How emojis can be the tool to creating a more empathetic digital healthcare service

Derisa Chiu

The four layers of empathy and its value in digital communication and healthcare

In the past few years, emojis have grown to be a fun way to enrich conversations, brands and videos. Unknowingly, they have also adopted a particular use to express concepts, humor, sarcasm, emotions, etc. What if we could use emojis as a tool to improve communication in areas where emotions are evident, such as healthcare? In this article I will discuss my research.

Humanizing Empathy and Emojis Humanizing Empathy and Emojis – Jonathan Ball, Poked Studio, Instagram

According to our research, empathy can possess a different meaning to different people (Bloom, 2016). Researchers have defined empathy from psychological and neurological perspectives as a part of an emotional domain, cognitive domain, or both (Colman, 2015; Dymond, 1949; Hojat, 2016; Ickes, 1997; Rushton, Chrisjohn, & Fekken, 1981). Empathy creates connectedness between people; with empathy, you have the ability to feel and understand what someone else is going through. This research helped me perceive empathy in a different way. Instead of the different (cognitive and emotional) elements of empathy being independent from each other, this research has allowed me to understand empathy as four different stages subsequent to one another.

Communication is essential for our day-to-day lives, but empathy is what gives nuances of saturation to the story of those communicating. With empathy stories are given color, meaning, emotion; the stories come to life. In healthcare services, this brings great impact to both doctor and patient. Before I am able to convince you of why empathy is stressed upon in healthcare and what can influence it to be beneficial or detrimental in healthcare, I am going to illustrate what a doctor-patient interaction could look like.

A patient walks into the doctor’s office, and meets the doctor for the first time. They both introduce themselves, shake hands and sits down. The doctor asks the patient what the reason for his visit is. The patient describes details specific to his visit, but provides limited information.

The Four Stages of Empathy

Stage One: Willingness to Empathize

The patient choses to give limited information, only detailing what he thinks is important to the issue he is there for. He did not automatically disclose all his concerns, as it was not clear if it was appropriate, at all relevant, and he did not want to waste the doctor’s time. The doctor listens attentively to the patient and looks the patient in the eyes. The doctor picks up relevant information, but realizes that there may be more to it, so he starts to ask further.

The doctor has just entered the first stage of empathy: Willingness to Empathize. Active and reactive listening, eye contact, leaning forward, or nodding and other physical reactions whenever appropriate communicates the doctors willingness to the patient. The doctor has given mental time and space to gain more information and insight to the situation. Seeing these signs shows allow the patient to open up more, communicate more openly, and slowly build upon his trust towards the doctor.

Stage Two: Ability to Understand

The doctor and the patient communicate about the issue. Questions are asked to clarify anything that is still yet unclear, and slowly the patient begins to trust more and share more. Having read through the patient’s medical history, the doctor now has quite a lot of information at hand. The doctor shows signs that he understands through nodding, acknowledging things by repeating and confirming details that he had previously listened to, his changing facial expressions, and many more.

This is stage two: Ability to Understand. Only when the doctor has been through stage one, being willing to empathize, can he truly understand what the patient is going through. The doctor, having learnt all of the information and conversed with the patient about additional information that might be important, now poses the ability to understand what the patient is going through. The doctor can now step into the patient’s shoes and comprehend what the patient is going through, what is affecting the patient, how the patient acts, thinks and feels.

Stage Three: Ability to Feel

With all of the given information and understanding the patient’s concern, the doctor can feel the emotions that the patient feels. The doctor begins to feel worried, frightened and a little sad, just like the patient himself.

Stage three is the Ability to Feel. To be able to feel what the patient is feeling, the doctor must have first empathized, as understanding, the patient. There are many reasons why the doctor may be able to feel what the patient is feeling. This stage of empathy can be activated by similar experiences or an interesting neurological activation called ‘mirror matching mechanism’. The latter is a mirror neurons system that activates and triggers us to mimic the other’s behavior and/or emotional state (Hojat, 2016; Tariq, 2017). A crucial part of being in this stage of empathy, is being aware that the source of the emotions is the other person, the patient (Davies, 2017). This is the key element to the research on social decentering theory encompassing empathy. As Dr. Redmond describes, this process involves doctors “take into consideration the thoughts, feelings, behaviors, and dispositions of other people”, recognizing and perhaps empathizing to stage three with their patients, but switching their route to compassion to develop strategies to address the problems (Davies, 2017; Redmond, 2018). As Katz’s researched showed, the skill to obtain to achieve this is detachment from shared feelings (Katz, 1963).

Stage Four: Empathetic Distress

The doctor is feeling of the emotions and mental pain that the patient is going through. Seeing and hearing the details, empathizing as feeling with the patient, it is a situation that causes the doctor to feel distressed. The doctor feels with the patient so much, that he loses sight that what he is feeling is not actually his emotions. The doctor is stressed, and unable to make the best decisions, diagnosis, plan of action for the patient as his judgement is clouded.

The last stage, stage four, is Empathetic Distress. While in stage three, the Ability to Feel, if left prolonged or unchecked, the doctor is likely to enter this stage. It is harmful and detrimental for the doctor, but it also negatively affects the patient as the doctor will not be able to give his professional advice and take professional actions as he is not capable of acting to his best of abilities.


Empathy in Healthcare

The four stages described above, is how the results of this researched has shaped the term empathy. To access any stage, the previous stages must have already been activated. One of the most important findings in the surveys conducted in this research is that being in one stage of empathy, does not necessitate going to the next stage of empathy.

The findings of this research shows that patients value doctors showing signs that they are in or have passed stage one, Willingness to Empathize, much more than merely signs that the doctor is in stage three of empathy, feeling what the patient feels. When doctors communicate their willingness to empathize, they are also building trust, encouraging patients to interact openly by making them gain more awareness about their own situation and make them feel cared for.

Healthcare is a people-centric industry. While patients are seen as the greatest subject of concern in healthcare, we need to equally keep the wellbeing of other stakeholders in this profession in mind, such as healthcare professionals. Learning the right balance between all stages of empathy, for whatever context empathy is applied in, is a skill learnt through experience. An interviewee expressed how she had to learn what coping methods that work for her, where to set boundaries and what emotions to block as a surgical nurse to protect herself from entering the stage of Empathetic Distress.

While this article encourages the communication of empathy, there is the responsibility of not enabling empathy to extend into empathetic distress. This is relevant to the next steps that I will take on this journey. It shows that decisions should be explicitly made to prevent users from reaching the state of empathetic distress. It provides a concrete boundary as a guideline to the design.

Emoji as a Tool

Communication is body language, choice of words, tone of voice, facial expressions, how you react, etc. The signs mentioned in the doctor-patient examples above such as reflective listening, eye contact, facial expressions are only a few of the many examples to be named. These are the signs that people recognize most in personal communication: tone, voice and body language. In Bellundi’s research, he quantified personal communication to 7% spoken words, 38% tone and voice, and 55% body language. These are risked being lost in digital communication.

Ursula and the Power of Body Language Ursula and the Power of Body Language - Body Language Disney Gif, Giphy

The most basic human communication method (face-to-face) does not just purely revolve around one method, such as spoken words. Why should technology merely be just about written text? Emojis have potential to do just this. Emojis, being the fastest growing universal language to exist, have increasingly grown in use in informal digital communication (Emogi Research Team, 2015; Zareen, Karim, & Khan, 2016). While emojis have the potential to enhance conversation, to bring in elements of body language, facial expressions, concepts, etc. into digital text, we should be aware that emojis have other functions too. The business world has begun to adopt emoji as a tool to target specific groups in which emojis already are a trend (Emogi Research Team, 2015; Emogi Research Team, 2016).

2016 emoji report Emoji in Brands and Products, 2016 Emoji Report, Emoji Research Team

Its communication ability extends further than the literal visuals of facial expressions and objects. There are also different ways in which it is currently being used in different cultures or demographics. I would like to focus on emoji uses that can communicate emotion, concepts, sarcasm, emphasis, metaphors, or symbols to express empathy. They possess these capabilities, but they have not yet adopted a specific use to benefit communication in the service industry, such as healthcare.

Digitalizing Empathy with Emojis Digitalizing Empathy with Emojis – Jonathan Ball, Poked Studio, Instagram

Next Steps

It is important to keep in mind while designing solutions that technology is a tool used to empower people, not to eliminate them. The challenge presented here is to design something that gives balance; balance between the scope of service healthcare professionals can supply without risking their own health and the scope of demand in which patients need and want and not making them feel objectified, or uncared for. It is a balance we are seeking to keep all interaction at a human level, with technology while using technology. It is a balance that encourages a caring relationship, awareness from both parties, and trust.

Through this article, I hope that it is clear that empathy is an important aspect in our lives. Defining empathy into four stages enabled me to clarify some things to take into consideration in my next steps. Designing a solution with the tool of emojis to encourage the communication of stage one, help enable doctors to detach themselves at any given stage to protect themselves and prevent stage four.

Emojis are a tool to be used to be able to understand one another better. It is a tool to enhance conversation, and I would like to do just this. Follow my journey in my goal to design a way for an improved, yet grounded to humanity, way for us to communicate digitally. Through my research, I have gained insight on how people perceive the signs of empathy, how people attribute their customer satisfaction to these signs of empathy, and the power of emojis. I can now begin my journey onto discovering and designing new ways to explicitly express verbal and non-verbal cues with emojis!  


Works Cited

  • Belludi, N. (2008, Oct 4). Albert Mehrabian’s 7-38-55 Rule of Personal Communication. Retrieved from
  • Bloom, P. (2016). Against Empathy. London: Penguin Random House UK.
  • Colman, A. M. (2015). A Dictionary of Psychology. New York: Oxford University Press.
  • Davies, G. (2017, Apr 07). Mindfulness - Empathy - Compassion. Retrieved from mind-lab:
  • Dymond, R. F. (1949). A scale for the measurement of empathic ability. Journal of Consulting Psychology, 127-133.
  • Emogi Research Team. (2015). 2015 Emoji Report. Emogi.
  • Emogi Research Team. (2016). 2016 Emoji Report. Emogi.
  • Hojat, M. (2016). Empathy in Health Professions Education and Patient Care. New York: Springer.
  • Ickes, W. (1997). Empathic accuracy. In S. D. Hodges, & D. M. Wegner, Automatic and controlled empathy (pp. 311-339). New York: Guilford Press.
  • Jibril, T. A., & Abdullah, M. H. (2013). Relevance of Emoticons in Computer-Mediated Communication Contexts: An Overview. Asian Social Science, 201-207.
  • Katz, R. L. (1963). Empathy: Its nature and uses. London: The Free Press of Glencoe.
  • Redmond, M. (2018). Social Decentering: A Theory of Other-Orientation Encompassing Empathy and Perspective-Taking. Berlin: DeGruyter Oldenburg.
  • Riva, G. (2002). The sociocognitive psychology of computer-mediated communication: The present and future of technology based interactions. CyberPsychology & Behavior, 581-598.
  • Rushton, J. P., Chrisjohn, R. D., & Fekken, G. C. (1981). The altruistic personality and the self-report altruism scale. Person Individ Diff., 293-302.
  • Tariq, N. (2017). A Quantitative Study of Empathy in Pakistani Medical Students: A Multicentered Approach. Journal of primary care & community health, 1-6.
  • Wei, A. C. (2012). Emoticons and the non-verbal communication: With reference to Facebook. Department of Media Studies. Bangalore: Christ University .
  • Zareen, N., Karim, N., & Khan, U. A. (2016). Psycho Emotional Impact of Social Media Emojis. ISRA Medical Journal, 257-262.


Innovation Empathetic design Research