Someone asked me recently at a public forum if empathy has been diminishing among nurses (and nursing students). Excellent question. In my answer, I pointed out that empathy is being sorely tried and spread quite thin in our country currently. That goes for everyone, including nurses and physicians, and students and teachers. And writers.
The question was in response to my reading of excerpts of my essay “Walk in My Shoes” included in my recently published book Soul Stories: Voices from the Margins(San Fransisco: The University of California Medical Humanities Press, 2018). In “Walk in My Shoes” I explore empathy, including if it is always a good thing. Empathy is “feeling with” as opposed to the more distancing “feeling for” of sympathy.
We all tend to be more empathetic to people who are similar to us. Climbing the socioeconomic ladder can diminish our empathy for people less well off than ourselves. It becomes easier to blame the poor and the homeless for their situations. Experiencing our own significant traumas can make us more empathetic to people who have experienced similar traumas—but only if we have had the resources to heal sufficiently.
In The Empathy Exams, Leslie Jamison describes empathy as “a penetration, a kind of travel. It suggests you enter another person’s pain as you’d enter another country, through immigration and customs, border crossing by way of query: What grows where you are? What are the laws? What animals graze here?” p. 6
I like this description because it includes the cognitive dissonance, the discomforting disorientation—and humility—that come with travel and with empathy as travel. It also highlights the healthy curiosity required of successful travel, successful empathy. Empathy takes work to gain and to maintain.
Empathy cannot be taught but it can be modeled and it can be nurtured.
What is a nurse? What images of nursing do you have? What images of nursing are portrayed in the media? What images of nursing do we want in the future?
These are just some of the many questions that can—and should—be asked about the profession of nursing. No matter where in the world you happen to be living, a healthy and positive image of nursing matters. Nurses constitute the largest segment of the healthcare workforce worldwide. Valuing the vital work they do—and can do when given the chance—is important for individual and population health.
Do we really want to stay stuck with the image of nursing portrayed by the lady with the (Victorian) lamp, Florence Nightingale? Do we want to stay stuck even further back in time to the monastic orders who provided nursing care? Do we want to stay stuck in the limiting hospital-based image of nursing portrayed our slightly more evolved TV soap operas (from General Hospital) of E.R. and Grey’s Anatomy or even Nurse Jackie?
In reviewing my own—literal—images of nursing that I have collected over the years, it struck me how few I have of hospital nursing. To be precise, I only have one photograph I took of a hospital nurse and that was quite by accident. I was taking a photograph of a shiny-surfaced piece of hospital artwork and a nurse happened to be walking past behind me. In contrast, I have numerous photographs I have taken of nurses providing foot care and health education in homeless shelters, tent encampments, and even under bridges. Intrepid, empathic, fearless nurses. They are my image of what nursing is and what nursing can become. They are from many parts of the world. Here they are and I hope they give you hope for the future of not just nursing. And check out the Nursing Now program, in collaboration with the World Health Organization and the International Council of Nurses, which aims to raise the status and profile (and image I suppose) of nursing.
Art and literature are powerful teachers if we open ourselves to listen to and see what they have to say. In reviewing the books I have read and the art I have seen during 2018, there is one book and one piece of art—that combined into one creation—has been the most impactful. The theme and lessons are quite timely given our current U.S. political climate. Walls and empathy. How can we grow the latter and tear down, or jump over, the former?
It seems the answer has to do with an alchemy of open-heartedness, willingness to reach across divides, courage, creativity, curiosity (the good, not prurient kind), and humor (the good, not the dark and destructive kind). And a good pair of shoes to wear in order to do this sort of essential and hard work.
First, the book and a few stunning quotes. One of the most powerful books I read this year was literally placed into my hands by nurse and bookseller extraordinaire, Karen Maeda Allman of the Seattle indie bookstore extraordinaire, Elliott Bay Book Company. Arlie Russell Hochschild’s Strangers in Their Own Land: Anger and Mourning on the American Right(The New Press, 2016) is a disturbing yet oddly hopeful book. Hochschild introduced me to the term “empathy wall” In her words:
“An empathy wall is an obstacle to deep understanding of another person, one that can make us feel indifferent or even hostile to those who hold different beliefs or whose childhood is rooted in different circumstances. In a period of political tumult, we grasp for quick certainties. We shoehorn new information into ways we already think. … But is it possible, without changing our beliefs, to know others from the inside, to see reality through their eyes, to understand the links between life, feeling, and politics; that is, to cross the empathy wall?” p. 5
With an obvious love of language and precision, Hochschild writes:
“The English language doesn’t give us many words to describe the feeling of reaching out to someone from another world, and of having that interest welcomed. Something of its own kind, mutual, is created. What a gift. Gratitude, awe, appreciation; for me, all these words apply and I don’t know which one to use. But I think we need a special word, and should hold a place of honor for it, so as to restore what might be a missing key on the English-speaking world’s cultural piano. Our polarization, and the increasing reality that we simply don’t know each other, makes it too easy to settle for dislike and contempt.” p. xiv (emphasis her own)
That I left this book sitting on the nightstand beside my bed at home in Seattle—unread— for many, many months (the paperback version has an ominous, off-putting cover), and that I finally read it after returning from a four-month stretch of living and working in a foreign to me country (Scotland), is partly why I found reading the book a profound experience. The disorientation of reverse culture shock with its own unique opportunity to explore ways across that empathy wall back into my own culture—with a changed perspective on it—was an excellent time to read about “strangers in their own land.” I can relate to that feeling. (Wait, we have this much visible abject poverty and homelessness in this city and land of plenty with its over-the-top consumerist tacky Christmas? Just one of the questions continuously running through my head since returning home.)
This is where art comes in providing a visual and different take on the empathy wall. In London, at the Tate Modern Museum, I came across the work of the Argentinian artist Judi Werthein. In 2005, she designed and produced a sneaker, Brinco (“jump” in Spanish), that she distributed free of charge to migrants crossing the Mexico/US border. The sneakers included a flashlight, compass, pockets to hide money, and a removable insole with the map of the border area around Tijuana to Mexacali. At the same time, across the border in the U.S., she sold the same sneakers as “limited edition art objects” for $200 and donated the money to a Tijuana shelter for migrants.
The Tate exhibition of Werthein’s work was so effective because it included videotaped and written media coverage of this controversial “art activism” project, along with threatening letters she received from various people in the U.S. I lingered in this exhibition space long enough to observe a variety of reactions from museum visitors, including—of course— British supporters of Brexit.
“…manipulating our ancient fear of ‘otherness’ is a time-tested method to gain power and get wealthy, if you have a public megaphone. Well-known media personalities—and too many political candidates and officeholders—exploit a market that will yield returns as long as fear haunts the human heart, a profitable enterprise in relation to their own financial or political fortunes but one that can bankrupt the commonwealth.” p 58
My hope for 2019 is that we can individually and collectively climb—or jump—the empathy walls that surround us.
Immersion experiences in another country, another culture, can bring out the best—and the worst—in people. While living abroad you cannot help but make moment-by-moment comparisons between where you find yourself and where you call home. Seemingly little things: if they drive on the left instead of the right as they do at home, which side of the sidewalk should you walk on? (Answer, at least here in the UK: there are no sidewalk etiquette rules. Expect complete chaos.) To deeper comparisons such as “Why are all British nurses forced into one of four possible specialties (Adult, Pediatrics, Mental Health, and Learning Disabilities) from the very beginning of their education?” Is this Florence Nightingale’s legacy?
As a cheeky American nurse (and nurse educator) living and working in the UK, this British approach to nurse education is something I sincerely hope that American nursing never tries to adopt. There is much to admire about the UK healthcare system, with the prime example being the existence of the NHS—although imperfect, as are all healthcare systems, it is much loved and functions so much better than the US healthcare ‘system.’ It occurs to me as ironic that while the US healthcare system is more fractured than the British NHS, British nurse education is more fractured than is ours in the US. Or at least that is how it appears to me.
This British nursing forced specialization practice is a holdover from the days (not so long ago here) of hospital-based apprenticeship, diploma-level nursing. Of course, in the US, we have also had this form of nurse “training” that is fast being phased out. In the UK, there continue to be debates about the value of a higher education degree for nurses, with some people arguing that university degrees are responsible for the apparent diminishment of empathy among British nurses. Empathy cannot be taught, but it certainly can be encouraged and modeled. I do wonder: how well can that happen in any nurse education model based primarily on traditional lectures with a class size of upwards of 700 (or more) students and multiple cohort intakes and graduations each year? That is the current reality of nurse education in the UK. Mass marketing of (or attempts to teach) empathy not only do not work—they have the opposite effect.
The photograph included with this blog post is one I took in London last month at the excellent Wellcome Collection Museum. Even if you cannot visit this museum in person, check out their website for amazing online resources, including their six-part series, “The History of the NHS.”
Although I am currently situated at a UK School of Nursing, I first learned about the strange (to me) structure of British nursing from two non-fiction/memoir books: 1) The Language of Kindness: A Nurse’s Story, by Christie Watson (London: Chatto and Windus, 2018 and 2) One Pair of Feet, by Monica Dickens (yes, related to ‘that’ Dickens), (Middlesex: Penguin, 1946). Monica Dickens’ book is based on her brief stint as a hospital nurse apprentice during WWII. Christie Watson’s book is based on her twenty years’ work as a pediatric nurse in London hospitals. I highly recommend Watson’s book, but not the one by Dickens unless you are a WWII buff of some sort.
Shoes are powerful markers of a person; shoes tend to hold the presence of the person who has worn them. In The Year of Magical Thinking, Joan Didion addresses this phenomenon. After the death of her husband from a massive heart attack, she finds herself holding on to his shoes. She writes, “I could not give away the rest of his shoes. I stood there for a moment, then realized why: he would need his shoes if he was to return. The recognition of the thought by no means eradicated the thought.”*
(…) It was the red sneakers Essie was wearing that drew me to her at the women’s shelter earlier that day. This was the second time in the past several months I had run into Essie at one of our foot care clinics. She wore an orange polyester shirt with a green chiffon scarf tied around her dreadlocks, a pink pleated skirt down to her ankles, and the red sneakers. She told me she only dressed in bright, Caribbean colors: “They keep me happy. I can’t be all down in the dumps when I got these colors on.” Essie had a perpetual and slightly crooked smile, the crookedness perhaps the residue of a stroke.
The women’s shelter is located in a church basement in downtown Seattle near the main shopping district. It is a day shelter, a safe zone for women and children, that serves homeless and marginalized “near homeless” women, especially women dealing with domestic violence. The shelter has multiple case managers, social workers, and volunteer nurses who try to connect women with health, housing, and social services. The shelter workers lend the women a hand, bend an ear to hear their problems, offer a leg up the socioeconomic ladder, a toehold on life. Empathy is their main tool. Empathy is what we try to cultivate in our health science students.
Empathy is “feeling with” as opposed to “feeling for,” which happens at arm’s length sympathy. “Walking in another person’s shoes” is how empathy is most commonly described. But can we ever walk in another person’s shoes? And is it always a good thing to try?
* quote is from Joan Didion, The Year of Magical Thinking (New York: Vintage International, 2006), p. 37.
Note: The above excerpts are from my essay, “Walk in My Shoes” in my book Soul Stories: Voices from the Margins(San Fransisco: University of California Medical Humanities Press), pages 11-12.
Empathy is in short supply. Anti-empathy, racism, xenophobia, misogyny and all things ugly are being modeled and stoked by too many people and institutions—including, of course, the President of the United States. Effective resistance to all of this comes in many forms. It is not enough and is self-indulgent to be simply outraged. Fire and fury is not the answer. Do something: Read like you give a d@#n.
You do not need to read or re-read Ray Bradbury’s dystopian novel Fahrenheit 451, or review the history of book-burning, book-banning, author suppression and outright killing (as by Hitler during WWII), to know that books and the mind (and empathy) expanding knowledge they contain is powerful stuff indeed.
My beloved local library system, Seattle Public Library (SPL), has a gutsy and well-read patron who posted “Sh**hole Countries: A Reading List” on their BiblioCommons site. The SPL has added a disclaimer that the post and the list of recommended books is not a publication of the SPL, but kudos to them for supporting the sharing of diverse opinions and resources. Even if you happen to find the content of the brief post either too in-your-face or borderline offensive, be sure to look at (and hopefully read) some of the amazing books on the recommended reading list.
Of course, reading real literature (non-fiction, fiction, poetry, plays) does not necessarily build empathy and equity. Mind and heart expansion require having at least a doorway or a window or a crack in the walls of mind and heart for them to open and expand. But good books and reading them like you give a d@#n do have amazing, lovely, powerful, radical effects on not just the individual reader but also the world.
What poetry does: inspires, transforms, moves, agitates, articulates, imagines, disturbs, delights, and mystifies.
What poetry does (according to Emily Dickinson): “If I read a book (and) it makes my whole body so cold no fire can ever warm me I know that is poetry. If I feel physically as if the top of my head were taken off, I know that is poetry.”
Poetry happens. All around us. Every day. Even if we aren’t fully aware of the fact, the muses are whispering subliminal sweet everythings in our ears.
Poetry needlessly intimidates; poetry is relegated to the shelf labeled ‘inaccessible.’ At least that is the case for most adults; children seem to be born poets and we educate them out of it. Goodnight Moon, along with most other popular children’s books, are really illustrated poems.
Along with Cicero so long ago, pragmatic people proclaim that poetry and art are dead. Not true.
I love poetry and have been a mostly closeted writer of poetry. My first (and so far, my only) published poem at age nine (in my elementary school newspaper) was a haiku: “A hurt cricket limps/helplessly and hopelessly/into the forest.” At the time, I wanted to be an entomologist, or a veterinarian, or a writer. I most definitely did not want to be a nurse, but when I re-read this haiku, I see the empathy and compassion that later led me to nursing. Several years ago when my mother was dying of cancer and in home hospice, I found that I could only read poetry. Poetry has a magical quality.
I use poetry in my teaching. For nursing students, I’ve found that it helps to use a healthy dose of poems written by nurses. They resonate more closely for the students, and also make poetry less frightening to students who equate poetry with totally inaccessible, frustrating writing. For instance, I often use the powerful poem by Cortney Davis, “I Want to Work in a Hospital” “where it’s okay/to climb in bed with patients/and hold them—” to spark a discussion on empathy and the murky realms of professional boundaries and burnout. I love the moment in class when I read that opening line, hear a dampening of background noise, and look out over the sea of faces suddenly fully attentive. Poetry is magic.
I use poetry writing in my teaching, but I often sneak this in by not announcing it as poetry writing. For many years, in my health policy undergraduate course, I had students write an American Sentence of their take-home message for that class session. (See my previous blog post “Nurses and Writing the American–Healthcare–Sentence.”) An American Sentence is an ‘Americanized’ version of haiku and is a sentence consisting of 17 syllables. With a class of 150 students, this assignment did double or triple duty: it reinforced their in-class learning of concepts; it forced them to focus and hone their writing skills, and it helped me to read all of their writing before the next class session. Here are a few of my favorite student American Sentences about health policy: “US healthcare: purposeful opacity in service to the rich.” and “Sticks and stones will break our bones, but prevention is the way to stop it #nopoetryskills.” OK, so obviously the student who wrote that last one had figured out the poetry part. Good use of humor and Twitter.
In the final class session of the narrative medicine course I taught this summer, I had the students write either a haiku or an American Sentence to sum up their overall take-home message from the course. Here are some they came up with in 10 minutes of writing time: “Words, poems, artwork/Express the unspoken pain/We need to release.” “Prompted to write, to my surprise, the narrative created healing.” “So close yet so far/More questions raised than answered/ Curiosity.” “Healing is an art/in this class/that is what I get.” (This last one is technically a Lune/American Haiku, but I like it.)
I continue to search for ways to sneak more poetry into not only my teaching, but also into my writing life and into my life. The photograph here is from the Te Papa Museum, New Zealand’s amazingly wonderful national museum in Wellington. They had a ‘make a poem’ board with those little magnetized words in both Maroi and English that adults and children could play with and change around into ephemeral poetry: word art (or toi kupu, which I think literally translates to ‘speak art’–lovely!). When I was there this past February I stopped and wrote a poem mixing English and Maori words, using the Maori words by instinct since I don’t know more than a few words of Maori. Here’s what I came up with (translated into English, and I suppose this counts as my second published poem. Move over hurt cricket!) Poetry happens; let it happen to you.
This, according to a recent NYT book review “The Pathological Altruist Gives Till Someone Hurts.” (Natalie Angier, 10-3-11). The book is an anthology entitled Pathological Altruism (Barbara Oakley, et al, editors/ Oxford University Press) due out December 2011. Altruism—behavior aimed at helping another person. True altruism is said to spring from empathy (vs. self-interested egoism). Authors included in this book link pathological altruism to animal hoarding, anorexia, personality disorders, codependency, and professional burnout for health professionals—especially nurses.
Barbara Oakley seems to have gotten the idea for this anthology while she was researching and writing her somewhat creepy (among other things—a cover photo of a black-widow spider), cumbersomely titled book Cold-Blooded Kindness: Neuroquirks of a Codependent Killer, or Just Give Me a Shot at Loving You, Dear, and Other Reflections on Loving That Hurts (Prometheus Books, 2011). A pseudo-scholarly take-off on Capote’s In Cold Blood, her book examines the story of Carole Alden, a Utah artist who killed her husband in what she claims was self-defense/Battered Woman’s Syndrome—but who was sentenced to 15 years for manslaughter. A collector of animals (and of drug-addicted men), Carole was known for her compassion.
But Oakley contends that Caroles’ type of compassion is an example of diseases of caring, of empathy gone awry. She quotes research by Jean Decety, a University of Chicago scientist who examines the neural pathways that underlie empathy. According to Decety, empathy has four components. Empathy is a mixture of all four, and if any one of them gets distorted—by genetics, developmental issues, or stress—empathy can become pathological. Decety’s four elements of empathy are:
1) ability to share someone else’s emotions
2) awareness of yourself and other people—and knowledge of where you “end” and where others begin
3) the mental flexibility to set your own perspective aside and view things from another person’s perspective
4) the ability to consciously control your emotions. (as quoted pg 57 Cold-Blooded Kindness)
Empathy can either lead to compassion/acts of kindness, or it can lead to empathic distress when the suffering of others becomes or compounds our own suffering. Empathic distress is something that nurses are particularly prone to, leading to burnout. There are empathy brain cells (of course!) called mirror neurons located in the right frontoparietal lobe—in left-handed people. And they’ve identified this area as being active when health care professionals are able to emotionally distance themselves from images and sounds of a patient’s pain and suffering. Researchers are looking at ways of teaching health care providers to be able to emotionally distance themselves “just enough” to protect themselves, while still providing compassionate care. A different kind of Universal Precautions.
In the NYT article referenced above, Angier writes, “Train nurses to be highly empathetic, and, yes, their patients will love them. But studies show that empathetic nurses burn out and leave the profession more quickly than do their peers who remain aloof.”
We know that educating nurses to be aloof Nurse Ratcheds isn’t the answer to burnout prevention. I think that a lot of what is called burnout in nurses is really moral distress: wanting to do the right thing by a patient, but being blocked by factors in the health care system that are outside the nurse’s control. And for prevention of real burnout in nurses, I think we can do a better job in nursing education—by helping students (and ourselves) examine and process the sometimes complex and unsavory motivations for ‘doing’ nursing. Otherwise we will continue to graduate burnout-to-be nurses, along with future crazy cat ladies (and lads).
I’m continuing on my line of thought from my last post “On Reflection,” and have been considering how reflective practice and its counterpart of empathy can be taught in nursing school. How can we do a better job of helping students grow in emotional and moral maturity? How can we as health care providers and teachers do a better job of growing in our emotional and moral maturity?
Maura Spiegel who teaches in the Columbia University Narrative Medicine program gave a talk “Reconceptionalizing Empathy” last fall at the Narrative Medicine workshop I attended. She maintains that empathy cannot be taught, it can only be cultivated, and that a common mistake for health care providers in thinking about empathy is the idea that “I can know you—or that empathy can be a conduit into a patient’s inner life.” The psychoanalyst Donnel Stern maintains that empathy is an interpretation like any other observation, and that empathy is often implicit knowing or “pre-reflective unconscious, an unthought known:” a dimension of experience which is in some sense known, but not yet available to reflective thought or verbalization.”
Metaphor, poetry and art speak directly to our implicit knowing—they are, in Maura’s words, “mediated sources of understanding.” In health care, this is where narrative medicine and the medical humanities step in. Attentively watching movies, reading novels or poetry—or writing and reading our own stories—can tap into the sources of empathy. Language can become an ally again, and the experience of empathy can be made available for reflection. Making more room in nursing curricula for narrative medicine/nursing would be one way to help cultivate empathy in students—and perhaps even in faculty members.
Being able to access empathy and then to reflect on the experience are important skills for nurses. Certain patients or health care situations will affect us more than others. It is easier to have empathy for patients we assess as being “like us” in whatever aspects. Patients, groups or populations viewed as “the other,” are more difficult to have empathy for.
I recently read a collection of essays called The Other by Ryszard Kapuscinski (Verso, 2008). Over his long career as a journalist, he traveled throughout the developing world, reporting on major wars and revolutions. Kapuscinski was influenced in his thought by the philosopher Levinas, who is known for the phrase, “the self is only possible through the recognition of the Other.” Kapuscinski extends that thought by writing, “…the Other is a looking glass in which I see myself, and in which I am observed—it is a mirror that unmasks and exposes me, something we would prefer to avoid.”
Whenever we talk about “The Other” or “Othering” in nursing education, it is almost always in the context of working with patients and groups from “other cultures” or who have stigmatizing conditions such as schizophrenia. We don’t do a very good job at helping students to use their own inevitable discomfort in looking in that mirror to see what is reflected back, to see what is exposed. Sometimes these sorts of issues get handled by students in reflective journals in their clinical rotations, and sometimes it gets discussed in small group seminars—but those times are very few and almost seem to happen by accident. They aren’t explicitly cultivated. One of the problems that I see is that nursing faculty aren’t very comfortable in looking in the mirror themselves, so they aren’t able to model that for students. Encounter Groups for nursing faculty sound like a horror movie in the making, and continuing education conferences on how to cultivate empathy are close behind in the shudder index. One promising change may be that the next generation of nurse educators will be—well—younger, and perhaps more widely educated, more well-traveled, and further along on the emotional and moral maturity scale. That’s my hope.