THE NEED TO improve the quality of the health care work environment has been identified as a top priority.1 This is partly because of the growing understanding that quality of patient care includes patient satisfaction with that care. Staff satisfaction has been demonstrated to be a strong driver of patient satisfaction. Leader-member exchange, the relationship between leaders and staff, impacts staff satisfaction.2 As leader relationships with staff improve, staff satisfaction increases and turnover intention decreases.2 A qualitative study of more than 1000 frontline nurses identified empathy and trust as one of the 6 priority focus areas in leader communication.3 Yet, we have little understanding of how nurses perceive empathy and trust in their interactions with their leaders. We have learned through evaluation of patient satisfaction and nurse staffing data that even if a facility has adequate levels of nursing staffing, patient satisfaction scores are below the mean if a poor work environment is present.4 The important influence of the work environment has been supported in a study of 146 Veterans Affairs medical centers, where a relationship between employee satisfaction with the organization and patient safety was confirmed.5
In short, the health care work environment affects the safety of patients as well as employee satisfaction. That environment for employees is strongly influenced by their relationship with their leaders. Good relationships with leaders require excellent communication and a perception that leaders are empathetic to staff. This article describes a study undertaken to gain a baseline understanding of how nurses perceive leader empathy.
The definition of empathy can be elusive. Pedersen defines it simply as an “appropriate understanding of another human being.”6(p332) This understanding has been described as both a cognitive construct and an affective construct.7 People who are empathetic can “perceive what others feel,” “process the information,” and “respond effectively.”8(p10) Empathy underpins many leadership theories, including as a component of emotional intelligence.9
One concept analysis has advanced an understanding of empathy with 4 identifiable components: to be able to see the world as others see it; to be nonjudgmental; to understand another person's feelings; and to communicate an understanding of that person's feelings.10(p1165) Brown11 has taken the foundational understanding of empathy and strengthened it with an application to the role of leadership. Brown describes empathy as “one of the linchpins of cultures built on connection and trust.” She also defines it as “an essential ingredient for teams who take risks and show up for rumbles.”11(p136) Brown notes that empathetic responses are as unique as individuals. What may be effective for one may not be effective for another. There is a need to be present and to seek to understand, combined with an ability to individualize leadership responses. Brown describes the “Me Too” movement as an example of empathy in action. While individual experiences may be different, common feelings are shared.
In nursing, the practice of empathy (both empathy for others and self-empathy) is not well defined.12 In the practice setting, when nurses lack trust and a feeling of support, they may keep their opinions to themselves to avoid harming their reputations or losing the respect of their peers. To champion innovation and change in the health care setting, nurses must feel supported if they will take risks to try something new.12
EMPATHY AND LEADERSHIP
Nurse leaders bear responsibility for environments that foster safe and excellent patient care.13 Successful leaders are attentive to the well-being of employees and understand that patient and staff outcomes are intertwined.14 Empathetic leadership is essential in the development of successful, empathetic teams. Empathetic teams have a commitment to network with interprofessional colleagues and are socially sensitive.14 Riess and Neporent8 note that leaders without empathy may accomplish tasks for the short term but are rarely successful for the long term. In fact, the absence of empathetic leadership has both psychological and physiological impacts on followers. When a leader demonstrates empathy, there can be positive emotions resulting even from the receipt of negative feedback.15 Leadership empathy is a critical influence on staff retention and communication with teams.16,17 A relationship has been described between nurses' perceptions of the work environment and intent to leave the employment.18 While seeking to understand leaders' perceptions of the importance of empathy, Holt and Marques19 explored empathy with MBA students. Empathy was consistently ranked as the lowest leadership quality needed in responses from 5 different MBA student groups. Yet, empathy has been identified as a significant part of emotional intelligence9 as well as a mediator in authentic leadership.20
An evaluation of an estimated 275 000 nurses' experience of providing care (EC) identified a strong relationship between EC and patient outcomes. EC was focused in 3 areas: dignity and respect, having resources needed in the job to make a meaningful contribution, and receiving recognition and thanks. Results of nurses' EC were compared with patients' hospital-acquired conditions, specifically falls and pressure injuries, from more than 2500 nursing units.21 For every 1-point increase in the nurses' EC, an 8% reduction was reported in hospital-acquired pressure injuries and a 3% reduction in the relative risk (IRR) for falls.21 The need for nurses' work environment to include dignity, respect, meaning, recognition, and appreciation translated to improved safety for patients. Strong leader empathy skills are needed in a work setting to ensure nurses perceive dignity, respect, meaning, recognition, and appreciation.
EMPATHY AND EMOTIONAL INTELLIGENCE
Empathy represents a significant part of emotional intelligence (EI). The term “emotional intelligence” was introduced nearly 3 decades ago by Salovey and Mayer.22 The concept of EI is described as “the ability to engage in sophisticated information processing about one's own and others' emotions and the ability to use this information as a guide to thinking and behavior.”23(p503) In early models of EI, empathy is identified as a component of appraisal and expression of emotion.22 Goleman subsequently focused the work of Salovey and Mayer to describe EI as encompassing 5 skills: (1) self-awareness; (2) self-regulation; (3) motivation; (4) empathy; and (5) social skill.13(p43) The importance of EI to nursing leadership has been supported by a meta-analysis of the moderately strong relationship between EI and effective leadership (n = 48, r = 0.38).24 EI has been positively correlated with transformational leadership.25 Bellack and Dickow26 have identified relationships, underpinned by EI, as an important influence on leadership effectiveness.
This article describes a study done to measure nurses' perceptions of leader empathy (NPLE). The definition of perceived empathy is “an index of the extent to which a person perceives he or she is understood by another.”27(p328) Although the role of empathy in patient care has been explored, this study is unique in providing an understanding of how nurses perceive empathy in communication with leaders. The research question for the study was as follows: Are nurse leaders perceived to communicate with empathy when interacting with nurses?
A descriptive design was used to collect data from licensed practical nurses (LPNs) and registered nurses (RNs) across the United States. The study inclusion criteria focused on LPNs and RNs who self-reported an active nursing license in an area recognized by the National Council of State Boards of Nursing (NCSBN) and who were actively employed 24 months before completing the survey. Participation was not limited to frontline staff nurses. Nurses who identified themselves as managers could participate if they met these criteria. Experience management software was used to identify the minimum sample size of 385 (95% confidence interval with 5% margin of error).
Recruitment of study participants was initiated following approval by a university institutional review board. Participant recruitment included the provision of the study's link in flyers, social media, and a national journal advertisement. The link routed to the survey on Qualtrics. The first page provided the participant with details of the study, notice of an absence of compensation or other forms of incentives, and an option to consent to participate in the study. Electronic consent at the beginning of the survey was required to participate in the survey. A self-verification process for inclusion was included prior to the collection of demographic information.
The survey was developed to obtain information on nurses' perception of leadership empathy. It included standard demographic questions; the Barrett-Lennard Relationship Inventory: Form Other-to-Self Empathy (BLRI: OS-Emp+); and 2 qualitative questions related to perception of leader empathy. No identifying information was collected from the participants to protect anonymity. Demographic questions included nurses' professional role, years of experience, age range, gender, race, and years of experience with the identified leader.
Barrett-Lennard28 developed the BLRI: OS-Emp+, a 24-item instrument, to evaluate perception of empathy (12 items), level of regard (4 items), unconditionality (4 items), and congruence (4 items) within relationships. The investigators received permission from the instrument developers to distribute the tool. When scoring the BLRI: OS-Emp+, only the 12 items measuring perception of empathy from others were scored, although study participants responded to all 24 items. Respondents were asked to think about an identified leader in their workplace and respond to each statement (eg, “My leader usually senses or realizes what I am feeling”) on a 6-point Likert scale ranging from 1 (No, I strongly feel that it is not true) to 6 (Yes, I strongly feel that it is true). Higher scores indicate higher levels of perceived leader empathy. There were 6 negatively worded items that were reversed for scoring. Responses were summed to obtain a total score, ranging from 12 to 72. The original BLRI tool has been tested for validity over a 40-year period.29 Validity of the BLRI: OS-Emp+ has been obtained by prior studies using data from the original BLRI tool.28 The Cronbach α of the BLRI: OS-Emp+ (12 empathy items) within our study's sample was excellent (α = 0.96).
SPSS version 25 was used for data analysis of quantitative data. Data analysis included reporting descriptive statistics and mean differences with t tests and analyses of variance (ANOVAs). Mean comparisons were conducted to determine the presence of any differences between participant characteristics and perceived leadership empathy using the BLRI: OS-Emp+ as the dependent variable.
For purposes of this study, the participants were asked to identify one workplace leader who met the following criteria: (1) the leader is the individual that you identify as having management responsibility for your employment position; (2) the leader is the member of the management team you believe has an influence on your feelings about your job; and (3) the individual who is identified as a leader could have many different titles including, but not limited to, manager, supervisor, director, senior management, executive, or any other title.
Two open-ended questions followed the structured survey to allow for further clarification and examples that supported participants' beliefs. The following are the 2 questions participants responded to: (1) In situations when you are interacting with your leader, describe the behaviors that represent the presence of empathy from your leader; and (2) In situations when you are interacting with your leader, describe the behaviors that represent the absence of empathy from your leader. The responses to the open-ended questions are not explored in this article.
An initial 701 participants consented to participate in the study. From the 701 submissions, 687 participants met the study's inclusion criteria. In the end, a total of 536 submissions were complete and without missing data. The demographics and means are presented in Table 1. Notably, every state was represented in the sample. The participants selected a nursing role (ie, category of nursing) when completing the demographic data; however, some participants identified their title as “other” and provided the name of the position. Responses for nursing roles were grouped into the following categories based on similarities of duties and are located in Table 2.
Table 1. -
Demographic Information on Nursing Sample
||% of Total
||BLRI OS-Emp+ Mean Score
|Black or African American
|Years of nursing experience
|>3 to <5 y
Table 2. -
BLRI OS-Emp+ Scores by Nursing Role
||% of Total
||BLRI OS-Emp+ Mean Score
Abbreviations: BLRI OS-Emp+, Barrett-Lennard Relationship Inventory: Form Other-to-Self Empathy; LPN, licensed practical nurse; LVN, licensed visiting nurse/licensed vocational nurse; RN, registered nurse.
The overall mean score on the BLRI: OS-Emp+ was 41.61 (standard deviation [SD] = 14.32). Group mean and respective SD for each of the 12 items are located in Table 3. Perception of leadership empathy was averaged within each category of nursing roles and also listed in Table 2. One-way ANOVA determined no significant difference between nursing roles and perceived empathy (F4,530 = 1.09, P = .36). There was an observable mean difference between BLRI: OS-Emp+ scores of staff nurses when compared with management, faculty, and other (Table 2). In addition, there was an observable mean difference between advanced practice nurses compared with management, faculty, and other.
Table 3. -
Empathy Questions With Means and Standard Deviationsa
|2. The leader usually senses or realizes what I am feeling.
|4. The leader reacts to my words but does not see the way I feel. (Reverse coded)
|6. The leader nearly always sees exactly what I mean.
|8. The leader appreciates just how the things I experience feel to me.
|10. The leader does not understand me. (Reverse coded)
|12. The leader's own attitude toward things I do or say gets in the way of understanding me. (Reverse coded)
|14. The leader realizes what I mean even when I have difficulty in saying it.
|16. The leader doesn't listen and pick up on what I think and feel. (Reversed coded)
|18. The leader usually understands the whole of what I mean.
|20. The leader doesn't realize how sensitive I am about some of the things we discuss. (Reverse coded)
|22. The leader's response to me is so fixed and automatic that I don't get through to him/her. (Reverse coded)
|24. When I am hurting or upset, the leader recognizes my painful feelings without becoming upset him/herself.
Abbreviation: BLRI OS-Emp+, Barrett-Lennard Relationship Inventory: Form Other-to-Self Empathy.
aQuestions were taken from the BLRI: OS-Emp+.
An independent-samples t test determined there was no significant difference on reported BLRI: OS-Emp+ scores for males (M = 42.16, SD = 13.83) and females (M = 41.50, SD = 14.42) (t532 = 0.36, P = .72). A series of one-way ANOVAs determined no statistically significant differences between age brackets and reported BLRI: OS-Emp+ (F5,525 = 0.81, P = .54) and years of experience and reported BLRI: OS-Emp+ (F8,521 = 1.15, P = .33). Next, mean scores for the BLRI: OS-Emp+ were coded into 3 groups separated by 1 SD (Table 4). A near equal proportion of scores were identified in the groups labeled weak (n = 111; 1 SD below the mean) and strong (n = 114; 1 SD above the mean).
Table 4. -
Grouped BLRI OS-Emp+ Scores
||BLRI: OS-Emp+ Mean Score
|Weak 1 SD below mean
|Average 1 SD within mean
|Strong 1 SD above mean
Abbreviation: BLRI OS-Emp+, Barrett-Lennard Relationship Inventory: Form Other-to-Self Empathy.
Opportunities to improve staff nurse NPLE were further confirmed with qualitative findings. Key comments have been identified that support and give meaning to the BLRI: OS-Emp+ scores. For example, one weak NPLE (score of 12) was explained with the following comment:
He does not allow me to express my feelings or talk about issues in my own way without taking offense. He constantly refers to himself with his title. He does not recognize good, only bad. He parrots administrative jargon in a way that leads me to believe he neither understand it nor feels it.
Another participant with a low average NPLE (score of 31) noted:
I went to my leader after coding a newborn that did not go well because of unclear roles and lack of supplies. I stated that it was a long and emotional night because the newborn ended up dying and she replied, “It was a good learning experience.”
Alternatively, participants with strong NPLE scores identified good rapport and positive interactions. For example, one wrote, “In professional/work situations I feel I can go to her with any suggestion or concern and that my knowledge is appreciated” (score of 68), while another wrote, “My leader always looks me in the eyes when we interact. She repeats my statements when we speak as her way of affirming that she is listening and then responds with her own thoughts on the particular topic” (score of 64).
The results of this study provide a baseline understanding of the NPLE. Twenty-one percent of leaders were perceived by reporting nurses to have strong empathy in the workplace, 58% were considered average, and 21% were considered weak. The range established as average, however, was established on the basis of a mean (μ = 41.61) that is significantly below a maximum potential score of 72. The mean score would suggest an opportunity for improvement in the perception of leader empathy.
Interestingly, participants who self-identified themselves as nurse leaders perceived the empathy of their leaders to be higher than staff nurses' perceived empathy of their leaders. An observable difference was apparent in the responses of nurses in their first year of practice and those with 1 to 3 years of experience. The finding that NPLE diminishes in year 2 may reflect the transition challenges from formal orientation programs to less supported staff roles. Although notable differences are observed in the mean of nurses with 1 year of experience ( = 46.74, n = 35) and 1 to 3 years of experience ( = 41.36, n = 108), the differences were not statistically significant.
Implications for nursing leaders
The findings identify opportunities for nurse leaders to examine how nurses perceive interactions with their leaders, as well as gaps between their own perception of empathetic communication and the perception of their staff. Assessments of leadership can be accomplished with 360° assessment to gain an understanding of perceptions of frontline staff, supervisors, and peers.26
Fortunately, empathy skills can be taught. There is a wealth of information available (and being developed) by renowned leaders in the field of empathy. One such program uses the acronym E.M.P.A.T.H.Y., which conveys 7 key steps to help develop and improve empathy in interactions.8 The importance of eye contact, awareness of the feelings of others, awareness of the nonverbal cues, tones of communication, listening skills, and response awareness are stressed in the E.M.P.A.T.H.Y. model.8 Busy, distracted leaders may not be aware that their communication is creating a perception of a lack of empathy. Early assessment of empathy skills and leadership empathy training may bring value to the team.
Furthermore, management concepts such as design thinking30 and mindfulness in leadership31 support the growing understanding of the important role of empathy. Liedtka notes that approaches to design thinking have evolved to recognize the importance of empathy to ensure processes are “human-centered and user-driven.”30(p9) Liedtka further describes risk of an empathy gap, where leaders may perceive frontline staff to share the same perception of a situation when there is a difference in perception based on roles and experience. Using design thinking as a model to underpin implementing mindfulness in leadership may allow employees to actively engage in improving care.31 As nurse leaders seek creative solutions to improve patient outcomes, understanding the risk of egocentric empathy in communication must be considered. Egocentric empathy occurs when leaders consistently overestimate the similarity of their beliefs or values with the beliefs or values of others. This tendency may bias decision making.30 Accurately assessing staff perceptions of leader empathy provides a foundation for ensuring leadership communication is posed for success.
There are some study limitations worthy of note. First, only surveys that were completed were included in the quantitative analysis. This was to ensure accurate scoring and interpretation with the BLRI: OS-Emp+. Second, convenience sampling was used, employing various modes of invitation. The sampling efforts may have introduced selection bias.
The findings from the NPLE study provide a foundation for increased leader awareness of the need for empathy in communication. Empathy is a part of EI, a mediator in authentic leadership, and can be learned. Staff perceived leader empathy has the potential to improve staff and patient satisfaction, which prior evidence suggests may lead to reduced turnover and a higher quality of patient care.4 It cannot be assumed that nurses and those who lead them have the same perceptions about particular situations. While all are members of the same profession, each has a history of individual experiences. It is also probable that each has different information about a given issue. Understanding how nurses view their leaders' empathy is a step toward increasing communication and team cohesion among nurses in all roles and specialties. Empathy between leaders and staff could lead to greater empathy between nurses, regardless of role, leading to better experiences for all nurses and those who receive our care.
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