Cognitive empathy

Cognitive empathy (i.e., rationalization or perspective-taking) is closely related to the popular expression: “Before you judge someone, walk a mile in their shoes”. In this case, a nurse may be cautioned to understand the patient’s perspective before deciding on the underlying causes of the patient’s own behavior. As you have likely learned some time ago, cognitive empathy requires nurses to evaluate the patient’s perspective in an objective manner. Cognitive empathy, therefore, is the most discussed form of empathy employed within most psychiatric and clinical interviewing.

To understand what it is like to be in ‘another person’s shoes’, the nurse must first develop cognitive skills to accurately understand the patient’s perspective (Howick et al., 2018).

This skill is known as ‘perspective-taking’, or what is required to ‘walk a mile’ in the patient’s shoes. Unlike emotional empathy, cognitive empathy doesn’t necessarily require the nurse to experience the patient’s emotional experience. The nurse just has to understand the patient’s perspective. Cognitive empathy is a rational process, and thus seen as more objective than emotional empathy (Martingano & Konrath, 2022).

Rationalization as an approach to clinical interviewing was first pioneered in 1895 by Freudian psychoanalysts who demanded strict adherence to objective thinking processes when evaluating the patient’s internal thoughts and experiences (Herzog, 2016). While objective analysis of a patient’s experience was helpful to the development of psychoanalysis, this perspective has become part of nursing practice. Like most health professionals, nurses are often trained to maintain distance from their patient’s experience to maintain objectivity (Herzog, 2016).

These assumptions carry forward to modern clinical practice, where empathy is often described as a purely cognitive (or thinking) process (Flasbeck et al., 2018).

What would Jean Watson do?

It is important to note that nursing theorists have since expanded the ideals of empathy to include concepts such as presence and emotion sharing. Despite these developments, nursing theorists still value cognitive empathy skills as an important part of nursing practice (Wright, 2021). Cognitive empathy, however, goes far beyond the ideals of active listening.

Mercer and Reynolds (2002) argue that nurses possess three key cognitive empathy skills, including:

Understanding the patient’s situation, perspectives, and feelings.
Impartially reflecting understandings back to the patient, confirming the accuracy of the listener.
Acting on the patient’s understandings in a helpful way.

Did You Know?!?

Cognitive empathy requires strong executive functioning skills. Perspective taking – a form of cognitive empathy – results from continuous activation of the prefrontal cortex and the supramarginal gyrus (Kogler et al., 2020). These brain regions are largely responsible for executive functions, such as decision-making.

Clinical Skill: Paraphrasing

A nurse often paraphrases what patients have said to confirm their understanding.

When using this skill in clinical practice, however, be careful not to ‘parrot’ back the exact words that the patient says. The nurse also must be careful to provide an accurate summary of what the patient said, not filtering parts of the patient’s story that may be convenient for the nurse to revise or ‘edit out’ of the conversation.

Let’s consider this example:

Patient: (looking around the room, visibly distressed) Do you see the snakes here? This place… not good. Not good at all. Nurse: (trying to reassure the patient) You’re feeling anxious right now. Don’t worry! Patient: (more agitated) No, you don’t understand! The snakes … Nurse: (paraphrasing incorrectly) I see that you’re feeling upset. Let’s try to focus on staying calm, okay? Patient: (frustrated and panicked) What’s wrong with you?!? I need to leave… now! Nurse: (editing parts of the patient’s lived experience) I understand you’re frightened. Let’s take some deep breaths together.

In this simulated conversation, the nurse makes a common error.

What would you change about how this nurse responded?

While it may be important to avoid confronting or directly challenging patients experiencing psychosis, it is ill-advised for the nurse to calm the patient without acknowledging the patient’s lived experience. The patient’s distress can increase if they feel misunderstood or ignored. To understand what it is like to be in ‘another person’s shoes’, the nurse must first be open to learning more about the patient’s experience.

What might happen if the nurse said this instead?

Nurse: (trying to reassure the patient) I’m sorry … I can’t see the snakes myself, can you help me understand what doesn’t feel safe about this place, right now?

In this revised initial response, the nurse acknowledges a ‘slice of truth’ in the patient’s lived experience. They are also careful not to confront or confirm the patient’s hallucination. This would likely encourage the patient to share more information about their experience.

Clinical Skill: Perspective-taking

To accomplish cognitive empathy, the nurse must first distinguish between their own emotions and those of other people (Engelen et al., 2023).

Perspective-taking is an important cognitive skill that is often overlooked. Due to cognitive bias, most health professionals assume they fully understand a patient’s perspective (mind-reading) when in fact the patient feels misunderstood (Bernardo et al., 2018; Moreno‐Poyato & Rodríguez‐Nogueira, 2021). This common cognitive error is referred to as self-serving bias.

Self-serving bias: Refers to a normal thought process that becomes distorted by the tendency to perceive oneself in a favorable manner.

One cognitive skill required for perspective-taking is something called theory of mind.

Theory of mind allows people to recognize differences between their own perspective versus other people’s perspectives (Keysar et al., 2003). Imagining the other person’s perspective provides added context for rational decision-making (Martingano & Konrath, 2022) and facilitates a more accurate understanding of the patient’s emotional state (Israelashvili et al., 2020b).

But, how can a nurse improve their thinking about the patient’s perspective?

One method to adopt a more holistic understanding of the patient’s perspective is to utilize narrative storytelling in practice. This can include changing the way report is done or adding a one-paragraph story about the patient’s life on their demographic profile page.

Narrative storytelling: A written or spoken story relating to the patient’s past experiences, or history. An effective narrative should be factitious, and accurately reflect a connected sequence of events in the patient’s life.

Muller et al. (2022) conducted a study examining the use of narrative stories in a nursing home caring for patients living with dementia. In this study, health care workers who read the patient’s life story reported significantly higher levels of empathy and confidence to care for the resident (Muller et al., 2022). Nursing staff also reported an improvement in the quality of the nurse-patient relationship, as the patients were significantly more cooperative and independent with care (Muller et al., 2022). This study highlights that cognitive empathy relies, in large part, on social schemas to understand the patient’s perspective.

Aside from framing clinical stories around the patient’s life history, Gilbert (2019) argues that nurses can also strengthen perspective taking through:

Self-awareness;
Reflective practice; and,
Goal-oriented planning.

In the next section, we will introduce some additional communication skills which facilitate perspective-taking in clinical practice.

Clinical Skill: Presence

Imagine talking to a friend who never listens to you and seems to ‘zone out’ just as you share an emotional story about your life. How would you feel? More importantly, would you continue sharing such personal and heart-felt stories with your friend?

If empathy feels like a warm blanket, presence is the blanket warmer.

Presence is a foundational skill required for cognitive empathy. Without presence, patients are likely to more likely to feel unheard and adopt a more defensive coping style (Fallahnezhad et al., 2023). Stockmann (2018) asserts that closeness requires the nurse to remain in close physical proximity or maintain high availability for the patient (also described as ‘being there’). Perceptions of closeness in the nurse-patient relationship facilitate open sharing of information, which is required for empathy.

In order to achieve presence during routine care, Finfgeld-Connett (2006) found that nursing staff had to demonstrate:

Sensitivity to the patient’s needs. Maintaining increased awareness and sensitivity to communication and feedback from the patient.
A holistic focus of care. The nurse should remain open to all clinically relevant aspects of the patient’s physical, psychological, and spiritual well-being.
Intimacy: Remaining highly available to the patient, which may include a high level of engagement in conversation or increased attention during clinical interactions.
Vulnerability: Maintaining an openness to talking about personal experiences or limitations of the nurse, also referred to as ‘therapeutic use of self’.
Adapting to unique circumstances: Remaining flexible and adaptable to changes in care needs, demonstrating unconditional positive regard and acceptance.

Clinical Skill: Non-oppressive, open approach

A nurse may demonstrate presence but soon find that the patient becomes guarded and uncomfortable from these ‘highly available’ (a.k.a. attentive) moments of care.

In this case, what might be causing discomfort for the patient?

While it is possible for the nurse to demonstrate presence, it is difficult to sustain open communication when the patient does not feel like their perspectives are accepted or valued by the nurse interviewing them (Carrero et al., 2022). Empathy thrives when there is a low power differential between the patient and the nurse (Holmström & Röing, 2010). However, in today’s environments for care, this can be hard to achieve.

To achieve openness, the nurse must accomplish the task of ‘being with’ the patient, taking time to honour the patient’s unique perspective (Stockmann, 2018).

A non-oppressive, open approach is best achieved by thinking about the common (or shared) humanity of the nurse and patient.

Common humanity may involve pausing briefly to consider how the patient is an important part of the greater whole of humanity (Fuochi et al., 2018).

Next, the nurse must accept that their patient is very much like them. Acknowledging at least one similarity between the nurse and patient – even if unrelated to the care task at hand – is likely to shift practice towards non-oppressive practice. Once accomplished, non-oppressive practice is associated with higher levels of nurse-patient empathy. For example, among specialized psychiatric nurses, reduced use of physical restraints on inpatient units is associated with higher levels of provider empathy (Yıldırım Üşenmez & Gümüş, 2021). In this way, a non-oppressive approach creates space for vulnerability in the therapeutic relationship (Finfgeld-Connett, 2006).

Let’s consider this example:

Patient: (Looking a bit anxious) Do you mind if I ask… I’m feeling nervous about my operation today. Nurse: (Nods understandingly) It’s completely normal to feel that way. Can you tell me more about what’s making you nervous? Patient: Well, I’m just worried about the pain and the recovery time. I’ve never had surgery before, and it’s overwhelming with work and everything. Nurse: I hear you. What worries you the most right now about having surgery?

The style of communication adopted by this nurse is uncommon within acute-care settings; however, it would be a welcome addition to most acute-care environments.
Notice how the nurse focusses on asking instead of telling in the above example.
Instead of telling the patient that they will be fine (reassurance), the nurse seeks evocation of the patient’s values by openly accepting their experience and asking more questions about it.

Evocation: Within motivational interviewing, evocation simply elicits and explores motivations, values, strengths, and resources the patient already has. A focus is placed on ‘uncovering’ the patient’s existing wisdom, instead of providing advice.

Providing endless advice to a patient can sometimes contribute to an ‘oppressive’ approach to care.
At the same time, providing advice only after listening to the patient’s barriers and values is likely to make advice much more powerful. Patient education is not so much a function of knowledge, but of empathy. It is important for nurses to offer advice that is helpful, at a time when it is most therapeutic for the patient to receive that advice. Some of the most persuasive nurses listen to patients, holding back on providing advice until the time is right. Those nurses have likely adopted a non-oppressive, open approach to care.