| |

Received: 4 June 2018    Revised: 31 October 2018    Accepted: 5 December 2018

DOI: 10.1111/jocn.14759

ORIGINAL ARTICLE

Implementing evidence‐based practices on the therapeutic

relationship in inpatient psychiatric care: A participatory action
research

Antonio R. Moreno‐Poyato1,2  | Pilar Delgado‐Hito3 | Juan M. Leyva‐Moral4 | 

Georgina Casanova‐Garrigós5,6 | Pilar Montesó‐Curto6

1
Escola Superior d’Infermeria del Mar,
Barcelona, Spain Abstract
2
IMIM (Hospital del Mar Medical Research Aims and objectives: To produce changes in the therapeutic relationship between
Institute), Barcelona, Spain
clinical practice nurses and patients in psychiatric units by implementing evidence‐
3
School of Nursing, L'Hospitalet del
based practices through participatory action research.
Llobregat, University of Barcelona,
Barcelona, Spain Background: The therapeutic relationship is the cornerstone of nursing care in psy‐
4
Department of Nursing, Faculty of chiatric units. The literature suggests that theoretical knowledge alone is insufficient
Medicine, Universitat Autònoma de
Barcelona, Cerdanyola del Vallès, Barcelona, to establish the therapeutic relationship in practice. Therefore, strategies are needed
Spain to adequately establish the therapeutic relationship in psychiatric units.
5
Fundació Pere Mata Terres de l'Ebre, Design: Participatory action research.
Amposta, Tarragona, Spain
6 Methods: Participants consisted of nurses from two psychiatric units of a university
School of Nursing, Universitat Rovira i
Virgili, Tarragona, Catalunya, Spain hospital. Data were collected through focus groups and reflective diaries, which were
analysed using the content analysis method. The COREQ guidelines were followed to
Correspondence
Pilar Delgado‐Hito, School of Nursing, ensure rigour.
L'Hospitalet del Llobregat, University of
Results: Nurses conceptualised the therapeutic relationship in their practice, identi‐
Barcelona, Barcelona, Spain.
Email: [email protected] fying facilitating elements and limitations. They were able to compare their clinical
practice with the recommendations of scientific evidence and constructed three evi‐
Funding information
College of Nurses of Barcelona, Grant/ dence‐based proposals to improve the therapeutic relationship: (a) a customised
Award Number: PR-1915-14/2014
nurse intervention space, (b) knowledge updating and (c) reflective groups, which
they subsequently implemented and evaluated.
Conclusions: This study shows that nurses in psychiatric units can generate changes
and improvements in the therapeutic relationship. The process of implementing evi‐
dence‐based practice enhanced participants’ awareness of their clinical practice and
allowed them to make changes and improvements.
Relevance to clinical practice: The process confirmed that the implementation of evi‐
dence‐based practice through participatory methods, such as participatory action
research, is valid and produces lasting changes. This study also reveals the need to
rethink nurses’ functions and competencies in current psychiatric units.

KEYWORDS
action research, evidence‐based practice, nurse–patient relationship, psychiatric nursing,
qualitative study

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© 2018 John Wiley & Sons Ltd J Clin Nurs. 2019;28:1614–1622.
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1 | I NTRO D U C TI O N
What does this paper contribute to the wider global
The therapeutic relationship (TR) is one of the most important clinical community?
tools for nurses in their clinical practice in general and for mental
• Participatory action research helps nurses to become
health nurses in particular. A rational framework for mental health
more aware of their clinical practice, the first step to
nursing was mainly developed by Peplau, who conceptualised the
change.
therapeutic purpose of the relationship between nurse and pa‐
• The process identified the need for organisational and
tient (O'Brien, 2001). Effective establishment of the TR increases
professional changes in clinical practice.
the effectiveness of any nurse intervention in clinical practice in
• The effects of the implementation of evidence through
psychiatric units (McAndrew, Chambers, Nolan, Thomas, & Watts,
PAR improved and unified the objectives for the whole
2014).
team.

1.1 | Background
The TR is composed of a series of attributes that nurses must pos‐ processes and their consequences, replanning change, action and
sess and integrate into their clinical practice. These essential ele‐ re‐observation and reflection again. Throughout this process, par‐
ments are as follows: (a) understanding, (b) interest and availability, ticipants act and reflect, simultaneously becoming aware of their
(c) individuality, (d) authenticity, (e) respect and (f) self‐knowledge practice and transforming it (Baum, MacDougall, & Smith, 2006).
(Moreno‐Poyato et al., 2016). However, despite theoretical and em‐ Scientific evidence confirms that theoretical knowledge of the TR
pirical knowledge of the TR among nurses, the reality of practice alone is insufficient to carry it out effectively, and as a result, it is dif‐
is that the biomedical model is a strong influence in mental health ficult to provide high‐quality care (Cleary, Hunt, Horsfall, & Deacon,
nursing and is often imposed (Duxbury et al., 2010). Work focused 2012). Therefore, there is a need to propose EBP‐based strategies that
on tasks, as well as the time taken for their performance in mental promote change and its adequate implementation. Exploring nurses’
health care, hinders individualisation and, therefore, the efficacy perceptions of the factors that hamper their clinical practice could
and quality of the TR (Hopkins, Loeb, & Fick, 2009). help in the design of appropriate strategies for evidence‐based change
In recent years, evidence‐based practice (EBP) has become the axis (Registered Nurses Association of Ontario, 2002).
for improving clinical practice, quality of care and excellence. However,
over the past few years, there have been some difficulties in integrating
this empirical knowledge into the complex clinical reality of health ser‐
vices (Stevens, 2013). As with the TR, limitations have been identified
for its use at both the individual and organisational levels. For nurses,
the main difficulties are a lack of time and knowledge and the high
workload, while the main organisational factors are a lack of human,
material, support and leadership resources (Warren et al., 2016).
One of the possible strategies for implementing EBP in health
services is participatory action research (PAR; Abad‐Corpa et al.,
2012). Its use has had positive effects on the implementation of EBP,
since it has had effects on nurses’ knowledge, professional perfor‐
mance, structural context and patient outcomes (Munten, Bogaard,
Cox, Garretsen, & Bongers, 2010).
Participatory action research is a dynamic process, carried out
on the basis of the unique needs, specific challenges and learning
experiences of a particular group (Kidd & Kral, 2005). Therefore,
the aim of PAR is to modify specific problems in communities. PAR
is based on the view that participants' actions need to be filtered
through experience and reflection before they can improve or
change their practice. Knowledge generation in PAR is a collabo‐
rative process, in which the skills and experiences of each partici‐
pant are essential to the project's results (Delgado‐Hito, 2012). As
shown in Figure 1, PAR is carried out through a sequence of steps
involving a spiral of self‐reflective cycles (Kemmis & Mctaggart,
2008): planning the desired change, action and observation of
the process and consequences of change, reflection on these F I G U R E 1   The participatory action research process
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1616       MORENO‐POYATO et al.

The main purpose of this study was to generate changes in nurses’ indispensable tool in qualitative research. The study procedure was
clinical practice through the implementation of EBP with respect to TR conducted in two phases, adapting the cycles’ model of Kemmis
through PAR. The specific objectives of the study were (a) to describe and Mctaggart (2008). The first phase consisted of an initial stage
the meaning assigned by nurses to establishing the TR with patients, (stage 0) in which we analysed the situation and the study context.
(b) to identify the factors facilitating and limiting the establishment of In the next four stages, the participants designed guidelines to self‐
the TR, (c) to identify strategies to improve the establishment of the observe their practice, and then conducted and registered their
TR by contrasting the evidence with real‐world clinical practice and self‐observations. Next, they described the contrast between their
(d) to qualitatively assess the effects of implementing the evidence. observed practice and the scientific evidence. In the second phase,
the nurses proposed strategies in relation to the evidence, and then
implemented and evaluated them. Finally, they narrated aspects re‐
2 |  M E TH O DS
lated to the PAR process. The process is described in Figure 2.
The content analysis method was used in this study (Mayring,
2.1 | Design
2000). All the data obtained were transcribed literally. Then, once
A qualitative methodology was proposed and the PAR method was the authenticity of the transcripts had been verified by the partic‐
selected, within the framework of the constructivist paradigm and ipants, we proceeded to fragment the text into descriptive codes
following the model of Kemmis and Mctaggart (2008). The COREQ assigned purely on the basis of their semantic content. In a second
guidelines were followed to ensure rigour (Tong, Sainsbury, & Craig, stage, these initial codes were grouped into more analytical sub‐
2007; See Appendix S1). categories, which classified the codes according to the meaning of
the linguistic units and their combinations. Thus, a third hierarchi‐
cal stage was reached, in which, taking into account the semantic
2.2 | Study setting
analysis of the previous subcategories, the codes were categorised
The study was carried out in the two psychiatric units of a tertiary deductively according to the study objective. The rigour of the re‐
care hospital in Spain. These units cover an urban population of ap‐ sults obtained was verified by triangulation of the researchers. The
proximately 380,000 inhabitants and consist of 39 beds for patients analysis process was assisted by QSR software nvivo version 10.
with acute decompensation of psychiatric pathology, mainly psy‐ Other rigour‐related factors guided the performance of the study.
chotic and affective disorders. There are three nurses in the morn‐ First, the participants were genuinely interested in the TR, leading to
ing shift, two nurses in the afternoon shift and 1 in the night shift. engaged participation and viable changes. Second, the detailed descrip‐
tions were considered in depth in the phases and stages of the study,
allowing us to focus on the research process rather than on its results
2.3 | Study period
(Kidd & Kral, 2005). Third, both the principal researcher and the par‐
Data were collected from October 2014–December 2015. ticipants maintained reflexivity throughout the process. Participating
nurses reflected on the self‐observation of their clinical practice and
noted their observations in their field notes, allowing us to obtain an
2.4 | Study participants
Audit Trail of their reflective process. Moreover, at each stage of the
Study participants consisted of nurses working in the psychiatric units. process, before each focus group took place, the principal investiga‐
The permanent and temporary workforce of these units consisted of tor sent a document to the participants with the preliminary results of
40 nurses. Participants were recruited through the director of nurs‐ the information they had provided from their field notes in the prior
ing, those responsible for acute care units and through personalised stage. Thus, at the beginning of each group, the information obtained
written information and institutional e‐mail to all nursing profession‐ from each individual was validated and complemented by group discus‐
als about the project and its objectives. For the sample selection, the sion. Given his professional experience in contexts similar to that of the
types of nurses' profiles in the units were identified and maximum study, the principal investigator initially had some difficulty in holding
variation sampling was carried out to ensure a variety representation himself back and not providing information, which would have worked
of gender, age, work shift, years of experience and specialised training against the aim of the study as a freely evolving process, hampering the
(Patton, 2002). The final sample was composed of 13 nurses. growth of awareness among nurses and their empowerment during the
process. Once the principal investigator had accepted his role as group
facilitator and provocateur, a relationship of equals was established,
2.5 | Techniques, procedure and data analysis
with an atmosphere of trust among the group. This in turn encouraged
To generate a model of change in clinical practice and to imple‐ participation and the generation of ideas by the nurses.
ment EBP through PAR, four focus groups were held, lasting from
1.5–2 hr. In addition, 19 reflective diaries were collected throughout
2.6 | Ethical aspects
the process. To monitor the research process both descriptively and
methodologically and to help integrate theory and practice (Taylor The project was approved by the Ethics and Clinical Research Committee
& Bogdan, 1987), we also used the investigators’ field diaries as an of the Parc de Salut Mar of Barcelona (Spain; 2014/5655/I). Participation
MORENO‐POYATO et al. |
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F I G U R E 2   Procedure and methods used in the study

was voluntary, and participants signed a consent form accepting the

3.1.2 | Stages 2 and 3: Action and observation
study conditions; at all times, they could withdraw from the study.
In these stages, the nurses carried out the interactions in clinical
practice, self‐observed and noted their observations in their reflec‐
3 |  R E S U LT S tive diaries. Once the nurses had handed in their diaries, they were
given a paper with scientific evidence on the establishment of the
The study was initiated by 13 nurses, but during the data collection TR (Registered Nurses' Association of Ontario, 2002). The nurses
process, four nurses withdrew and therefore the final sample was reviewed the guide and drafted reflections on its recommendations
composed of nine nurses, who maintained representative criteria. The and on their observations of their own clinical practice.
characteristics of the participants who completed the study are shown
in Table 1.
3.1.3 | Stage 4: Collective reflection
Figure 3 shows how the process was conducted and the results were
generated, and how the nurses generated knowledge, compared it with Once the nurses had detected the limitations of the study objective
the evidence, proposed and implemented EBP, and then evaluated it. in clinical practice, having contrasted it with the scientific evidence
provided, it was time to collectively reflect on the results obtained.
To do this, the second focus group was held.
3.1 | Phase I
The results of this stage were that nurses conceptualised the TR
from their perspective. Thus, they identified the importance of es‐
3.1.1 | Stage 1: Plan
tablishing a bond with the patient and of setting objectives agreed
Through a focus group, the nurses decided how, when and where with the patient, not only the nurses’ goals. They also stressed the
they would carry out the reflective self‐observation of their clinical importance of the therapeutic environment. Among the barriers
practice regarding the establishment of the TR with their patients. identified to establishing the TR were the priority given to routine
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1618       MORENO‐POYATO et al.

TA B L E 1   Overview of participants’ sociodemographic and their practice. The participants agreed to read, describe and
professional characteristics reflect on the two selected articles and make notes in their

Characteristics (n = 9) n (%) diaries.

3. Reflective groups: a strategy aimed at improving the TR by devel‐
Gender
oping the nurses’ self‐knowledge and self‐awareness through a
Male 4 (44.5)
space where they could verbalise the concerns affecting their
Female 5 (55.5)
clinical practice.
Age (years)
28–38 6 (66.7)
39–49 2 (22.2)
3.2.2 | Stages 2 and 3: Action and observation
>50 1 (11.1)
Mental health nursing specialty In these stages, the nurses individually implemented and evalu‐
Yes 2 (22.2) ated the strategies they had designed to improve their clinical

No 7 (77.8) practice.
From the evaluation of the Customised nurse intervention space,
Work shift
the nurses emphasised the improvement in the effectiveness of the
Morning 4 (44.4)
TR with their patients and the continuity of care. In addition, the
Afternoon 4 (44.4)
strategy enhanced trust and bonding with patients. The strategy re‐
Night 1 (11.1)
quired nurses to carry out more individualised care planning, improv‐
Working day (hours)
ing the achievement of goals and enhancing patient empowerment.
40 6 (66.7)
21 3 (33.3) Developing this activity has improved (...) everything
Mental health experience (months) in general. The patients wait for the space to make
72–119 4 (44.4) their demands, resolve doubts (...) there hasn’t been
120–240 3 (33.3) a continual drip of small conversations, demands,
>240 2 (22.2) questions, doubts, (...) This way of working is infinitely
more productive (...)  (Achilles)

tasks in their practice and, only after these were completed, to the Evaluation of the strategy of Knowledge updating revealed that
relationship. Other factors limiting the TR were a lack of time and the nurses emphasised that self‐training had increased their knowl‐
professional motivation, workload, routines and nurses’ preconcep‐ edge and skills, which had facilitated the evaluation, reflection and
tions about the patients. application of these elements in clinical practice. Self‐training was a
stimulus for nurses to confirm and reinforce the quality of the care
provided.
3.2 | Phase II
The scientific method contributes "mastery and re‐
3.2.1 | Stage 1. Replanning
flection". (...) It implies a re‐evaluation, self‐correc‐
In this stage, the nurses planned three evidence‐based improvement tion and personal and group effort to improve. (...) It
strategies for clinical practice through the third focus group: increases knowledge and skills. (...) It gives me strat‐
egies to try to develop human potential to the max‐
1. Customised nurse intervention space: a strategy aimed at im‐ imum (open mind) and the professional (which are
proving the TR through patient care interventions in a scheduled closely connected)  (Idalia).
and systematised manner.
2. Knowledge updating: a strategy aiming to improve the TR Evaluation of the Reflective groups showed that the nurses em‐
through the training of professionals by regularly reading, de‐ phasised that the groups should be neutral and protect spaces where
scribing and reflecting on scientific articles, in addition to the they could discuss emotionally draining activities and the coexistence
evidence already provided in the study process. To do this, the between professional and other circumstances of clinical practice; the
nurses decided that the principal investigator should select space allowed them to express their feelings and increased motivation
four articles of interest and send them by e‐mail. To control among participants.
variability in these articles, the principal investigator selected
and sent two review articles and two original articles from in‐ It would be beneficial if these groups were held to‐
dexed journals. After reading the abstracts of each article, the gether with the unit supervisor. That would allow a
nurses voted on which two articles would be most useful for consensus among everyone, possible solutions or
MORENO‐POYATO et al. |
      1619

Stage 1. Plan Stages 2 and 3. Action and

observation
How to Self-Observe TR in
Clinical Practice (Focus group 1) Recording observations Stage 4. Reflection
(Reflective diary 1) Contrasting practice with evidence
Interview with involuntary (Focus group 2)
patient Elements facilitating TR
Elements facilitating TR
Interview with voluntary patient Factors limiting TR
Factors limiting TR

Improvement proposals for TR

Taking vital signs Improvement proposals for TR

Reflections on the process of change

Phase I
Reflections on the process of change

Stage 4. Discussion and final reflection

(Focus group 4)
Stages 2 and 3. Action and observation
Implementation and evaluation of EBPs
Phase II
(Reflective diary 1)

Improvements for TR Stage 1. Planning review

The TR and its interventions
EBPs proposals
Improvements for the patient (Focus group 3)
Customised nurse intervention space
Customised nurse intervention
space
Improvements for the team
Reflective groups for nurses

Reflective groups for nurses

Improvements for the nurses Knowledge updating

Opportunity for professional and organisational Knowledge updating

changes Reflections on the process of change

F I G U R E 3   Process of generating and implementing evidence‐based practice regarding the therapeutic relationship

conclusions to day‐to‐day problems, and would also Unlike a year ago, I now realise that I am going to do
be a place where people could express their feelings this. Until now, perhaps I was doing it, but I was not
(...) Criticism should always be constructive, with as‐ aware of a pattern or a beginning, a development and
pects to be solved or improved, and not destructive, a termination of this therapeutic relationship, and
well, otherwise, it wouldn´t solve anything, help to now that´s how it is (...)  (Nymph).
improve the dynamics or the atmosphere of the room
and the workers. (...)  (Jason). 2. Improvements for the patient: the change in practice enhanced
patient empowerment, involving them in the treatment goals
and in the tasks to be carried out.
3.2.3 | Stage 4: Final reflection and conclusions
This stage was the culmination of the process and included the Unlike before, maybe in the objectives I included the
group's final collective reflection. In it, the nurses indicated that patient's goals, which (...) yes they are there, I know
the process had empowered them to change their practice and pro‐ they were there, but they were not my priority. And
duced changes at five levels: then, now it’s a way of working not with "my" priori‐
ties, but (...)  (Valentina)
1. Improvements in the establishment of the TR: participants believed
that the change in practice had enhanced the effectiveness 3. Improvement for the team: the process motivated the rest of the
of interventions with patients. In fact, the nurses became aware team members to introduce improvements agreed on by the PAR
of the theory in practice and the need to plan and structure group and also allowed improvement and unification of the objec‐
their interventions more specifically. tives for the whole team.
 |
1620       MORENO‐POYATO et al.

(...) there´s a ripple effect, because even if that part‐ 2011) and sometimes reported a lack of support from supervisors
ner is not with you, because of the shift or whatever, (Bowers, Nijman, Simpson, & Jones, 2011).
when it´s known that an intervention is being carried The participants’ proposals regarding the design and implemen‐
out, as a general rule, the change produced spreads to tation of EBP were related to the limitations detected. The nurses
your colleagues who continue with the intervention created a space where they could attend to their patients in their
(...)  (Idalia) day‐to‐day practice in a scheduled and systematised way. This space
was free from interference, where patients could feel welcome, lis‐
4. Improvements for the nurses themselves: the process increased tened to and, above all, understood (Borille, Paes, & Brusamarello,
nurses’ security in their clinical practice. In fact, the process of 2013; Wyder, Bland, Blythe, Matarasso, & Crompton, 2015), unlike
change allowed the nurses to become more aware of clinical prac‐ what usually happens in routine practice in psychiatric units (Stewart
tice and thus be able to change and improve it. et al., 2015). Importantly, these types of spaces have already been
introduced in other countries such as the UK (Mental Health Act
(...) it helped me to be a little more organised, a little Commission, 2008). Although evidence has not yet been obtained
more structured, because you often do things on the of their success, there are indications that they increase patient sat‐
fly, when you can, how you can and where you can. isfaction in terms of coverage of their needs (Sweeney et al., 2014).
(...)  (Remus) Following EBP, reflective groups were conducted. The nurses had
detected that they needed to pool their experiences and be able to
5. Improvement for the profession and organisation: needs and op‐ make constructive criticisms. No doubt, this commitment to fostering
portunities for change in psychiatric units were detected, such reflexive practice is inherent in the research method used (Dawber,
as finding therapeutic spaces, the need to regulate and provide 2013; Kemmis & Mctaggart, 2008; Oelofsen, 2012). When nurses pro‐
training in the TR and to restructure the functions of mental posed the purpose of these groups, it was evident that they needed
health nurses. these spaces to gain confidence and security and feel protected and
understood by the rest of the team (Bowers et al., 2011; Dawber, 2013).
(...)Someone should incorporate it into our work‐ The last strategy implemented was updating of knowledge. After
loads and developing the therapeutic relationship reading the evidence, the participants detected that, to improve their
should the main task of nursing rather than automat‐ practice, they needed to have more training and to be able to transfer
ically going for the pills and putting them into a glass that knowledge to their day‐to‐day work (Oelke, da Silva Lima, & Acosta,
(...)  (Achilles) 2015). This proposal again confirmed the high level of the nurses’ in‐
volvement in the project, demonstrating a strong capacity for self‐
awareness and self‐knowledge (Munten et al., 2010; Oelofsen, 2012).
4 |  D I S CU S S I O N When reporting the effects of the EBP implementation process,
the participants emphasised that the change in practice gave them
Participants in this study were able to improve their daily care ac‐ greater self‐confidence and also allowed them to reflect, present ideas
tivity by implementing EBP through the PAR process. The nurses and gain knowledge (Dawber, 2013; Munten et al., 2010; Oelofsen,
conceptualised the TR in their practice in a very similar way to that 2012). The process of change therefore allowed them to become
described in the literature (Hawamdeh & Fakhry, 2014; Stenhouse, aware of their clinical practice and thus generate improvements.
2011). They reported that the TR was fundamental to their clini‐ Professional satisfaction and motivation increased because the nurses
cal practice, but that daily activity regarding the TR was not in‐ felt they participated in improving the organisation (Abad‐Corpa et al.,
cluded in the protocols and clinical pathways, and consequently, it 2012; Dawber, 2013; Munten et al., 2010; Oelofsen, 2012).
was not always a priority in their daily work (Pazargadi, Fereidooni In their evaluation, the nurses reported that patients’ trust and
Moghadam, Fallahi Khoshknab, Alijani Renani, & Molazem, 2015). confidence in them had increased. This is an important desire and
This finding is in agreement with that of Cutcliffe, Santos, Kozel, expectation among patients in the framework of the TR because it
Taylor, and Lees (2015), who noted that there was increasing evi‐ increases patient empowerment (Borille et al., 2013; Duxbury et al.,
dence that the importance and value of the TR were not recognised 2010; Hopkins et al., 2009; Schroeder, 2013; Wyder et al., 2015).
in clinical practice. As well as observing improvements in the nursing team, participants
Likewise, the nurses identified barriers to establishing the TR. also noted that the changes increased motivation in other colleagues
Some of them were related to the organisation and lack of time, (Dawber, 2013; Kemmis & Mctaggart, 2008; Oelofsen, 2012). In ad‐
since they reported that the excessive time devoted to completing dition, the effects of the implementation of evidence enhanced and
registries and the high pressure of care prevented them from de‐ unified the objectives of the whole team (Abad‐Corpa et al., 2012;
voting sufficient time to establishing an appropriate TR (Hawamdeh Dawber, 2013).
& Fakhry, 2014; Pazargadi et al., 2015). Another barrier was lack of Similar to other studies with the same design, one of the most
motivation and job dissatisfaction among some nurses, who were important findings of this study was that the implementation of
dissatisfied with their role in the team (Roche, Duffield, & White, EBP through PAR identified the need to propose organisational and
MORENO‐POYATO et al. |
      1621

professional changes (Munten et al., 2010). The results showed the C O N FL I C T O F I N T E R E S T

need to restructure activities to facilitate the establishment of the
No conflict of interest has been declared by the authors.
TR, since its operationalisation is currently affected by organisa‐
tional policies and the prevailing biomedical model (McAndrew et
al., 2014; McCrae, 2014). ORCID

Antonio R. Moreno‐Poyato  https://orcid.

4.1 | Limitations org/0000-0002-5700-4315

First, the results of this study cannot be generalised. However, they Pilar Montesó‐Curto  https://orcid.org/0000-0002-0833-2152

can be extrapolated to settings and participants with similar charac‐

teristics to our own.
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