Social Behavior Research and Practice

Open journal

ISSN 2474-8927

Empathy: Challenges Experienced by Social Workers in the Healthcare Sector on the Island of Crete, Greece

Trigoni Maria*, Mikits Militsa and Mpanagi Evaggelia

Trigoni Maria, PhD

Head of Department of Social Services University Hospital, Crete, Greece; Tel. 6970889091; E-mail:


Despite the fact that researchers have different opinions about empathy, and give it different definitions,1,2,3 empathy is perceived as fundamental for social work practice.4 It is mentioned as one of the general guidelines by the way a social worker should act5,6 and communicate to create a positive outcome and patient experience.7 Empathy is defined as the understanding of the another person’s feelings8,9 as “The act of perceiving, understanding, experiencing, and responding to the emotional state and ideas of another person,”10 and as “The action of understanding, being aware of, being sensitive, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner”.11

Robert Vicher12 introduced the word “einfuhlung” meaning ‘in feeling’ or ‘feeling into’; “feeling and seeing through.” Empathy is referred as the “talent” of entering the personality of others and experiencing their experiences.13

The interest in the concept of empathy and its role emerged in the 1960s and the 1970s, as researchers sought to study Carl Rogers’ view about the exploration of the unique therapeutic relationship.14 This research highlighted the importance of empathy in the relationship between therapist and patient, to improve doctor-patient relationship, to obtain better patient confidence in and compliance with treatment.15,16,17,18

There appears to be a consensus in the definition of empathy, namely, that an empathic person is able to understand, be aware of and know another person’s state, consciousness or condition.19,20

According to the literature, the concept of empathy in social work is important, as it improves outcomes,21 by developing a productive relationship between social workers and patients. It is a critical factor ineffective social work, quality of care, patient safety, and satisfaction.22

When social workers use empathy with patients, improved results are observed, and feel they are more effective in their roles.4 Empathy is at the core of the relationship among social workers and patients,23 as without it, successful outcomes might be difficult to obtain. Empathy is an innate human capability, and a major tool for professional social work greatly enhanced through words and body language.4,24 Holm explains that respect, attention, sense of ‘‘caring’’, empathy and professional knowledge are all parts of the mandatory/pre-requisite professional behavior of social workers.8

Lazo et al,18 found that social workers gave different descriptions of the concept of empathy, and its use with patients. Neumann in a German-Israeli research17,25 attempted to implement empathic training in healthcare students and found that it could produce significant improvement in empathy, and results in the improvement of the health provider-patient relationship. Such training would be important to include in the educational curriculum for social workers.

According to several studies26,27,28,29,30 the extensive use of empathy and compassion could result in a sense of fatigue among professionals. It is reported that social workers and health professionals using empathy and compassion towards patients with mental or physical trauma are at risk of developing professional fatigue or traumatic stress, implying that they could be at personal risk while using these skills.27,28,29,30 However, a study by Nilsson contradicted this finding and argued that there is no empirical evidence to suggest a relationship between empathy/compassion and professional fatigue. On the contrary, the use of empathy and compassion may contribute to a health professional’s ability to regulate his or her feelings.31

The purpose of this study is to explore how social workers in a health setting (a) perceive the role of empathy, (b) how they apply it in their experience, (c) what difficulties and obstacles they face in the use of empathy, and (d) what challenges are experienced in the healthcare sector in Crete.


Study Design

A qualitative approach was used to study the view of social workers in depth.32 The original sample targeted 14 social workers who were working in healthcare services. The sample that eventually participated in the survey was 12. One person refused to participate due to increased workload and another one was outside Crete due to weather conditions. The eligibility criteria were to be graduates of the Department of Social Work and to have worked in a health department over two years. Participants worked at: Heraklion University General Hospital (5), Venizelio Hospital of Heraklion (3), General Hospital of Chania “Agios Ioannis” (2) and Health Centers of the Prefecture of Heraklion such as Moires (1) and Arkalohori Health Center (1). The interviews were conducted one-on-one and took place from May to October 2016 in their workplace. All interviews were conducted in Greek.

Research Tool

Interviews were conducted with the use of a semi-structured questionnaire that had been used in a similar Swedish survey by Lazo et al, in a study titled, “Reflections on Empathy in Social Work Practice”.19 The interviews were flexibly guided by a list of topics including demographics profile, kind of work, as well as the concept of empathy (definition-meaning, difficulties, influence, ways of improvement). The original Swedish version was translated into Greek.

Ethical Issues

In order to carry out this study permissions were obtained from the Ethics Committee (5275/09-2016 with number 8922/04-07-2016) of the 7th Health District of Crete, and from each hospital’s Ethics Committee. Then, following a telephone conversation with the social workers where they were informed about the survey, a meeting was set for the interview.

Respondents signed a consent form with information about the purpose of the study and to ethical considerations. A tape recorder was used during the interview, with the consent of the participants, to ensure complete and reliable record. All data were encoded with a pseudonym during processing to ensure anonymity of the participants’ identity.32,33

Data Analysis

The research team performed content analysis to analyze the data.32,33 The interview recordings were transcribed verbatim. The information was classified into four thematic categories, where common elements were identified: 1) Concept of empathy; 2) Applying empathy within the Social Work practice; 3) Difficulties and obstacles in the implementation of empathy; and 4) Ways to tackle difficulties and challenges.


Demographics of Participants

All twelve (12) participants were working in the public health sector; ten (10) in a hospital, managing people mainly with physical health problems. Ten (10) of the participants were women, aged between 43-56-years, with a professional experience of about 6-34-years (Table 1).


Table 1. Demographics of Social Workers


 Age Sex Professional experience
SW 1




SW 2




SW 3




SW 4




SW 5




SW 6




SW 7




SW 8




SW 9




SW 10




SW 11




SW 12






The Concept of Empathy

The participants tried to describe how they perceived the concept of empathy. Common points involved performance. Everyone agreed that empathy is a social worker’s ability to recognize, understand and accept a patient’s perspective and problem in order to be able to provide appropriate support.

Two participants said that empathy is a professional’s ability to understand the feelings and the reality that the patient is experiencing, without being identified with him or her: SW 8: “I think it is the ability to understand the feelings of the patient, to be able to understand his or her own conceptual field, how he or she perceives reality without putting in your own elements…”.

One of the participants said: SW3: “Empathy for me means that I can get into the shoes of another person, without making these shoes mine”. One of the participants was unable to give a clear answer as he assumed that empathy was a complex notion. SW5: “…… I do not understand it very well…if it was clearer or something simpler… I cannot give you any answer. …..”.

Another view was expressed, as a combination of talent, theory and experience, embedded in the ethics of the profession. SW 9: “… I would say that it is a talent to be able to enter into the psychological composition of somebody. But let’s say it is a way of combining the theoretical direction of our specialty and the experience that is acquired…”.

One of the participants believes that empathy is a characteristic of the professional’s personality and not a tool that is taught in University. SW 1: “I think it is also a characteristic of a personality that is something that you must have learned from a very young age. It is not a skill that is learned in university or school”.

In general, they described empathy as a process whereby a social worker tries to understand and feel the feelings of the patient by taking their perspective while at the same time holding the necessary distance that is needed in order to be able to help.

Applying Empathy Within the Social Work Practice

Care, interest, understanding, sensitivity were the major themes: Many of the respondents gave examples to describe the application of empathy. One of the participants chose to share the case of an elderly woman with serious health problems, abandoned by all her family members. After a lot of effort her family refused to cooperate, and Social Services undertook her post-hospital care. SW3: “If there was no empathy….. we would take her out of the hospital and forget about her. I would go to her house (…) we tried to save as much dignity as we could. We informed the Public Prosecutor about her loneliness and neglect, we got an order for placement in a nursing home, we followed all the necessary steps to get in, and we still keep in touch with the nursing home …”.

A common point was found in two participants (SW7 and SW11), who did not answer with specific examples, but said that empathy was due to experience, especially when dealing with something intimate. More specifically, the first one (SW7), due to long experience with patients with mental health problems, recognized the symptoms of their illnesses and could understand more easily how they felt, feeling closer to this category of patients. The second participant (SW11) stated that when patients face a problem that he has also gone through, such as unemployment, he is more “sensitive” since he experienced similar difficulties in the past and understands the situation of the person being served. However, he pointed out that this does not mean that he will help an unemployed person more than a sick person, but that it depends on there sources that are available.

Another participants (SW8) responded that in all cases it is necessary to use empathy. SW 8: “Generally, in difficult situations, when somebody has lost control, and you approach them with empathy, you can say,  I understand you, and I take your hand, and we are going through this togther slowly…”.

These examples show that empathic qualities are expressed in practice, in addition to and in combination with showing genuine interest in comprehending a patient’s problem.

Respect and acceptance: All participants agreed that in order for social workers to gain the confidence of patients, they should speak with honesty, show them that they accept and respects them, and uphold their dignity regardless of their problem.

According to SW 11 when social workers are clear and honest with patients, as well as treat them with dignity and respect, patients appreciate it because they feel heard with kindness. SW 11: “……. When you are clear with a patient and talk to him or her with courtesy and with respect (….), irrespective of his or her financial situation or social status, and you don’t treat him or her as inferior, that is what matters. You know, many times people say thank you just because you heard them and you talked to them with kindness”.

One of the social workers (SW8) argued that a patient knows that it is not possible to solve all his or her problems through the hospital or the healthcare center. But hearing it from an empathic professional it is often quite enough to calm down the patient. SW 8: “At this time the patient expects from you to give him or her the solution (…). But even the tone of your voice, how you welcome them, as well as the way you behave towards them…, it is enough to give them the chance to calm down”. SW3 argued that it is important for the patient not necessarily to find a solutions for his or her problem, but to know that he or she has been understood and accepted. Participant SW1 reported that a patient understands when the practitioner has empathic ability, and this determines the quality of their relationship. SW 1: “I think yes. When the other person that stands opposite you understands that you understand how he or she feels, you feel how he or she feels, and participate in his or her emotion. This makes the quality of the relationship better”.

In order for patients to realize that the social worker can “put himself/herself in their position”, the practitioner should be honest and clear, not necessarily promise solutions, but inform them to what extend they can be helped. It gives patients the opportunity to express themselves, and be accepted without judgment.

Hearing and confirmation: Incidents referred to health services mainly deal with patients that have health problems requiring support and empowerment.

Two of the participants (SW3 and SW12) reported that in their cooperation with the patient, they use active listening without interfering and without hurrying to offer solutions and advice, but always treat them as individual cases. SW 12: “By listening carefully …. By seeing somebody as a special case.. you treat each person in a special way because every person manages problems in a different way. So, each person’s problem is individualized. You have to deal with it differently. So what I’m telling you is the individualization of each person”.

Also, two other social workers (SW4 and SW5) indicated the use of dialogue above all and that they try to mobilize patients to act, urging them to talk without pressing them. Three participants (SW2, SW9 and SW11) relied on helping patients to believe in themselves and the potentials they have. Through dialogue, using examples and coaching, they attempt to create trust and lead them to mobilize and act.

Hearing and confirmation through dialogue on the part of the specialist creates a climate of safety and care. SW12: “I think the most important way to increase empathy is to listen carefully to what the other person is telling us, to reflect on what we are hearing in order not to make quick decisions and to take some quick action. Let us be better able to hear the other, with attention, so that any decision we take or any direction we move in is after careful thought and reflection”.

Only when the practitioner listens carefully patients can feel understood, both in terms of what they say and what they feel. The answers and solutions social workers may provide is best when they are individualized where each case is treated with utmost respect and special attention without making quick decisions.

Non-verbal communication in empathy: All participants reported that they did not use gestures towards patients in order to show empathy even though a participant SW6 noted that they may have a positive effect. SW 6: “I do not gesture because it is not of my character (…). Of course, I suppose that it helps in some cases, but it’s not my character”.

SW7 said that he tries to understand what a patient has, wants and needs, through visual contact. One of the participants (SW10) expressed a very different point of view. After working on his own ability of emotional recognition, which he considered very important, he managed to understand better the needs of a person who is asking for help. SW 10: “(…) and I do not get involved in the expression of compassion and so on. Recognition of emotion helps me recognize the patient’s need, and to define my relationship with him or her. I told a student yesterday, ‘Empathy is not the sympathy we show to someone.’ No, it is not the sympathy. It has nothing to do with sympathy. My point is that you need to know yourself well enough to help others. Emotional recognition for me is very important”.

Two of the participants (SW1 and SW8) believe that many factors influence the relationship with patients, such as dialogue, behavior, and body language, and they manage each case accordingly.

By listening carefully to patients, understanding their weaknesses, using dialogue and a well developed professional behavior, social workers seem to feel confident in their ability to help. None of the respondents mentioned the use of gestures to show empathy towards the client.

Difficulties and Obstacles in the Implementation of Empathy

Burnout and empathy: There are several barriers and difficulties to empathy’s implementation. A major difficulty is burnout and the pressure experienced by social workers.

Three participants (SW1, SW6, and SW11) said that it was difficult to show empathy when they felt tired, depressed, or simply not well, and that it is not easy to approach a patient when they feel exhausted.

Three other respondents had similar responses (SW5, SW11 and SW12). In some cases, due to experience, they focus on practical procedures as they feel they do not need to do anything but give instructions, so their long experience sometimes leads them to operate mechanically without empathy. SW 11: “Many times, it is work experience … that you don’t have to get into the other person’s shoes. So, many times you do it mechanically and you need to be careful, because they may have a special and unique problem… everyone is different. So, he or she may require a different handling”. Two of the participants (SW9 and SW4), agreed that there is no empathy in every incident.

Professional’s own mood seems the main obstacle, since he/she can be affected by his/her own professional fatigue, exhaustion and psychological pressure during work. The result is not being able to help patients. Long-term experience in a particular field with certain vulnerable groups tends to lead the social worker to operate mechanically by often suggesting past solutions and instructions, and avoid approaching patients emotionally, ignoring the fact that every person and every problem is unique.

Difficulty in applying empathy to a particular patient group: Two of the participants (SW2 and SW7) said that they have difficulty being empathetic towards a particular category of patients, specifically towards those who repeatedly visit social services thinking that all their problems have solutions to be provided by the social services. Social workers feel frustrated when they see no improvement in patients’ condition, so they stop feeling empathy towards them, even sometimes feel negative emotions, such as anger and indignation. SW 7: “For example, we help drug users repeatedly and they comeback over and over again in the same condition. I often feel sorry for the negative result of our interventions, but eventually I realized that it is impossible to help them because drug abuse is a serious disease. So, I eventually realized that, regardless, I should not feel angry at them.”

Identification: Participant SW6 was dealing with a problem similar to a patient’s problem. She was struggling as she tried to deal with her problem, It caused her to panic, and she was having difficulty concentrating. SW 6: “I was neither abrupt, nor upset with them. The truth is that I was trying so hard to help. First of all, I tried to concentrate and listen, but then I thought that my own problem was bigger than theirs. So, I realized that I have difficulty working with the patient…because the patient reminded me of my own story, and I was afraid that I would soon have to confront it in myself.  I panicked and I could not really concentrate on my thoughts”.

It appears that when a professional encounters a common problem with a patient it may present an obstacle to working on a patient’s problem.

Not acceptance: Another participant reported that there are cases when it is difficult to serve some patients and accept them because they do not agree with their actions. In these cases acceptance of the uniqueness of the individuals, not their actions and deviant behaviors, are difficult to work with. SW 8: “But for me, I cannot justify their actions”.

A social worker does not always accept patients’ behavior, especially when it is against his/her moral and personal values. However, with professionalism the social worker could proceed to help, but not feel empathic towards the patient.

Difficult personal situations: Several of the social workers noted that there are periods in their lives when they may be experiencing personal problems and concerns that are likely to have a positive or negative effect on their work as well as on how they treat patients. Four participants (SW2, SW9, SW10 and SW12) believe that even when professionals are going through difficult personal situations, they must separate them from work and not allow them to influence the way they deal with patients. SW2: “No, I do not think that we should be affected by our personal problems because they should be kept aside. If we face a common health problem with our patient at the same time I think that we should not be involved, and, if possible, refer to someone else”.

Three participants (SW1, SW4 and SW6) said that their work is affected when they face personal problems. One of them said that this influence could sometimes be positive and enhance feelings of empathy towards the patient. Another participant (SW5) said that one’s personal experience or problem in common with a patient’s problem or situation should not be shared or allowed to be perceived by the patient. SW1 was the only one who noted that one could manage having a personal problem in common with a patient through personal psychotherapy.

The majority of social workers agreed that professionals’ personal problems should be left outside the workplace and not affect the way they serve and help their clients. However, the ability to deal with such situations depends both on the case in question and onprior experience of having worked with such cases..

The transfer of professional work experience into personal life: Separation of work and personal life is quite important. If they are not separated work maybe affected as well as their personal life outside of work. Five of the participants (SW5, SW6, SW9, SW10 and SW12) manage to separate their personal life and work. SW 10: “No, I separate it completely. Absolutely. But I never let the two affect each other.. There is no reason to allow that”.

Five of the participants (SW1, SW4, SW7, SW8 and SW11) reported that at the beginning of their professional career they transferred to their home and personal life the concerns and problems faced in their patients, since identification with their patients was more common. Overtime, they managed to separate work and personal life. SW 1: “At first I used to do it so much, particularly in my early professional years. But I think that is normal at first. I sometimes see that student trainees are completely out of it… they do not care…and they have distancing problem… and it scares me. When I came here, at the beginning, I had that problem too… I was always thinking about it. Then, through work experience I could separate them…and said that one is part of my job and the other part of my home life”.

Another participant (SW2) did not always manage to not think about what is worrying him at his work. Several times he could not provide meaningful solutions due to reduced and inadequate sources at work. This worried him very much, and he continued to feel much pressure when he returned home. This pressure affected, as he said, his psychosomatic health.

Similarly, another participant (SW3) noted that sometimes he transferred work home, especially when he was concerned about cases where he was not sure about the effectiveness of what he did, and needed another point of view to see if what he had done was acceptable. He attributes this fact to the lack of interdisciplinary communication where different views of health professionals are shared.

Five participants were absolutely certain that there is no reason to shift work anxiety into their personal lives, and that they do it well. Another significant number of participants said that they were able to separate work and home after some years in the profession. As young professionals, they did not know how to do it well, but experience taught them how to.

Ways to Tackle Difficulties – Sources of Empathy

Collaboration with colleagues: Developing cooperation and collaboration among professionals is a way of providing feedback and sharing knowledge. In such collaborations different perspectives and opinions are shared and discussed, and different options are taken into account. Many of the participants noted that cooperation between them and the interdisciplinary team affects positively their work and the way they handle cases and incidents. There are moments and instances when they are very worried because of particularly unusual instances or cases where a second opinion would be helpful. As mentioned above, one of the participants (SW2) needed to discuss a case and was forced go alone and carried his anxiety into his family due to lack of collaborative support at the workplace.

Creating emotional support groups for professionals: The creation of support groups of co-workers composed of professionals is considered to be of value. This idea was expressed by the majority of the participants. They thought it would give stressed-out professional express their negative emotions and feeling resulting from work with their patients, and the difficult working situations they face daily. Such an opportunity would help them leave work related problems and anxiety at the office and not transfer them to their spare time away from work and into their family life.

Education and social employee experience: Another important factor for the expression of empathy by social workers is education and experience. Among the undergraduate studies of social work, it was reported that insufficient knowledge of the empathic techniques was provided. Respondents suggested that experiential seminars should be held to highlight the important role of empathy and ways to apply it. Many years of experience, according to the majority of respondents, helped them overcome the difficulty of using empathy. They indicated that young professionals could enhance empathic skills through experiential seminars and lifelong learning.


This study explored the views of experienced social workers about the concept of empathy, and focused to examine general challenges faced by social workers who worked in the healthcare sectors in Crete, Greece. They did not give a clear definition, but empathy was described as a social worker’s ability to recognize, understand and accept a patient’s position and reality in order to be able to offer needed help without identifying with the issues and problem presented. The majority of the participants noted that empathy is an indispensable asset. Interestingly, the words they used to characterize it were: a skill, a talent, a process that can recognize, understand and accept patient’s position and problem in order to be able to offer appropriate support and help without identifying with the patient.

The ability of social workers to empathize and distance at the same time, combined with the Code of Conduct of Social Work, helped them carry out their duties more efficiently and effectively. Awareness of ethnical issues that arise is an important part of providing professional help with best possible outcomes.

It seemed that most social workers did not manage to feel empathy in all cases. Empathy levels could vary depending on the issues and the cases, as well as by social workers ability distance from the issues appropriately. In some cases they focused on the practical procedures in the context of bureaucratic issues. They sometimes worked mechanically and do not take into account that each person is different, even if the problem is the same. There are those who find it difficult sometimes to see the reality of the patient when faced with something new in which they have no experience or specialization. The variations observed in the practice of social work can be as unique as the professionals themselves.

As the literature suggests,9 the commitment to do social work to help patients and deal with their problems depends on the consciousness of the importance of developing and applying empathic skills effectively.

There are several barriers and difficulties in the expression and use of empathy. A major difficulty is burnout and the pressure experienced by social workers. When social workers have themselves faced problems in the past similar to the patients’ it maybe easier to use empathy, since they can relate to and understand more easily how a patient feels and what he/she needs. This makes them to be more sensitive and helps them empathize more readily. However, such common experiences may also interfere with the need to distance themselves, potentially leading to less than adequate interventions and personal distress. After a long-term demanding work in the healthcare sector, empathy is sometimes difficult to achieve and may lead to burnout and professional fatigue.

The mood of social workers seems to be the main obstacle, since they can be affected by professional fatigue, exhaustion and psychological pressures during work. The result is that they are less effective in helping patients. Long-term experience of confronting and dealing with different incidents and vulnerable groups with less than adequate resources and personal support leads them to operate mechanically, offering simple and arbitrary solutions and instructions, and frequently avoiding approaching patients with empathy. Such conditions often lead to what is called compassion fatigue as noted by may studies and surveys.26,27,28,29,30,34,35 Over time and with experience social workers seem to develop ways of coping with compassion fatigue and better able to manage their ability to empathize with patients.19

There is evidence to suggest that experiential seminars on empathy as described by Neumann et al17 and Williams et al15 that involved empathic training and seminars could result in improvement in empathic abilities,22 However, while some participants in this study supported the value of training, others tend to think that empathy is hard to train as it is characteristic of the personality of the professional.

Comments by social workers in this study indicate that the role of an interdisciplinary group of healthcare professionals involving discussion of cases and incident among colleagues could contribute positively in improving the management of cases.

There was a feeling that sometimes when social workers were experiencing personal difficulties it contributes to the inability to listening to the patient’s problem and feelings empathetically. This finding is consistent with a previous study where most of the interview participants that reported personal struggles in their life it influenced their ability to practice their duties adequately as social works.23

Another important element highlighted by participants in this study was that early on in one’s career, it may be more difficult setting limits on distancing when empathy and identifying with the patient leads to transferring patients’ problems and concerns into one’s personal life. However, with experience it may become easier to manage the separation of the professional and the personal by distances and avoiding the transfer of work to personal life.

Participants noted that to avoid compassion fatigue and burnout the creation of interdisciplinary and emotional support teams would be helpful, in addition to proper training and education, to their able to express empathic intervention in a more consistent manner.


This study has the potential of forming the basis of further research regarding challenges experienced by social workers in the healthcare sector on the island of Crete. As far as we know, there are no studies about what empathy means for social workers in the healthcare sector. This limited qualitative exploratory study raised a number of issues that invites further study to identify ways of improving the practice of social work on this island. It was encouraging that we were able to get access to a group of social workers in healthcare who were prepared to talk about their experiences and issues surrounding empathy. It would be helpful to see similar research conducted elsewhere in Greece to learn more about the challenges social workers face, and to find ways of improving the quality of services provided by them.


The authors received no financial support for the research and

authorship and/or publication of the article.


The authors express their grateful to all social workers – participants of this study.


The authors declare that they have no conflicts of interest.

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