Utterances used by the therapist to demonstrate understanding of the thoughts, feeling, or behaviour of the patient are identified as “cognitive empathy” . An instance of cognitive empathy was shown in extract 1 where the nurse offers a candidate understanding of what the patient is feeling. Extract 1 is taken from an interaction between a female nurse and a male patient who suffered from pneumoconiosis. This session occurs when the nurse makes her rounds. In this sequence, it is the nurse that initiates an exchange by making an assumption that the patient seems not to be happy. The nurse has arrived at this assumption through the observation that the patient has a negative facial expression. In line 2, the patient makes an explanation why he does not look happy. In the ensuing talk, the nurse responds to the patient’s troubles talk with an acknowledgment token“En”(uhm) repeated twice, displaying his supportive orientation toward the troubles talk in line 2. Immediately following this, the nurse’s demonstration of cognitive empathy occurs in line 4, where the nurse offers an alternative way to pin down the patient’s ongoing feeling, that is, replacing ‘cannot feel happy’ with ‘feel down’. In this sense, the nurse attempt to provide a more specific description of the patient’s unhappiness following the onset of disease and thus seems to have more accurate knowledge about the contents of the patient’s ongoing feeling. In line 5, the nurse encourages the patient to keep a good mood which could contribute to his recovery. Using an agreement token “right”, the patient shows his acceptance of empathy and encouragement the nurse offers in lines 4 and 5. In this extract, it seems that the nurse accurately perceives and understands the patient’s feeling and communicates that understanding back to the patient successfully, thus displaying cognitive empathy.
01 Nurse: You seems not to be happy.
02 Patient:My health got (.) really bad, I cannot feel happy.
03 Nurse: Uhm uhm.
04 people feel down when they are (.) not in a good health,
05 but you should keep in a good mood that can help aid your recovery.
06 nurse: right
Extract 2 shows a sequence where the nurse displays a candidate understanding of what the patient is thinking. In line 1, the nurse suggests that the patient should not do that work again. In line 2, the patient responds with a full acknowledgment of the nurse’s recommendation, which can be shown by the fact that once he goes back home, he will change his job to another one. In what follows, the nurse gives the patient a supportive feedback on what he has said. In lines 4 and 5, the patient says that health is much more important than money and thus he will change his job after his hospital discharge, implying that the way for him to earn money was at the expense of his health. The nurse’s expression of cognitive empathy occurs in line 6, where she provides an upshot formulation of the patient’s preceding utterance. Several CA studies have suggested that formulation is one conversational action that regularly functions as a vehicle for empathetic responses [27,28,29]. In a formulation, one speaker (in this case, the nurse) shows his or her understanding of the other’s (in this case, the patient’s) preceding utterances by proposing a rephrased version of it . In this study, formulation refers to the act that nurses try to show a candidate understanding of what has just been said by clients. By means of formulation, the nurse rephrases the patient’s current thought that health is much more important than money. In line 7, the patient receives and acknowledges the patient’s expression of empathy by means of laughing. What the patient says in line 8 indicates that he shows high degree of agreement with the empathic response the nurse made in line 6.
01 Nurse: Don’t do that work again.
02 Patient: Uh, once I go back home, I will (.) change my job.
03 Nurse: Change it to another one, change it to another one.
04 Patient: Uh, health is much more important than money.
05 and I will change-change my job after my hospital discharge.
06 Nurse: Health is a priceless wealth.
07 Patient: Ha ha ha.
08 It does not make any sense to earn much more money without health
Sharing empathy is understood as the sequences where the therapist displays that he/she has something in common with the patient, specifically, his/her personal opinions or experiences are similar to the patient’s ongoing situation and thereby the patient does not feel alone . In Extract 3, a patient who has trouble in sleeping is discussing his symptom with the nurse. The nurse initiates the topic by an indirect speech act, that is, she has heard that the patient had trouble in sleeping. The information about the patient’s sleep problem may come from the attending doctor or the medical record. In line 2, the patient offers a candidate understanding of the cause for his symptom. In line 3, the nurse first repeats the utterance produced by the patient in line 2. Here, it is an extreme case formulation “quite right”, justifying the patient’s self-assessment of the cause for his sleeping problem. Immediately following the justification, the nurse shows that she also has the same problem as the patient has, that is, she also has trouble in sleeping in that she works too much at night, thereby expressing ‘sharing empathy’. In this sense, by expressing a sense of shared understanding, the nurse may prevent the patient from feeling alone and isolated. Towards the end of line 4, the nurse chooses to use “We”, which is a “we-inclusive” pronoun, including both the nurse and the patient, which aims to shorten the psychological distance between them and bind them into a temporary alliance, contributing further to indicating her shared understanding of the patient’s problem. At this point, it can be seen that the nurse and patient are in perfect alignment with each other in terms of sleeping problem. It could be suggested that sharing empathy can strengthen the nurse-patient relationship and put them on equal footing.
01Nurse: I heard that you have not been (.)sleeping well, right?
02Patient: Uhm, (0.5) it may be connected with (.) working at night.
03 Nurse:Quite right, because of working at night too much, I also have sleeping problem.
04 We are prone to sleep problems due to working too much at night.
5 Patient: Right, right.
Affective empathy occurs in the sequences where the therapist shows that he/she partakes of the same feelings the client is personally experiencing at that moment . In the following extract, an instance of affective empathy is presented. In this instance, the patient has been hospitalized for almost one month. In line 1, the patient asks the nurse when he could be discharged from the hospital. In the same turn, he continues to say that he cannot eat well and sleep well, which indicates that he is annoyed over hospitalization. Here, the patient’s negative emotion hides behind the literal meaning of his utterance. Coulehan et al’s (2001) report that in some cases the patient present an indirect expression of suffering or emotion,which are embedded in quasi-factual statements . In this sequence, the nurse does not ignore the patient’s underlying concerns, but empathetically responds to his negative emotion. In lines 3–5, the nurse says that she experienced a similar troubling situation as the patient last year, namely, being hospitalized for three weeks. Thus, she could deeply understand that it is inconvenient for the patient to be in the hospital for a long time. It is clear that the nurse share the same feeling as the patient, namely, being uncomfortable in the hospital for a long time. In this way, the patient seems to describe it as ‘your pain in my heart’. This could contribute to help the nurse build emotional connections with the patient. The nurse thus expresses her empathy and partakes in the patient’s feelings. The patient’s “ye:ah” in line 6 serves to indicate that the patient has received the nurse’s expression of empathy and also functions as a confirmation of the nurse’s statement that she also feels inconvenient. After this, the patient continues to say an utterance “all things are not convenient”, showing that what the patient feels is consistent with the empathic statement the nurse made in line 3. It thus can be seen that communicating empathy is just as important as care delivery.
01 Patient: When could I (.) be discharged from hospital?
02 I cannot eat well and sleep well in the hospital.
03 Nurse:I were hospitalized for three weeks last year.
04 I could (.) deeply understand that it is downright inconvenient for you to be in.
05 the hospital for a long time.
06 Patient:ye::ah, all things are not convenient
The final type of empathy that will be presented and described here is that of ‘nurturant empathy’, which is characterized by the therapist being supportive, security-providing or totally attentive . In the following extract, an instance of nurturant empathy is demonstrated. In line 1, the patient tells the nurse that she worries about the surgery that will be performed tomorrow. The nurse follows up on this by stating that she feels assured because the doctor, Prof. Zhang, who will do surgery for her tomorrow, is a skillful practitioner. It appears that the nurse’s contribution conceives the patient’s concern as unreasonable and thus the nurse is confident about providing security to tomorrow’s surgery. In line 4, the patient uses two minimal responses “uh” and an acknowledgment token “that is right” to show her receipt of the nurse’s expression of nurturant empathy. In line 5, the nurse says that 300 patients similar to her condition have received successful surgeries in this department last year. The nurse attempts to convince the patient that she would just like the other 300 cured patients in performing her surgery. In this sense, drawing on the previous successful experiences of other patients, the nurse is very confident about the patient’s surgery. In other words, what the nurse states here contributes to displaying her optimistic stance toward tomorrow’s surgery, which in itself may achieve a therapeutic effect . The patient’s utterance “If so, I will not be worried about tomorrow’s surgery.” in line 7 can be seen as a favorable response to the nurse’s empathic utterance in lines 5 and 6, and as an indication of nurturant empathy as a good nursing strategy achieving good effect on the patient’s concern.
01Patient: I am going to (.) receive a surgery tomorrow. I am very scared.
02Nurse: Please be at ease, Prof. Zhang will perform the surgery (.) for you.
03 He is a skillful doctor
04Patient: Uhm uhm, that’s right.
05Nurse: 300 patients similar to your condition are at our department last year.
06 They all have received successful surgery
07Patient: Uh, (0.5) if so, I will not be worried about tomorrow’s surgery.