I was taught in Nursing School that when someone expressed a feeling to reflect it back. I tried this technique in the room of a patient who had just received a diagnosis of cancer. He was obviously angry, so I said, "You sound angry." He replied, "Hell yes, I'm mad and you nurses and doctors don't give a damn." I felt scared to have this anger directed at me and confused about what to say, so I mumbled an excuse and slipped out of the room leaving his angry words hanging heavily in the air.

For the next few years, I avoided angry patients as much as possible. I would perform my duties as a nurse cheerfully and efficiently and thought I was doing a great job. I was puzzled as to why I wasn't receiving more appreciation. After all, I constantly sacrificed my own needs to meet the needs of patients and administration, and I was efficient, tireless, strong, and had excellent skills. I worked much of the time in intensive care units where I was free to apply my skills and knowledge to keep patients alive, and where I didn't have to communicate much because the patients were intubated. I often was distressed because I wanted respect and acknowledgment, but no matter how hard I tried, these needs remained unfulfilled.

It was not until I began taking workshops in Nonviolent Communications that I began enjoying working with the "whole" patient. I found out that before I could deal effectively with angry patients, I had to first receive accurate understanding (empathy) for what caused the fear reaction in me that led me to avoid their anger. My own childhood pain in relation to my angry parents was heard accurately and clearly for the first time in my life. I was not told, as I had been in the past, to forgive my parents or that I should not have these feelings because my parents did the best they could. Next, I learned communication techniques for listening to what occurs inside a person and for expressing what was going on inside me. I had never learned how to deal with feelings because my family avoided expressing them until they built up and then explode with anger. Giving and receiving empathy became my passion. A whole new world opened up to me, and my view of the world changed. Thought patters that kept me stuck in a state of depression began to shift. My relationships changed drastically and I began enjoying my work as a nurse.

After this I began empathizing with my patients and I noticed how much they appreciated me and how much calmer they felt after having someone listen to them express their feelings. I realized how in the past I had blocked communication by offering advice or trying to fix the problem when I heard someone express a feeling. It was a relief to me to know that I didn't need to do anything when someone expressed feelings, and I became aware of how therapeutic it was for the patient when I was just present to share whatever was going on inside them.

The way we are taught to communicate in our society seems to be harmful to esteem and destroys intimacy. I saw an example of this type of non-therapeutic communication on national television recently. A woman was in the emergency room with her baby who had been injured when the car overturned.

Woman: "I only took her out of her car seat because she was choking."
Nurse: "You should never take a baby out of a car seat while the car is moving."
Woman: "When your baby is choking you just don't stop and think."
Nurse: "You should pull the car over and stop first."
Woman (crying and sobbing): "But she was choking."
Nurse: "Now, you need to calm down, you need to be calm for your baby because babies can sense when their mothers are upset."

I felt embarrassed for the nurse when I watched this and sad that the woman didn't get the empathy she needed. If the nurse had used empathy instead of judgment and advice, she would have learned what really was happening with this woman and could have the offered appropriate intervention to prevent such a tragedy from recurring. If therapeutic communication had been used, the following dialogue may have occurred:

Women: "I only took her out of her car seat because she was choking."
Nurse: "Are you feeling scared that you are being judged for what you did?"
Woman: "Ever since this happened people have been acting like the whole thing is my fault."
Nurse: "Are you angry about that and need some understanding about all the factors involved in making this happen?"
Woman (sobbing): "Yes, I feel so guilty already that when everyone is putting all the blame on me and I just feel horrible."
Nurse: "When you see what happened to your baby and hear people's reaction to it, I wonder if you feel ashamed?"
Woman: "Yes, I'm scared I'm not a good mother. It was so stupid of me to take her out of her car seat."
Nurse: "You really regret taking her out of the car seat while the car was moving and wish you had done it differently."
Woman (calmer now): "Yes, I wish I knew how to be a better mother. I would do anything for my baby. I love her so much."
Nurse: "Would you like information about community resources available to help you?"
Woman: "Yes, that would be helpful."

In the first example, the woman remained defensive and scared throughout the communication. This type of communication created such a defensive reaction in the woman that it is doubtful she would have been receptive to hearing about community resources that could help her. She may have lacked the tools she needed to be an effective parent, and without help, her baby may have ended up back in the emergency room. To be an effective communicator we must be willing to let go of judgment, accept our own imperfection, and have a desire to connect with others' feelings and needs.

To illustrate how I use therapeutic communication I offer the following dialogue, which occurred recently between a patient and myself:

Patient: "They found a new spot [of cancer] on my hip."
Me: "Are you distressed about that?"
Patient: "Yes, you know the doctors said that chemotherapy isn't going to help."
Me: "Are you feeling sad about that because you were hoping the chemo would work?"
Patient: "You know, that doctor doesn't know anything."
Me: "So you distrust it when you hear that the chemo won't work."
Patient: "There's a doctor at the University who's supposed to be good,"
Me: "You'd like to get a second opinion?"
Patient: "I can't get a ride to the hospital because my son is always too busy to take me places."
Me: "Are you angry because you would like your son to spend more time with you?"
Patient: "Yes; I never see him anymore, he has his own life."
Me: "Are you feeling lonely and would like to see him more?"
Patient: "We used to be so close and now he'll hardly speak to me."
Me: "Are you confused about what is going on with him that is preventing him from seeing you?"
Patient: "I know I wasn't the perfect mother, but this is no way to treat me."
Me: "So are you angry because you would like a different quality of connection with your son?"
Patient: "I know it wasn't easy for him, what with the divorce and all, but I did the best I could."
Me: "Are you feeling guilty and would have liked to protect him from suffering?"
Patient (crying): "Yes, I would have done anything to help him."
Me: "Are you feeling sad and wish that things could have been different?"

In working with patients it seems that the problem for which the patient is admitted to care is not really the issue with which the patient wants to deal. Supporting patients by using empathy allows them to go to the place inside and find the feelings that need to be expressed and enables the patient to deal with repressed feelings and painful issues. This kind of support is essential in helping patients either to recover from their disease process or to resolve painful relationships before they die.

There are four steps in the Nonviolent Communication paradigm for listening empathetically. The first is observing what patients are seeing, hearing, thinking, smelling, etc., that is creating their reaction. The second step is understanding how a patient feels when they observe the former. The third is recognizing the needs or the unmet needs of the patient. (It is important to realize that feelings are caused by needs or unmet needs and not by other people). The last step is learning what the patient wants to fulfill their needs. When working with patients I almost always assume that they are requesting empathy so I don't ask them if that is what they want. I've found that without having the skills of Nonviolent Communication most people cannot tell you what their request is and often are out of touch with their feelings and needs.

This is why as a nurse I need to identify what they are feeling and needing. I do this by translating their judgments and thoughts into feelings and needs. For example, a patient might say, "I can't do anything."

The response in my interpretation of such a phrase would be: "Are you feeling frustrated because you would like to be able to do more for yourself?" (1 not only identified the feeling in this statement but also translated the negative-I can't-into a positive "you would like").

Patients either will agree or disagree with my guess and go on to reveal the next layer of their feelings. They may say, "Yes, I'd like to do more for myself, but I'll never be able to do anything again." An empathetic response might be: "Are you feeling hopeless right now and need reassurance that your condition will improve?" A patient may say, "Yes, do you think I'll ever get better?" At this point, the patient is ready for information (I know that the 'request' has changed from empathy to information). The patient now can be educated about the disease process and what kind of rehabilitation is available. It may have been impossible for the patient to hear the information and absorb it if it were offered before the patient's feelings and needs were expressed.

A rule of communication is "empathy before education." When empathizing with patients, I continue to identify their feelings and needs until they stop speaking, sigh, or seem more relaxed. They may say, "I feel better." or "You are the only one I can talk to about these things." I believe that patients need to resolve whatever they are dealing with on an emotional level. The most help I can give is to translate their labels and judgments, which keep them stuck dealing with the issue on a mental level, to feelings and needs that take the energy into their bodies where it can help them move through the grieving process.
A practice exercise on translating judgments into feelings and needs will help illustrate this point. Suppose you are late in seeing a patient. The patient says, "You are the most inconsiderate person I have ever met." Write down how you would respond empathetically to this. (There is no right or wrong solution to this problem. The most important ingredient in giving empathy is your intention - your desire to connect nonjudgmentally).

I would respond to this statement by saying: "When you notice that it is 30 minutes past your scheduled appointment time (the observation) , you feel angry (the feeling) because you want consideration for your needs and time (the need), and right now you would like me to hear what is going on with you about this (the request)." This is theformal translation used when teaching the process of empathy. I usually shorten my response to: "Are you feeling angry because you would like more consideration for your needs." Once the observation and request are obvious to nurses, they don't need to be stated out loud. However, when first learning this new paradigm, it may be helpful to use all four steps.

The trick to giving empathy is to practice. Stick your neck out and try using this technique the next time you come across a patient who is in distress. You may find that your whole experience of nursing changes for the better.

Melanie Sears, MBA, RN is an official trainer for The Center for Nonviolent Communication, Melanie has worked in most areas of health care and currently works at in an inpatient psychiatric unit in Seattle. She uses NVC to connect with her patients and to transform the medical system's Command and Control culture to one of Partnership and Accountability. Melanie teaches NVC to the community at large and to businesses that want to change their existing structures into a life serving systems. To contact her, email her at awakegiraffe@yahoo.com.

A version of this article originally appeared in Home Healthcare Nurse ~ volume 14 ~ number 8 ~ 1996
Reprinted with permission by PuddleDancer Press. For more information on Nonviolent Communication visit www.NonviolentCommunication.com. For more information about the Center for Nonviolent Communication please visit www.CNVC.org.