the clinical practice of nursing; (2) establishment of inclusion criteria and search of primary databases; (3) selection and categorization of studies through the organization and summarization of the extracted information; (4) evaluation of studies selected through a description of the quality of the assessment tools employed and standards of quality in qualitative studies; (5) interpretation, critical discussion, and comparison of results with theoretical knowledge; and (6) synthesis of knowledge with recommendations for the practice.

In step 1, the guiding question of the study was formulated using the PICOS strategy (Patient or Problem, Intervention, Control or Comparison, Outcome and Study design). The following was the guiding question: What evidence is there on the benefits of empathetic relationships between nursing staff and older people in geriatric care settings?

The inclusion criteria were as set out in step 2 as follows: complete scientific articles available in electronic databases on primary studies with a level of evidence from I to IV (corresponding to meta-analysis or meta-synthesis (level I), experimental study or clinical trial (level II), quasi-experimental study (level III), and non-experimental study, such as a descriptive and qualitative study (level IV))¹⁵ that address the issue in question and the population of which were nurses who work in geriatrics, nursing students, and/or older people. No restriction was imposed regarding the date of publication. The exclusion criteria were duplicate articles in different databases or the same database and studies with level V evidence, such as opinions, methodological studies, and case reports.

After the definition of the eligibility criteria, searches of the international literature were performed by two independent researchers in the following primary databases: American National Library of Medicine (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), The Cochrane Collaboration Library (COCHRANE), American Psychological Association (PsycINFO), Elsevier B.V. (Scopus), and Thomson Reuters Scientific (Web of Science). Combinations of the following MeSH terms were employed: “empathy,” “nurse–patient relations,” “aged,” and “geriatric nursing” (Figure 1). The level of agreement between the researchers was determined at the end of the process.

Figure 1.

Flowchart of search strategy and study selection process.

Step 3 was the selection and categorization of the articles through an analysis of the titles and abstracts based on the inclusion criteria. To control bias, preselected articles were submitted to full-text analysis by two independent reviewers, who extracted data with the aid of an adapted form¹⁶ composed of seven items: identification, objectives, methodological characteristics, assessment tools employed, results related to empathy in the nurse–patient relationship, limitations, and conclusion. The “snowball” search strategy was also used, which consists of the identification of further publications through a reading of the reference lists of the selected articles.¹⁷

In step 4, the assessment tools employed to measure empathy in the nurse–patient relationship were presented in terms of validity and reliability based on the data described in the selected articles.¹⁸ The quality of the qualitative studies was evaluated based on the clarity of the research problem and objectives, identification of the research paradigm, interaction between the researchers and subjects of the study, criteria for sampling saturation as well as the data collection and analysis methods.¹⁹

Step 5 was the descriptive discussion and interpretation of the results with the aim of answering the research question. Step 6 was the systematization of the main contributions that affect the nursing practice and a summary of the main recommendations.

Results

Fourteen articles were selected from international periodicals developed mainly in the United States (57%) and Sweden (14.3%). Nine were quasi-experimental studies (evidence level III) (64.3%) and five were descriptive studies (evidence level V) (35.7%). Chart 1 summarizes the studies selected for the present review (Table 1).

Table 1.

Characterization (identification, objectives, type of study/level of evidence and sample) of studies selected for present review.

	Authors, periodical, year, and country of study	Objective	Type of study/level of evidence	Sample
S1²⁰	Bagshaw M, Adams M Int J Aging Hum Dev 1986 USA	Explore the nature of relationships between psychosocial variables that affect the work of nursing home personnel	Quasi-experimental study Level III	363 nursing staff members at seven long-term nursing homes
S2²¹	Åström S et al. J Adv Nurs 1990 Sweden	Compare levels of empathy, burnout and attitudes among categories of nurses and examine connections among empathy, burnout, and attitudes	Quasi-experimental study Level III	358 nursing staff members (registered nurses, licensed practical nurses and nurse aides at long-term nursing homes and psychogeriatric clinics)
S3²²	Åström S et al. Int J Nurs Stud 1991 Sweden	Analyze the relationship between burnout/empathy/attitudes and experience in the practice of caring for patients with dementia	Quasi-experimental study Level III	60 nursing staff members who work in geriatrics (15 with higher scores and 15 with lower scores on each scale of each nursing category)
S4²³	Hollinger-Samson N, Pearson JL Aging Ment Health USA 2000	Analyze how self-rated depressive symptoms in older people nursing home residents are associated with resonated empathy reported by caregivers, expressed empathy observed by supervisors of caregivers and empathy as perceived by the older people residents	Quasi-experimental study Level III	62 older people individuals, 36 staff members (registered nurses, nurse aides, unregistered nursing attendants and supervisors) at six long-term nursing homes
S5²⁴	McGilton KS et al. J Nurs Scholarsh 2003 Canada	Examine the effects of a relationship-enhancing program for residents and care providers at long-term nursing homes	Quasi-experimental study Level III	40 older people residents (24 in intervention group and 16 in comparison group) 34 nursing staff members (19 in intervention group and 15 in comparison group)
S6²⁵	Liu S J Nurs Res 2004 Taiwan	Describe the meaning of care for nurses providing care to older people	Descriptive study Level IV	30 nurses in medical–surgical wards in a university hospital
S7²⁶	Kayser-Jones J, Chan J, Kris A Geriatric Nurs 2005 USA	Investigate factors that influence the quality of nursing care with older people individuals in the terminal phase at a long-term care facility	Descriptive study Level IV	33 older people residents at a palliative care unit and nursing staff who provide care
S8²⁷	Heliker D, Nguyen HT Res Gerontol Nurs 2010 USA	Report the results of two interventions: story sharing and communication skills	Quasi-experimental study Level III	84 nurse aides (43 in the story sharing (SS) group and 41 in the communication skills (CS) group 54 older people residents (26 in the SS group and 28 in the SC group) at six long-term nursing homes
S9²⁸	Van der Cingel M Nurs Ethics 2011 The Netherlands	Understand the benefits of compassion to the practice of nursing in the context of long-term care	Exploratory-descriptive Level IV	30 nurses (specialists in chronic diseases, homecare and nurse practitioners) 31 older people with chronic diseases
S10²⁹	Stenbock-Hult B, Sarvimäki A Nurs Ethics 2011 Finland	Clarify the meaning of vulnerability to care providers caring for older people	Descriptive study Level IV	16 female nurses with experience working in different care contexts for older people
S11³⁰	Irvine B et al. Gerontologist 2011 USA	Evaluate individualized Internet training designed to teach nurse aides strategies to prevent or, if necessary, react to aggression on the part of older people residents of long-term rest homes	Quasi-experimental study Level III	159 nurse aides who care for older people individuals, divided into two groups: 80 in intervention group 79 in control group
S12³¹	Irvine B et al. Geriatric Nurs 2012 USA	Evaluate Internet training designed to teach strategies to nurse aides to deal with aggressive behavior on the part of older people residents of long-term rest homes	Quasi-experimental study Level III	103 nurse aides at six long-term rest homes divided into two groups: immediate treatment group (n = 58) and delayed treatment group (n = 45)
S13³²	Chen AMH et al. Nurse Educ Today 2015 USA	Examine the impact of participation in an aging simulation game on empathy and attitudes toward older adults among nursing students	Quasi-experimental study Level III	58 sophomore-level baccalaureate nursing students
S14³³	Brown KM, Bright LM Nurse Educ Pract 2017 USA	Explore experiences and attitudes toward older adults with cognitive and/or physical limitations as well as the effects on the knowledge and skills of students during a baccalaureate nursing course	Descriptive study Level IV	45 undergraduate nursing students

The studies with a quasi-experimental design were divided into two categories: cross-sectional studies and intervention studies. The main methods and findings of the nine quasi-experimental studies are organized by category in Table 2.

Table 2.

Summary of methods and main results of quasi-experimental studies in sample organized by category.

	Category of quasi-experimental study	Data collection instruments/intervention/analysis of results	Main findings
S1²⁰	Cross-sectional	Kogan’s Old People Scale (1961) to assess attitudes; Gilbert & Levinson Custodial Mental Illness Scale (1956); LaMonica Empathy Construct Rating Scale (1981) The F test and Scheffé’s individual test used to study differences between groups	Low level of empathy was significantly correlated with negative attitudes of nursing staff toward old people and orientation toward conservative treatment. Positive attitudes toward older people were not significantly associated with greater empathy or type of treatment
S2²¹	Cross-sectional	LaMonica Empathy Construct Rating Scale (1981); Burnout Experience Scale (Pines et al., 1981); Attitudes Toward Demented Patients Scale (Åström et al., 1987a,b; 1990) The t-test was used to study differences between groups and Pearson’s correlation coefficients were calculated for the empathy, burnout, and attitudes scales	Registered nurses demonstrated greater empathy, higher levels of positive attitudes, and lower levels of burnout compared to licensed practical nurses and nurse aides. Among all participants, 27.4% were at risk of burnout
S3²²	Cross-sectional	LaMonica Empathy Construct Rating Scale (1981); Burnout Experience Scale (Pines et al., 1981); Attitudes Toward Demented Patients Scale (Åström et al., 1987a,b; 1990) Pearson’s correlation coefficients were calculated and a linear regression model was used (Draper and Smith, 1981; Press, 1982) for correlations among burnout, empathy, and attitudes	The occurrence of burnout among the nurses changed from a mean of 2.7 points in 1987 to 2.5 in 1988. Empathy skills increased from 398 in 1987 to 450 in 1988. Attitudes remained unaltered throughout the period. Higher levels of burnout were correlated with lower levels of empathy
S4²³	Cross-sectional	For older people residents: Mini-Mental Health Examination (Folstein et al., 1975); Physical Self-Maintenance Scale (Lawton et al., 1982); Geriatric Depression Scale (Brink et al., 1982); adaptation of the perceived social support network system (Wells & Macdonald, 1981) For nursing staff: three versions of the Relationship Inventory Empathy Subscales (Barrett-Lennard, 1962) Multiple regression and correlation tests were used for the results of the different data collection instruments	Only a low level of empathy among the nursing technicians for type of empathy as perceived by the older people residents was associated with depression. Self-rated depression among the older people residents was not associated with the types of empathy: resonated by nurses or expressed by supervisors. Perceived empathy and resonated empathy were positively correlated
S5²⁴	Intervention study	The intervention occurred with nursing staff through the implementation of educational sessions for 7 months guided by the use of Beer’s (1988) formula for change and Winnicott’s (1970) theory of relationships Older people: Self-Report Relational Scale and Observational Scale (based on Winnicott, 1970); Relational Care Scale (based on Nunley, Hall, & Rowles, 2000 and Caris-Verhallen et al., 1999) Visual Analog Scale to measure closeness between nurse and older individual and relational behavior scale The t-test and repeated-measures analysis of variance were used to examine differences between groups	Care providers were taught to improve their relational skills with the older people. The statistically significant effects were a greater perception of the older people regarding the relational care of nursing, empathetic behaviors of the nursing staff and the continuity of care
S8²⁷	Intervention study	CS group: sessions of traditional teaching with nurse aides on communication strategies, with discussion on verbal and non-verbal communication SS: interactive story sharing sessions intercalated with drawing sessions with nurse aides The assessment tools were administered pre-intervention as well as 3 and 6 months after the intervention with staff and older people residents Nurse aides: Emotional Empathy Tendency Scale (Mehrabian, 1996; Mehrabian & Epstein, 1972); Story Sharing Self-Efficacy Scale; Job Attitude Scale (Helmer, Olson, & Heim, 1993) Older people residents: Caring Behaviors Assessment (Cronin & Harrison, 1988) and phenomenological interviews Both participants: Mutuality Scale (Archbold, Stewart, Greenlick & Harvath, 1990, 1992) Analysis of covariance (ANCOVA) was performed to evaluate the efficacy of the intervention. The qualitative content was analyzed using Heideggerian hermeneutic phenomenology	Among the nurse aides, mutuality scores and post-intervention empathy scores were significantly higher in the intervention group compared to the control group. No statistically significant changes occurred regarding job attitude or story sharing self-efficacy. Among the older people residents, a significant change was only found on the teaching/learning subscale of the Caring Behaviors Assessment
S11³⁰	Intervention study	Internet training was held in two phases. Evaluations were conducted prior to the course as well as 4 and 8 weeks after the beginning of the course. To measure the effects, psychometric assessment tools were used to evaluate knowledge in video simulations, self-efficacy, attitudes, empathy, and user acceptance with regard to the course. The effect sizes are reported using Cohen’s (1988) statistic, with pooled standard deviations for the ANCOVA models and independent t-test	The comparison of post-intervention means adjusted for the pre-intervention scores demonstrated greater gains in the intervention group for each of the measures evaluated. The effect sizes between the phases of the study suggest stability in the magnitude for self-efficacy, empathy, and knowledge on video simulation tests, but a small effect size for attitudes
S12³¹	Intervention study	Rest homes were randomized. Nurse aides were recruited from each home and separated into two groups. The immediate intervention group performed two weekly visits to online training. The delayed intervention group began the online visits 17 days after the first group. Three evaluations were conducted: one prior to the course, one 8 weeks after the beginning of the course and 16 weeks after the beginning of the course To measure the effects, knowledge and self-efficacy in video simulations, attitudes, empathy, and user acceptance regarding the course were evaluated. A simple random intercept model of the change in score (post-intervention score minus pre-intervention score) was used	The scores of the groups for self-efficacy, empathy, and attitude improved with large statistical effect. Participant knowledge regarding care strategies in situations of aggressive behavior on the part of older people residents increased significantly in the immediate intervention group, with the effect maintained 16 weeks after the beginning of the course
S13³²	Intervention study	Kiersma-Chen Empathy Scale (2012); Jefferson Scale of Empathy for students (Fields SK, 2011) and Aging Simulation Experience Survey (Chen et al., 2011). All assessment tools were administered before and after participation in a simulation game. The data were analyzed using SPSS for Windows (Armonk). Changes between pre-intervention and post-intervention were evaluated using paired t-tests	Empathy among the students toward older adults improved significantly and globally after the intervention. Improvements were also found on seven of the 13 items related to health attitudes and understanding. On the post-test, the students agreed that they experienced frustration and impatience during the aging simulation game

The decision was made to summarize the quality of the main psychometric assessment tools employed in the studies above. Table 3 displays information on the validity and reliability of the assessment tools according to data presented by the authors in the description of the methods in the studies.

Table 3.

Assessment tools employed for data collection with respective validity and reliability according to data presented by authors in studies.

Study	Assessment tool	Validity	Reliability
S1, S2, S3	LaMonica Empathy Construct Rating Scale	Weak	High
S1	Kogan’s attitudes toward of old people scale	Moderate	Moderate
S1	Gilbert and Levinson Custodial Mental Illness Scale	Not identified	Moderate
S2, S3	Burnout Experience Scale—Pines et al.	Moderate	Moderate
S2, S3	Attitudes Toward Demented Patients Scale—Åström et al.	Moderate	Moderate
S4	Mini-Mental Health Examination—Folstein et al.	Not identified	Not identified
S4	Physical Self-Maintenance Scale—Lawton et al.	Not identified	High
S4	Geriatric Depression Scale—Brink et al.	High	Moderate
S4	Relationship Inventory Empathy Subscales—Barrett-Lennard	Moderate	Moderate
S5	Self-report relational scale, observational scale, nurse-resident relational care scale—McGilton et al.	Not identified	Not identified
S5	Visual analog scale to measure closeness between older people residents and nursing staff—McGilton et al.	Moderate	High
S5	Assessment of perception of care behavior—McGilton et al.	Moderate	Moderate
S8	Job attitude scale—Helmer, Olson, &Heim	Not identified	Not identified
S8	Caring Behaviors Assessment—Cronin & Harrison	Moderate	Moderate
S8	Tool for self-efficacy story sharing—Heliker & Nguyen	High	Not identified
S8	Mutuality scale—Archbold, Stewart, Greenlick & Harvath	Low	Very high
S8	Emotional Empathy Tendency Scale—Mehrabian and Mehrabian & Epstein	Moderate	High
S13	Kiersma–Chen Empathy Scale	Moderate	Moderate
S13	Jefferson’s scale of empathy	Moderate	Moderate
S13	Aging Simulation Experience Survey—Chen et al.	Not identified	Not identified

The studies employed different tools for measure empathy and other phenomena in the nurse–patient relationship in the older people care setting. Only one assessment tool was used in more than one study: LaMonica Empathy Construct Rating Scale. The studies that used this scale were similar, addressing the relationships among levels of empathy, attitudes, mental illness, and burnout among nursing staff.^20
–22 Although the authors classified the assessment tools as having weak to moderate quality, three studies identified a positive correlation between lower levels of empathy and negative attitudes toward older people, demonstrating that these assessment tools were able to measure this phenomenon.

Studies S5²⁴ and S8²⁸ conducted interventions with nursing staff and older people residents. The levels of empathy among the nursing staff and the perception of the residents regarding the relational care received demonstrated statistically significant improvements immediately following the intervention. However, the studies recognized the difficulties in collecting data from the older people, which could represent response bias. Another point the authors raised was the lack of time among these people for the administration of longer data collection instruments.

Studies S11,³⁰ S12,³¹ and S13³² performed interventions with nursing staff and students. The teaching strategies led to significant improvements in levels of empathy as well as significant gains in self-efficacy regarding the participants’ (both nursing staff and students) work and attitudes toward older people.

The descriptive studies in the sample are divided into three qualitative research approaches: phenomenological interpretation, content analysis, and Grounded Theory. Table 4 summarizes the data on the methods and results of these studies.

Table 4.

Summary of methods and main results of descriptive studies in sample organized by qualitative research approach.

	Approach	Data collection instruments/intervention/analysis of results	Main findings
S6²⁵	Phenomenological interpretation	Non-structured interviews based on Parse’s (1992) phenomenology with heuristic interpretation	Regarding empathy, the nurses reported that older people often express themselves strongly and expect to be perceived, making it necessary to know what was understood in their thoughts and feelings. The concept of caring involved empathy, deliberation, initiative, sincerity, tolerance, and dedication
S14³³	Phenomenological interpretation	The data collection was derived from a combination of online research with open-ended questions and the construction of journals for reflections on the part of the participants based on their service-learning experience. The data were coded independently by each researcher to ensure inter-rater reliability. Data analysis was based on phenomenological interpretation	Empathy was characterized as a satisfactory, rewarding emotion. Empathy generated a positive attitude after the intervention. The participants cited enhanced learning, especially with regard to patient-centered care, collaboration, communication, advocacy, empathy, assessment skills, and evidence-based practice
S7²⁶	Content analysis	Chart review, participant observation, in-depth interviews, and event analysis. Content analysis based on Strauss (1990)	Empathy was seen as a process closely related to compassion. Care culture, community, and compassion were the three predominant components in the philosophy of the participants regarding palliative care in the context analyzed
S10²⁹	Content analysis	Semi-structured interviews for 3 years, when pre-analyzed data demonstrated saturation Content analysis was based on Thorne, Kirkham & McDonald-Emes (1997)	Empathy stood out as part of the meaning of vulnerability (as an existential attitude). The meaning of vulnerability was being human. This aspect was illustrated by six dimensions: having feelings, experiencing moral indignation, being harmed, having courage, protecting oneself, and maturing and developing. Sensitivity, sympathy, and openness were considered prerequisites for empathy
S09²⁸	Grounded theory	Semi-structured interview on the nature of compassion related to a theoretical framework in different moments of providing care, with nurses and older people patients. The data were analyzed using Grounded Theory (Chenitz & Swanson, 1986)	The nurses reported putting themselves in the place of the older people patients, experiencing their pain and feelings. Empathy was related to compassion as a process of identification between individuals. The nature of compassion was analyzed in seven dimensions: attentiveness, listening, confronting, involvement, helping, presence, and understanding

Regarding the quality of the articles with a qualitative approach, the procedures for the collection, organization, and analysis of the empirical material demonstrated good methodological rigor. The paradigm of the studies was identified by the authors and was situated between philosophical–phenomenological and interpretative. The theoretical descriptions and justifications for the construction of the data collection tools were good.¹⁹ Study S10²⁹ solved the methodological problem regarding the researcher-participant relationship for having developed the study over a period of 3 years. The authors demonstrated a good level of organization in the data collection and analysis through the participation of experienced researchers, training of the interviewers, and reworking of the data collection tools at different times throughout the study.

From the dialogical engagement with the subjects, the qualitative studies in the present review revealed that empathy means being tolerant and respectful of others’ feelings in order to gain a genuine understanding of their needs.²³ Empathy is seen as a preliminary condition for compassion and patient-centered care in the clinical practice of geriatric nursing in general as well as specifically in palliative care. The vulnerability of the nursing staff seems to be important to the nurse–patient relationship when one considers that empathy is a prerequisite of this phenomenon in the geriatric care setting.²⁷

Discussion

Levels of empathy increase when activities are developed with the aim of teaching, sensitization, and training for relational care between nursing staff and older people. The same is true for situations in which there is some type of aggression or violence in the geriatric care setting. This is corroborated by studies in which empathy or empathetic capacity³⁴ is considered an important part of the content of effective training and teaching programs. Empathy is related to development with regard to affective, cognitive and behavioral aspects,³⁵ relational care,³⁶ and compassion in the therapeutic process.³⁷ Such training and teaching methods serve for registered nurses, nursing students,^34

–37 caregivers of older people,³⁸ and those who work in other contexts, such as caring for individuals with cancer.³⁹

The analysis of empathetic relationships is important to the evaluation of the quality of care provided to older people. Ethical aspects of the experience of empathy are related to the quality of nursing. Empathy is therefore part of the ethical experience of nursing care. Certain aspects are intrinsic to this context, such as the promotion of dignity and the management of feelings, uncertainties, and ambiguities that emerge in ethically difficult situations.⁴⁰ Critical reflection⁴¹ on ethical aspects, such as empathy in the care experience, is necessary in the practice of caring for older people.

Open to a range of interpretations, empathy is related to sensitivity, sociability, adaptability, and consideration in nursing.38 For older people, empathy is among the main characteristics of a good nurse. A previous review study found that it is important for nursing staff to anticipate the needs of older people in a relationship based on empathy, respect, and availability.⁴²

Both aging and nursing care for older adults are complex processes that can cause reactions running the gamut from acceptance to rejection on the part of both care recipients and care providers. The particular experience of empathy in nursing care for older adults can assist in establishing an interpersonal atmosphere free of defensiveness. Empathetic relationships enable individuals to speak about their perceptions and needs promote person-centered care.⁴

For the use of empathetic capacity, it is necessary for nurses to identify with others by imagining themselves in a similar situation to that of their patients.²⁷ Empathy is part of the broader concept of compassion. Compassionate care is that with the capacity to develop close, empathetic relationships with one’s patients while not distancing one’s own feelings.⁴³

The vulnerability of the nursing staff is another important characteristic of the nurse–older person relationship. As an experience of human nature, empathy is a prerequisite for vulnerability in this type of relationship in the geriatric care setting.²⁸ However, compassion fatigue is a real danger in this context. Even considering empathy as a central value of nursing, compassion fatigue can emerge in the absence of adequate emotional balance. Thus, the experience of empathy in the geriatric care setting can lead to emotional vulnerability.⁴⁴

Contributions and recommendations for nursing

Following the discussion on the findings of the present review, correlations between the main results were investigated. Table 5 summarizes the main recommendations and contributions for nursing.

Table 5.

Main contributions and recommendations for nursing based on analysis of articles in present review.

	Contributions	Recommendations for nursing practice
S1–S4	Low levels of empathy influence the development of negative attitudes and burnout among nursing staff and depression among older people in the geriatric care setting	Strategies to enhance empathy among nursing staff are needed for the prevention of burnout. Moreover, such strategies could diminish the risk of depression in older people
S5, S8	Practices in geriatric nursing care should be oriented by activities that promote the enhancement of relationships with older people	Educational programs to strengthen relational care based Beer’s formula for change and Winnicott’s theory of relationships and the development of a story sharing program increase levels of empathy among nursing staff
S6, S7, S9	Geriatric nurses in the chronic care setting consider compassion to be an important factor to the qualified care model	Empathy and compassion can improve the quality of care because the results of nursing care become more viable and precise and are better understood and accepted on the part of older people. A care model for older people with chronic diseases and those in the terminal phase should involve a relational process in which the nursing staff recognizes the loss, suffering, and emotions of such individuals
S10	Vulnerability is seen as both a burden and care resource for nurses who work in geriatrics	Strategies are needed for the incorporation of the resource of vulnerability for the promotion of sensitivity, moral conscience, strength, courage, and support for the development of the nursing staff in geriatric care
S11, S12	Teaching strategies focused on situations of aggression enhance empathy and positive attitudes among nursing staff in the occurrence of such events	Empathy on the part of the nursing staff in situations of physical and verbal aggression in the geriatric care setting can be increased through teaching strategies, such as video simulations on the Internet
S13, S14	Teaching methods, such as an aging simulation game and keeping a journal to record reflections on geriatric care, increase the empathetic capacity of nursing students	The laboratory aging simulation game Geriatric Medication Game exerts a moderate impact on levels of empathy toward older people among nursing students. The use of teaching strategies that address attitudes of anticipation, apprehension, anxiety, fear, and stereotypes can broaden empathetic skills among nursing students when caring for older people

Validity and limitations of study

The principal aim of review studies in the health field is to contribute to the incorporation of scientific evidence in the practice of care. The few studies in the literature on empathy in nurse–patients relationships in the context of geriatric nursing care and teaching employ heterogeneous approaches and definitions. With the aim of systematizing a large part of the knowledge generated in this field, the present review included the findings of both qualitative and quantitative studies, analyzing empathy as part of the theoretical framework and hypotheses as well as in the findings and analysis of the empirical data.

Empathy remains insufficiently and sparsely addressed in the field of nursing. Therefore, the validity of the present review is directly related to the complexity of this concept as an inter-subjective phenomenon in the care process. It is also related to the need for the organization and systematization of the scarce knowledge generated thus far. The limitations of this review are related to the difficulties in the systematic structuring of the diversity of knowledge produced in the field.

Conclusion

Empathy in the nurse–patient relationship constitutes an important ethical aspect in the context of geriatric care and can provide benefits that are directly related to the quality of the professional practice of nursing. Such practices establish experiences inherent to humans that transcend professional skills. Empathy is a phenomenon that is difficult to understand and measure, as it involves combinations of skills constructed from networks of interpersonal relationships.

Robust psychometric assessment tools for measuring and descriptively analyzing empathy are scarce in the literature. Therefore, further studies are needed for a broader evaluation of the quality of assessment tools employed to study nurse–older person relationships and the association with empathy.

The drafting of strategies aimed at enhancing levels of empathy and, consequently, the benefits of empathetic relationships are directly related to the possibility of improving the quality of geriatric nursing care. The findings of the present review can contribute to the planning of future studies on empathy in this care context by assisting in the choice of more effective assessment tools, theories, and methods for the analysis of this important experience and its relationship to the clinical and educational practice of nursing.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Tiago José Silveira Teófilo

Rafaella Felix Serafim Veras

Valkênia Alves Silva

Nilza Maria Cunha

Jacira dos Santos Oliveira

Selene Cordeiro Vasconcelos

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