Emotional empathy

Earlier in this module, it was noted that emotional empathy (i.e., affective empathy or emotional contagion) was one of two types of empathy nurses may express. This type of empathy maintains a close connection to our emotions and internal body states (Eslinger et al., 2021).

Emotional empathy is best described as being sensitive to feeling other people’s emotions, noticing how our own emotions change in response to other people.

The ability to ‘transmit’ or ‘absorb’ emotions means that both the nurse and patient in a therapeutic relationship share some part of an emotional experience whether or not they personally experienced that event (Herzog, 2016).

This emotion sharing can be either active or passive:

Active emotion sharing:

The nurse shares a similar past or present emotional experience with the patient. Due to their similar (but different) experiences, the patient’s emotions are framed from the perspective of emotions directly experienced by the nurse.

Passive emotion sharing:

Back-and-forth communication builds mutual understanding, causing the nurse to simulate the patient’s emotional experience in their mind (emotional pathways).

(Herzog, 2016).

What are some advantages and disadvantages of emotional empathy?

Compared to simply thinking about the patient’s perspective, emotional empathy is interesting because it appears to motivate nurses to have deeper concern for patients in their care (Flasbeck et al., 2018). Let’s take the example of pain assessment.

One would think that increased nursing knowledge of pain would enhance a nurse’s ability to assess a patient’s pain; however, a nurse’s level of pain-specific knowledge does not necessarily predict their ability to understand the patient’s experience of pain (Dag et al., 2023). The recognition of distress appears to be moderated by emotional empathy. For example, nurses with higher levels of emotional empathy recognize pain behaviors more consistently and respond more proactively (Dag et al., 2023).

At the same time, having a shared understanding of the patient experience may also distort the nurse’s objectivity.

This process – known as intersubjectivity – is important as the nurse may no longer describe the patient’s underlying concern in an objective way after successfully adopting emotional empathy practices (Israelashvili et al., 2020a).

For example, nurses with higher levels of emotional empathy may become overly sensitive to small changes in the patient’s tone of voice or general sentiment and interpret those perceptions from their own assumptions (Esteve-Gibert et al., 2020). A nurse’s emotional state may also shift their perceptions of the patient and, in turn, their decision-making processes during care (Martingano & Konrath, 2022).

Watson’s Caring Theories: Emotional empathy in practice.
Since 1979, Jean Watson’s Theory of Human Caring has recentered ‘human caring’ at the foundation of nursing (Akbari & Nasiri, 2022). Watson’s theories have since advanced to assert that the nurse, patient and environment have “braided streams of consciousness” which hold the power of linking various emotional experiences together to create a single, shared experience of care (Perkins, 2021, p. 157). Watson claims that nurses care for patients by co-creating these shared understandings and experiences (Akbari & Nasiri, 2022). In this way, nursing care is best described a communal experience marked by human emotions of compassion and caring (Perkins, 2021). Watson’s work is well-supported by neurobiological research on empathy. For example, Batson (2022) asserts that empathy is the primary mechanism by which ‘caring’ emotional pathways are activated among almost all mammals. Nursing theorist Jean Watson also describes the sense of ‘conscious coherence’ as a key part of any successful nurse-patient relationship (Perkins, 2021). When caring for patients, emotional empathy is nothing to laugh at. This nursing phenomenon may generate powerful insights and a more intuitive awareness of how to care for patients in relationship with their environment.
Clinical Skill: Co-regulation and intersubjectivity
When nursing staff notice a shift in their own emotions after listening to the patient’s experience, emotional co-regulation and intersubjectivity is likely in play.
Nurses come to feel their patient’s emotions when they simulate (or re-create) the emotion in their own mind. Functional magnetic resonance imaging (fMRI) studies show that simply observing emotions in someone else can cause this shift in emotions (Eslinger et al., 2021). For example, a nurse who watches video clips of facial emotions would activate brain pathways related to the emotions they viewed, suggestive of a shift in their own emotions from simply observing these emotions in someone else (Wicker et al., 2003).
Intersubjectivity also affects the patient’s experience of care.
We often assume that the nurse passively ‘contracts’ emotions from their patients. While this can be true, it is also true that nurses can consciously model emotions (e.g. a calming presence) to produce transformational shifts the patient’s emotional experience of care. In one study, untrained food service volunteers significantly reduced patient experiences of loneliness, depression, and anxiety among home-bound patients by simply calling them and consciously conveying a reassuring presence over the phone (Kahlon et al., 2021).
But, how does the nurse simulate a patient’s emotions in their own mind?
Also known as ‘mirroring’, emotional empathy naturally occurs due to the action of something called mirror neurons (Holland et al., 2021).

Mirror neurons allow us to learn by observing other people (Bonini et al., 2022). For example, instead of practicing a skill, mirror neurons allow us to ‘copy’ others.

For example, a review of several studies on the topic found that smiling would activate the same emotional centres of the brain as simply imagining someone else smile (Bonini et al., 2022). It is hypothesized that people activate similar parts of their brain when they feel happy versus when they simply observe someone else express happiness (Engelen et al., 2023).
Emotional empathy does not produce an exact copy of another person’s emotions but rather a shared set of experiences (Martingano & Konrath, 2022). Health professionals sometimes experience these ‘shared emotions’ by embodying the patient’s experience (Armstrong, 2020). This intersubjective process sets the stage for a more intuitive nurse-patient collaboration. In many ways, intersubjectivity is exemplified by horses, who are known to react quite strongly to anxiety-provoking cues in their immediate environment.
Did You Know?!?
We can clearly ‘see’ emotional contagion, or the spread of emotions, in the brain.
Emotional empathy is marked by convergent activation of the dorsomedial prefrontal cortex (dmPFC) and the inferior frontal gyrus (IFG) in the brain. Both the dmPFC and IFG have many ‘mirror neurons’ which directly activate emotional networks, including pain pathways (Kogler et al., 2020).