Characteristics of the participants
The characteristics of the participants are reported in Table 1.
Table 1
Characteristic of the participants (n = 26)
Nurses | Gender | Age | Education | Title | Work experience (years) | Region |
N1 | Female | 43 | bachelor’s degree | supervisor nurse | 2 | Shanghai |
N2 | Female | 36 | bachelor’s degree | supervisor nurse | 6 | Shanghai |
N3 | Female | 39 | bachelor’s degree | supervisor nurse | 5 | Shanghai |
N4 | Female | 41 | bachelor’s degree | senior nurse | 9 | Shanghai |
N5 | Female | 35 | master’s degree | supervisor nurse | 4 | Shanghai |
N6 | Female | 26 | bachelor’s degree | senior nurse | 3 | Changzhou |
N7 | Female | 33 | bachelor’s degree | supervisor nurse | 8 | Changzhou |
N8 | Female | 43 | bachelor’s degree | associate professor of nursing | 8 | Changzhou |
N9 | Female | 40 | bachelor’s degree | supervisor nurse | 8 | Changzhou |
N10 | Female | 51 | bachelor’s degree | professor of nursing | 8 | Lianyungang |
N11 | Female | 35 | bachelor’s degree | supervisor nurse | 3 | Lianyungang |
N12 | Female | 36 | bachelor’s degree | supervisor nurse | 3 | Lianyungang |
N13 | Female | 35 | bachelor’s degree | supervisor nurse | 1 | Lianyungang |
N14 | Female | 39 | bachelor’s degree | supervisor nurse | 1 | Lianyungang |
N15 | Female | 34 | bachelor’s degree | supervisor nurse | 1 | Lianyungang |
N16 | Female | 59 | bachelor’s degree | professor of nursing | 5 | Shijiazhuang |
N17 | Female | 50 | bachelor’s degree | associate professor of nursing | 4 | Shijiazhuang |
N18 | Female | 45 | bachelor’s degree | supervisor nurse | 3 | Shijiazhuang |
N19 | Female | 50 | bachelor’s degree | professor of nursing | 5 | Suzhou |
N20 | Female | 56 | associate’s degree (3 years) | supervisor nurse | 15 | Suzhou |
N21 | Female | 45 | bachelor’s degree | professor of nursing | 15 | Suzhou |
N22 | Female | 41 | bachelor’s degree | associate professor of nursing | 10 | Suzhou |
N23 | Female | 31 | master’s degree | supervisor nurse | 10 | Suzhou |
N24 | Female | 56 | associate’s degree (3 years) | senior nurse | 7 | Beijing |
N25 | Male | 32 | bachelor’s degree | supervisor nurse | 2 | Shenzhen |
N26 | Female | 48 | bachelor’s degree | professor of nursing | 10 | Nanjing |
Experience of “empathic labor” in hospice nurses
Categories were identified according to the theory of empathy and emotional labor. Each category had two to three sub-categories, which were exemplified by participants' narrative examples (see Fig. 1).
Category 1: “empathic labor” process
The first category shows the process of empathy for Chinese hospice nurses. It includes two sub-categories
Sub-category 1: cognitive empathy
The first sub-category, “cognitive empathy”, shows the ability of hospice nurses to perceive and understand terminal patients' emotions, behaviors, and experiences.
Empathic imagination: imagine the patients’ role and integrate into it
At the beginning of empathy, hospice nurses should imagine the patients’ role and integrate it since they first visit the patients, which is the basis of establishing a trusted nurse-patient relationship.
“When I empathize with terminal patients, I will first integrate into the role of patients and their families.” (N16)
Under these circumstances, to better convey empathic care to patients, nurses will change their roles according to different empathic objects.
“If you want to enter the patients' heart when empathizing with them, you should constantly change your role and remind yourself that you are not just a medical staff.” (N19)
Empathic consideration: consider problem from perspective of patients
Because of their suffering from illness and approaching death, most dying patients have different mentalities and behaviors from ordinary people. Many hospice nurses stated that they can empathize with patients by considering the problem from the perspective of the patients and understanding patients’ thoughts and behaviors.
“My biggest professional characteristic is that I am good at putting myself in the patient's position and thinking about many things. You can imagine that if it's our relatives or ourselves lying in the hospital bed, what do we want others to do to me?” (N3)
Empathic perception: perceive patients’ experiences and discover their needs
Furthermore, some nurses indicated that they could even perceive the pain of patients suffering from illness, just as if they had experienced it. Therefore, they can discover and analyze patients’ real needs at a time when they directly experience patients’ inner world and then will be eager to help patients alleviate their pain.
“When I empathize with patients, I have the same sense as if I had gone through their situation personally, that is, I can perceive the pain of patients in all aspects, including psychology, physiology, and so on.” (N21)
“I can't bear to see the patients and their families in that kind of miserable pain and helplessness, I want to do everything possible to help them.” (N15)
Sub-category 2: affective empathy
The second sub-category, “affective empathy” is the ability of hospice nurses to emotionally attune to or resonate with the patients' experiences. According to the theory of emotional labor and the research data, the emotional response of nurses in the process of empathy with patients will show three different expressions, including natural empathy, surface empathy, and deep empathy.
Natural empathy
Natural empathy means that no emotional conflict exists in the process of empathy between hospice nurses and patients, and the emotional response of nurses is true and natural. When natural empathy occurs, nurses can meet the requirements of professional norms without adjusting their emotional responses.
According to the field data from Lianyungang, one of the notes was recorded as, “Today is the Lantern Festival. However, the patients were unable to reunite with their families because of the COVID-19 prevention and control. To let the patients leave no regrets at the end of their life, nurses cooked dumplings and sent them to the patients’ bedside to for celebrating the festival with the patients. Nurses’ holiday companionship conveys the warmth of ‘home’ to the hearts of patients. The whole process is full of happiness, and the emotional response of nurses is natural and unmodified.”
Surface empathy
When there is a conflict between nurses and patients in the process of empathy, some nurses' emotional responses will take the form of surface empathy. For hospice nurses, who always face negative emotional events from patients or the working environment, our study found that in this empathic expression, nurses have to passively inhibit their emotional release, thus making their explicit behavior and emotional response such as voice, expression, and action conform to professional norms; however, their internal emotion and sense of value have not changed. This surface empathy of hospice nurses can manifest in the following two situations in this research.
One situation is that when hospice nurses passively accept a bad temper from patients, they will choose to hide their true feelings and try their best to cater to the feelings of the patients, so they will show appropriate explicit emotions that are inconsistent with their inner feelings.
Field notes as follows, “Nurse N8 could keep calm and pretend not to be angry for a moment while she encountered the patient's bad temper. However, she felt that this patient was unreasonable when she returned to the nurse station, and in fact, she felt very wronged.”
According to the research findings, another situation is that our hospice nurses face a group of dying patients and may face the emotional impact of the patients’ death at any time. This working environment is inconsistent with their original professional belief of "saving the dying and healing the wounded". Therefore, when some nurses face sob stories during the process of empathy with patients, they may pretend to be calm, endure sadness, or even force a smile until the end of the care process.
“Sometimes, if the symptoms of my patients are not well controlled, although I can show calm and insist on completing the nursing work while caring for patients, I am very depressed and want to cry with them.” (N24)
Deep empathy
In this study, deep empathy also occurred when there was a conflict between nurses and patients in the process of empathy. The difference is that nurses who can deeply empathize with patients can often actively adjust their inner emotions, understand and help patients from the heart, and respond to negative emotional events with a rational and professional attitude.
“Patients’ bad temper is only temporary, don't be angry about it and argue with them. I can treat patients’ anger more objectively and rationally during the deep empathy process… There must be a reason why the patients get angry, and we should discover their deep needs through empathy with them, rather than just seeing the appearance of the patient losing his temper.”(N23)
“Patients’ bad attitude is not against me but is more of a dissatisfaction with the disease and the cruelty of the world. So I can understand their feelings, and enter their inner world through empathy.”(N25)
Meanwhile, we also found that nurses with deep empathy can engage in the altruistic behavior of spontaneously helping patients with practical actions according to the perceived needs of the patients.
“My patient was dying, and I perceived that what he most wanted to see was his son abroad. However, his son was still isolated because of the COVID-19 epidemic. I used many methods to help them meet, including communicating with the epidemic prevention and control department to discuss the isolation time of my patient's son, accompanying and encouraging my patient, helping them to have a video call, etc.”(N20)
Category 2: “empathic labor” outcomes
According to the participants, they have different outcome experiences for “empathic labor”, and in general, we can summarize those as positive and negative outcomes.
Sub-category 1: positive outcomes
Most participants indicated that they could get inspiration from patients’ life experiences during the empathy process, thus having a deeper understanding of the true meaning of life and death and having beneficial experiences in their professional ideologies and life values.
Sense of professional achievement
Empathy can help nurses better understand patients’ life experiences and perceive patients’ needs, and their altruistic and creative behavior will be stimulated and can provide more comfortable care for patients; thus, patients’ caring needs can be more satisfied.
“With empathy, I found that this patient cared about her hygiene very much and didn't like our oral care liquid and even resisted it. For that reason, I consulted the literature and relevant experts, and finally made flower tea into oral care solution to let her feel more comfortable.”(N11)
Therefore, nurses can improve their nursing quality, and their nursing work can be approved by patients and caregivers. Finally, they can realize their professional value and gain a sense of professional achievement at the end of a nursing process.
“Now I can establish deep feelings with my patients through empathy. They want to tell me anything, and their caregivers also like and trust me.”(N3)
“It is very meaningful when the patient says ‘thank you’ to me before he closed his eyes, so I think it is greater to accompany dying patients with empathy, which will bring me a certain sense of achievement.”(N10)
Get reverse emotional caring behavior from patients
Our findings revealed that the empathy path between nurses and patients can be bidirectional, which means that nurses’ empathy can lead to patients’ reverse emotional caring behavior, including considerate words and supportive actions.
“Patients can understand everything I do for them when I establish an empathic bond with them. Meanwhile, they can even comfort me, understand me, help me and tolerate me. In order not to disturb me and reduce my workload, they do what they can do by themselves.” (N7)
In addition, this reverse emotional caring behavior can promote the spread of altruistic culture in society, and produce a self-transcendent function.
“Most families were greatly impressed by the concern we had shown them during the empathy process, many of them want to support us reversely, and some even come to our ward as volunteers to care for more dying people.” (N22)
Enrichment and growth from personal life experiences
Most nurses indicated that they can benefit and learn from the life experiences of the patients they cared for through empathy, which is conducive to their self-growth and promotes their outlook on life values.
“Now I have become more able to calmly face life and death, more open-minded and indifferent to fame and wealth since I went through too many stories about patients’ death.” (N10)
Some nurses expressed that they became more able to cherish their life and family and willing to spend time with and care for their family members.
“I cherish what I have now, care more about my family, and respect the meaning of my life.” (N12)
Sub-category 2: negative outcomes
However, our findings found that when nurses consider problems from the perspective of the patients’ roles, they will also fall into patients' negative emotions, resulting in certain emotional trauma.
Negative emotional contagion
Some participants said that they were easily infected by patients’ bad emotions during the emotional communication process and came into bad moods such as sadness and loss. As time passed, their emotions became vulnerable and fragile for suffering from those sad events for a long time.
“When I saw this child, I suddenly thought of my child, and at that time, I couldn't control my tears when I saw her suffering from the illness.” (N11)
“I was immersed in this lost mood for several days during the period when my patients died. I even felt more depressed and thought of him when I walked to the door of his ward.” (N25)
However, because of the particularity of hospice work, some nurses expressed that it is difficult for them to find ways to pour out their bad emotions, and most of them chose to endure these bad experiences. In the long run, this will even cause them to have psychological diseases such as depression.
“My family and friends don't want to listen to my experience of hospice work, so I won’t tell them so as not to upset them.” (N12)
“I really can't find a way to relieve my mood, and now I also feel a little depressed.” (N20)
Negative emotion involved in life
Meanwhile, when nurses cannot adjust those negative emotions in time, they may be unable to separate from the empathy situation and have emotional trauma. Furthermore, some nurses may unconsciously bring those bad emotions into their lives, which can destroy the harmony of their family relations and reduce the quality of their personal lives.
“Finally, the patient still died in pain and I couldn't get out of the empathy state with him for a long time. I've seen several psychologists, but it was useless. I even went to Japan to take a hot spring to relax.” (N16)
“If those bad emotions can't be released, I will still be in a bad mood when I get home. I even can't help losing my temper with my family sometimes, so my family relations will also be affected.” (N9)
Empathic fatigue
Nurses need to spend much time accompanying and listening to patients during the empathy process; however, nurses’ long-term emotional investment will easily cause them to lose sensitivity and motivation to empathize with others. In the long run, it is easy to cause nurses to feel empathic fatigue and even empathic exhaustion.
“The state of patients willing to give their life history to you without hesitation cannot be achieved in a day or two. For example, you may say 10 words before the patient is willing to answer you at the beginning of nursing work…I will control myself not to have the self-emotions opposite to my patient and find ways to go into the patient’s heart. Therefore, when I follow a patient from beginning to end, I really feel exhausted and I have no patience to stick to it.”(N15)