I was taught in Nursing School that when someone expressed a feeling
to reflect it back. I tried this technique in the room of a patient
who had just received a diagnosis of cancer. He was obviously angry,
so I said, "You sound angry." He replied, "Hell yes,
I'm mad and you nurses and doctors don't give a damn." I felt
scared to have this anger directed at me and confused about what
to say, so I mumbled an excuse and slipped out of the room leaving
his angry words hanging heavily in the air.
For the next few years, I avoided angry patients as much as possible.
I would perform my duties as a nurse cheerfully and efficiently
and thought I was doing a great job. I was puzzled as to why I wasn't
receiving more appreciation. After all, I constantly sacrificed
my own needs to meet the needs of patients and administration, and
I was efficient, tireless, strong, and had excellent skills. I worked
much of the time in intensive care units where I was free to apply
my skills and knowledge to keep patients alive, and where I didn't
have to communicate much because the patients were intubated. I
often was distressed because I wanted respect and acknowledgment,
but no matter how hard I tried, these needs remained unfulfilled.
It was not until I began taking workshops in Nonviolent Communications
that I began enjoying working with the "whole" patient.
I found out that before I could deal effectively with angry patients,
I had to first receive accurate understanding (empathy) for what
caused the fear reaction in me that led me to avoid their anger.
My own childhood pain in relation to my angry parents was heard
accurately and clearly for the first time in my life. I was not
told, as I had been in the past, to forgive my parents or that I
should not have these feelings because my parents did the best they
could. Next, I learned communication techniques for listening to
what occurs inside a person and for expressing what was going on
inside me. I had never learned how to deal with feelings because
my family avoided expressing them until they built up and then explode
with anger. Giving and receiving empathy became my passion. A whole
new world opened up to me, and my view of the world changed. Thought
patters that kept me stuck in a state of depression began to shift.
My relationships changed drastically and I began enjoying my work
as a nurse.
After this I began empathizing with my patients and I noticed how
much they appreciated me and how much calmer they felt after having
someone listen to them express their feelings. I realized how in
the past I had blocked communication by offering advice or trying
to fix the problem when I heard someone express a feeling. It was
a relief to me to know that I didn't need to do anything when someone
expressed feelings, and I became aware of how therapeutic it was
for the patient when I was just present to share whatever was going
on inside them.
The way we are taught to communicate in our society seems to be
harmful to esteem and destroys intimacy. I saw an example of this
type of non-therapeutic communication on national television recently.
A woman was in the emergency room with her baby who had been injured
when the car overturned.
Woman: "I only took her out of her car seat because she was
Nurse: "You should never take a baby out of a car seat while
the car is moving."
Woman: "When your baby is choking you just don't stop and think."
Nurse: "You should pull the car over and stop first."
Woman (crying and sobbing): "But she was choking."
Nurse: "Now, you need to calm down, you need to be calm for
your baby because babies can sense when their mothers are upset."
I felt embarrassed for the nurse when I watched this and sad that
the woman didn't get the empathy she needed. If the nurse had used
empathy instead of judgment and advice, she would have learned what
really was happening with this woman and could have the offered
appropriate intervention to prevent such a tragedy from recurring.
If therapeutic communication had been used, the following dialogue
may have occurred:
Women: "I only took her out of her car seat because she was
Nurse: "Are you feeling scared that you are being judged for
what you did?"
Woman: "Ever since this happened people have been acting like
the whole thing is my fault."
Nurse: "Are you angry about that and need some understanding
about all the factors involved in making this happen?"
Woman (sobbing): "Yes, I feel so guilty already that when everyone
is putting all the blame on me and I just feel horrible."
Nurse: "When you see what happened to your baby and hear people's
reaction to it, I wonder if you feel ashamed?"
Woman: "Yes, I'm scared I'm not a good mother. It was so stupid
of me to take her out of her car seat."
Nurse: "You really regret taking her out of the car seat while
the car was moving and wish you had done it differently."
Woman (calmer now): "Yes, I wish I knew how to be a better
mother. I would do anything for my baby. I love her so much."
Nurse: "Would you like information about community resources
available to help you?"
Woman: "Yes, that would be helpful."
In the first example, the woman remained defensive and scared throughout
the communication. This type of communication created such a defensive
reaction in the woman that it is doubtful she would have been receptive
to hearing about community resources that could help her. She may
have lacked the tools she needed to be an effective parent, and
without help, her baby may have ended up back in the emergency room.
To be an effective communicator we must be willing to let go of
judgment, accept our own imperfection, and have a desire to connect
with others' feelings and needs.
To illustrate how I use therapeutic communication I offer the following
dialogue, which occurred recently between a patient and myself:
Patient: "They found a new spot [of cancer] on my hip."
Me: "Are you distressed about that?"
Patient: "Yes, you know the doctors said that chemotherapy
isn't going to help."
Me: "Are you feeling sad about that because you were hoping
the chemo would work?"
Patient: "You know, that doctor doesn't know anything."
Me: "So you distrust it when you hear that the chemo won't
Patient: "There's a doctor at the University who's supposed
to be good,"
Me: "You'd like to get a second opinion?"
Patient: "I can't get a ride to the hospital because my son
is always too busy to take me places."
Me: "Are you angry because you would like your son to spend
more time with you?"
Patient: "Yes; I never see him anymore, he has his own life."
Me: "Are you feeling lonely and would like to see him more?"
Patient: "We used to be so close and now he'll hardly speak
Me: "Are you confused about what is going on with him that
is preventing him from seeing you?"
Patient: "I know I wasn't the perfect mother, but this is no
way to treat me."
Me: "So are you angry because you would like a different quality
of connection with your son?"
Patient: "I know it wasn't easy for him, what with the divorce
and all, but I did the best I could."
Me: "Are you feeling guilty and would have liked to protect
him from suffering?"
Patient (crying): "Yes, I would have done anything to help
Me: "Are you feeling sad and wish that things could have been
In working with patients it seems that the problem for which the
patient is admitted to care is not really the issue with which the
patient wants to deal. Supporting patients by using empathy allows
them to go to the place inside and find the feelings that need to
be expressed and enables the patient to deal with repressed feelings
and painful issues. This kind of support is essential in helping
patients either to recover from their disease process or to resolve
painful relationships before they die.
There are four steps in the Nonviolent Communication paradigm for
listening empathetically. The first is observing what patients are
seeing, hearing, thinking, smelling, etc., that is creating their
reaction. The second step is understanding how a patient feels when
they observe the former. The third is recognizing the needs or the
unmet needs of the patient. (It is important to realize that feelings
are caused by needs or unmet needs and not by other people). The
last step is learning what the patient wants to fulfill their needs.
When working with patients I almost always assume that they are
requesting empathy so I don't ask them if that is what they want.
I've found that without having the skills of Nonviolent Communication
most people cannot tell you what their request is and often are
out of touch with their feelings and needs.
This is why as a nurse I need to identify what they are feeling
and needing. I do this by translating their judgments and thoughts
into feelings and needs. For example, a patient might say, "I
can't do anything."
The response in my interpretation of such a phrase would be: "Are
you feeling frustrated because you would like to be able to do more
for yourself?" (1 not only identified the feeling in this statement
but also translated the negative-I can't-into a positive "you
Patients either will agree or disagree with my guess and go on
to reveal the next layer of their feelings. They may say, "Yes,
I'd like to do more for myself, but I'll never be able to do anything
again." An empathetic response might be: "Are you feeling
hopeless right now and need reassurance that your condition will
improve?" A patient may say, "Yes, do you think I'll ever
get better?" At this point, the patient is ready for information
(I know that the 'request' has changed from empathy to information).
The patient now can be educated about the disease process and what
kind of rehabilitation is available. It may have been impossible
for the patient to hear the information and absorb it if it were
offered before the patient's feelings and needs were expressed.
A rule of communication is "empathy before education."
When empathizing with patients, I continue to identify their feelings
and needs until they stop speaking, sigh, or seem more relaxed.
They may say, "I feel better." or "You are the only
one I can talk to about these things." I believe that patients
need to resolve whatever they are dealing with on an emotional level.
The most help I can give is to translate their labels and judgments,
which keep them stuck dealing with the issue on a mental level,
to feelings and needs that take the energy into their bodies where
it can help them move through the grieving process.
A practice exercise on translating judgments into feelings and needs
will help illustrate this point. Suppose you are late in seeing
a patient. The patient says, "You are the most inconsiderate
person I have ever met." Write down how you would respond empathetically
to this. (There is no right or wrong solution to this problem. The
most important ingredient in giving empathy is your intention -
your desire to connect nonjudgmentally).
I would respond to this statement by saying: "When you notice
that it is 30 minutes past your scheduled appointment time (the
observation) , you feel angry (the feeling) because you want consideration
for your needs and time (the need), and right now you would like
me to hear what is going on with you about this (the request)."
This is theformal translation used when teaching the process of
empathy. I usually shorten my response to: "Are you feeling
angry because you would like more consideration for your needs."
Once the observation and request are obvious to nurses, they don't
need to be stated out loud. However, when first learning this new
paradigm, it may be helpful to use all four steps.
The trick to giving empathy is to practice. Stick your neck out
and try using this technique the next time you come across a patient
who is in distress. You may find that your whole experience of nursing
changes for the better.