Accepted Articlei.

Title

The association between empathy and the nurse-patient therapeutic relationship in mental health
units: a cross-sectional study

ii. Short running title

Empathy and the therapeutic relationship

iii. Authors

Antonio R. Moreno-Poyatoa, b, RN, MHN, MSc, PhD

Óscar Rodríguez-Nogueirac, PT, MSc, PhD

On behalf of MiRTCIME.CAT working group

iv. Author’s institutional affilations

1. Antonio R. Moreno-Poyato [email protected]

orcid.org/0000-0002-5700-4315

a Department of Public Health, Mental Health and Maternal and Child Health Nursing, Nursing
School, Universitat de Barcelona, L´Hospitalet de Llobregat, Spain

bIMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain

2. Óscar Rodríguez-Nogueira [email protected]

orcid.org/0000-0002-4203-5784

cNursing and Physical Therapy Department, Health Sciences School, Universidad de León,
Ponferrada León, Spain

v. Authorship statement

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/JPM.12675
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 ARMP, ORN and MiRTCIME Working Group contributed to substantial contributions to the
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conception or design of the work; or the acquisition, analysis or interpretation of data for the work.
ARMP contributed the main part of the data analysis. ARMP, ORN and MiRTCIME Working
helped in drafting the work or revising it critically for important intellectual content. ARMP, ORN
and MiRTCIME Working contributed to final approval of the version to be published. Agreement
to be accountable for all aspects of the work in ensuring that questions related to the accuracy or
integrity of any part of the work are appropriately investigated and resolved by ARMP.

vi. Corresponding author’s contact

Antonio R. Moreno-Poyato

Department of Public Health, Mental Health and Maternal and Child Health Nursing, Nursing
School, Universitat de Barcelona

Campus Bellvitge

Pavelló de Govern, 3d floor, office 305

C Feixa Llarga, s/n

08907-L'Hospitalet de Llobregat (Barcelona)

E-mail: [email protected]

vii. Acknowledgements

We would like to acknowledge all the participants and the College of Nurses of Barcelona for
financial support (PR-218/2017). We also thank Xavier Duran from the Methodological and
Biostatistical Advisory Service of the IMIM, Barcelona, for his cooperation.

viii. Ethic committee

Comité Ético de Investigación Clínica Parc de Salut MAR de Barcelona, Spain.

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 Project number: 2017/7381/I entitled “Mejorando la Relación Terapéutica en los Cuidados
Accepted Article
Enfermeros a Través de la Evidencia. Estudio multicéntrico en unidades de agudos de psiquiatría
de Cataluña”

ix. Conflict of interest

No conflict of interest has been declared by the authors.

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Accepted Article
DR ANTONIO R. MORENO-POYATO (Orcid ID : 0000-0002-5700-4315)

Article type : Original Article

The association between empathy and the nurse-patient therapeutic relationship in

mental health units: a cross-sectional study

ABSTRACT

Introduction: Empathy and its dimensions (perspective taking, empathic concern, personal
distress and fantasy) are essential for establishing the nurse-patient therapeutic relationship. It
is important to know how this influences the construction and development of the therapeutic
alliance during the different phases of the therapeutic relationship.

Aim: To examine whether the dimensions of empathy influence the nurse-patient therapeutic
relationship within mental health units.

Method: A cross-sectional design was used to collect data to measure the therapeutic alliance
and the different dimensions of empathy via an online form completed by nurses working at
18 mental health units. Linear regressions were used in the analysis.

Results: A total of 198 participants completed the questionnaires. Nurses established a

greater therapeutic alliance with patients when they were able to adopt their patient's
perspective and experience concern.

Discussion: Nurses’ perspective taking is an influential factor impacting the nurse-patient

bond in the orientation phase, whereas experiencing greater concern, and decreased
emotional distress were associated with improved therapeutic alliance in the working phase.

Implications for practice: These findings may help gain awareness among nurses of the
importance of empathy in the nurse-patient relationships, as well as inform educational
programs, by including training in empathic strategies and emotional management.

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 KEY WORDS: empathy, therapeutic relationships, acute care, acute mental health.
Accepted Article

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 ACCESSIBLE SUMMARY
Accepted Article
What is known on the subject?

 Empathy is one of the main attributes for establishing the nurse-patient therapeutic
relationship. Davis (1983) identified four components on an empathic response:
perspective taking, fantasy, empathetic concern and personal distress.
 It is essential to deepen our knowledge on the influence of the dimensions of empathy
for the construction and development of the therapeutic alliance during the different
phases of the therapeutic relationship.

What the paper adds to existing knowledge?

 A significant association exists between the dimensions of empathy and the

construction and development of the therapeutic alliance during the different phases
of the therapeutic relationship between nurses and patients in mental health units.
 This study shows that the nurses' perspective on the patient's situation improves the
bond and therefore this skill is especially useful in the first phase or orientation phase
of the therapeutic relationship. However, for the second phase or working phase of the
therapeutic relationship a greater empathic concern among nurses, together with less
personal distress improves collaborative goal setting with patients.

What are the implications for practice?

 It is important for mental health nurses to be aware of the importance of personal self-
awareness and the emotional management of empathy for the construction and
development of therapeutic relationships of quality with patients.
 Knowledge of the relationship between each of the dimensions of empathy in the
different stages of the therapeutic relationship is useful for the design of educational
programs, by including training on empathic strategies.

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 Introduction
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The therapeutic relationship is of central importance to mental health nursing practice. In the
1950s, the nursing theorist, Peplau, was the first to conceptualize the therapeutic aim of the
relationship between the nurse and the patient (Peplau, 1988). The therapeutic relationship is
characterized as being a relational process via which the nurse attempts to improve the health
situation of the person cared for (Moreno-Poyato et al., 2016). The establishment of the
therapeutic relationship has been empirically demonstrated to be associated with improved
health outcomes among patients (Kelley, Kraft-Todd, Schapira, Kossowsky, & Riess, 2014).
Furthermore, it increases the effectiveness of any nursing intervention in the clinical practice
of acute mental health units (McAndrew, Chambers, Nolan, Thomas, & Watts, 2014).

According to Reynolds and Scott (1999), the aim of any therapeutic relationship should be
to initiate an interpersonal communication to understand the perceptions and needs of the
other person, and thus empower their learning, improve their ability to confront different
situations and ultimately help them reduce or resolve their problems. Thus, it is evident that,
with regards the nursing competencies necessary to establish a therapeutic relationship,
empathy is considered one of the main attributes, both from the theoretical perspective
(Peplau, 1988; Rogers, 1972), as well as from the perspective of clinical nurses and mental
health unit patients (Gerace, Oster, O’Kane, Hayman, & Muir-Cochrane, 2018; Moreno-
Poyato et al., 2016; Reynolds & Scott, 1999; Staniszewska et al., 2019). Empathy can be
considered as being the intention, on behalf of the nurse, to remain within the patient’s
framework of reference, understanding the patient’s feelings and demonstrating this
understanding in detail (Rogers, 1972; Turkel, Watson, & Giovannoni, 2018). Consequently,
empathy is an essential nursing attribute during the entire the process of construction and the
development of a therapeutic relationship, and especially during the initial orientation phase
(Peplau, 1988). During this phase, the nurse should show an interest in understanding what is
happening or concerning their patient (Forchuk et al., 1998). This aspect is essential in the
context of mental health units, where hospitalized people especially value the nurse’s
perspective and their understanding of the situation (Gerace et al., 2018). Indeed, the nurse’s
empathic ability enables them to adopt non-defensive positions and facilitate the attainment
of satisfactory and productive results for their patients. This capacity is helpful in the context
of the therapeutic relationship (Reynolds & Scott, 1999), facilitating the ability for the
relationship to progress to the subsequent phases of the therapeutic relationship, known as the
working phase, and the termination phase (Forchuk et al., 1998; Peplau, 1988; Peplau, 1997).

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 In the second phase or working phase, most nursing interventions take place. Here, a nurse’s
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empathic abilities accompany patients and encourage learning and understanding of their
health situation, supporting their need to narrate their experience and promoting shared
decision making (Peplau, 1988; Peplau, 1997). Finally, in the third phase, or termination
phase, according to Peplau (1988; 1997), the main objectives are to summarize and evaluate
what has happened, jointly with the patient.

To evaluate the therapeutic relationship in clinical practice, several measurement tools are
described in the empirical literature, such as the Working Alliance Inventory (WAI: Horvath
& Greenberg, 1989), the Scale to Assess the Therapeutic Relationship (STAR: McGuire-
Snieckus, McCabe, Catty, Hansson, & Priebe, 2007), the Helping Alliance Questionnaire
(HAQ: Luborsky et al., 1996) and the California Psychotherapy Alliance Scale (CALPAS:
Marmar, Weiss, & Gaston, 1989). However, the most commonly used instrument for
measuring the therapeutic relationship is the Working Alliance Inventory Short (WAI-S:
Horvath & Greenberg, 1989). The WAI-S has been translated into the most languages and
has the greatest amount of data regarding its reliability in different populations (Harris &
Panozzo, 2019). This tool evaluates the level of therapeutic alliance based on the theoretical
assumptions by Bordin (1979). Bordin (1979) defined the construct of therapeutic alliance as
the collaborative relationship between the patient and the therapist in which three essential
elements are established: 1) agreement on the treatment goals, based on the patients’
expectations about their recovery, what they expect to achieve with the treatment and when
they expect to achieve it; 2) agreement on the tasks or treatments via which the goal will be
achieved - this is not unilaterally established by the expert therapist, but rather the result of a
consensus between the therapist's knowledge and the patient's perception of self-efficacy; and
3) the development of positive feelings towards each other: these feelings will be the guiding
principle by which the therapist offers expert help and the patient actively collaborates in the
treatment. This tool is especially useful in the framework of mental health nursing as it
enables the assessment of aspects related with psychotherapeutic processes, therefore
facilitating the ability to specifically relate aspects, such as the affective bond. This bond is
considered essential for understanding the patient’s needs during the initial orientation stage
and enabling an assessment of the agreement concerning goals and activities, which is also a
characteristic of the working phase (Forchuk et al., 1998; Peplau, 1988).

In the case of empathy, one of the most commonly used instruments worldwide is the
Interpersonal Reactivity Index (IRI: Davis, 1983). This is a general measure of empathy

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 which is used to evaluate empathic tendency (Davis, 1983). In this sense, despite not being a
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measurement tool which concretely examines empathy among nurses and their patients (an
aspect, in itself, which presents a certain complexity) (Yu & Kirk, 2008), the IRI has been
used to explain the empathic capacity of nurses in mental health units (Gerace et al., 2018),
having been constructed based on a model proposed by Davis (1983; 1994). Nonetheless, we
were unable to find any papers using the IRI to research empathy in mental health nurses.
Empathy is a multidimensional construct which includes cognitive and affective factors. In
his theoretical model, Davis (1983; 1994) proposes that an empathic episode is constituted by
the experiential background of the person who empathizes, supported by the processes of
cognitive construction that enable the recognition of the emotional experience of the other
from these experiences and by the cognitive and emotional responses that arise in the person
who empathizes, both on an intrapersonal level and on an interpersonal behavioral level
(Davis, 1983; 1994). In Davis' (1983) measure the IRI, he measures four empathic responses,
two are cognitive responses:1) the tendency to adopt the psychological point of view of
others, a dimension which was termed the perspective taking (PT) scale and 2) the capacity
to imagine the situation and feelings of others (in Davis' scale specifically fictitious
characters), a factor which was termed the fantasy (F) scale. Furthermore, according to Davis,
affective empathy is comprised of another two dimensions: 3) the tendency to experience
feelings oriented towards others, such as compassion and concern (empathic concern; EC)
and 4) the tendency to emotionally react based on the other’s suffering. These are emotional
reactions of anxiety and discomfort that the person experiences when observing the negative
experiences of others, which generally produce a flight reaction and ineffective actions
towards others (personal distress; PD). From the theoretical point of view, the first three
dimensions are favorable for developing a greater empathic capacity from a therapeutic point
of view, whereas a greater personal distress on behalf of the professional would be an
unfavorable factor (Davis, 1983).

Rationale

A recent review of the literature reaffirms that empathy continues to be an essential

component of the nurse-patient therapeutic relationship in current mental health units
(McAllister, Robert, Tsianakas, & McCrae, 2019). Indeed, there is a body of evidence that
supports this statement based on several studies which have examined this relationship from a
qualitative perspective, such as the studies featured in the aforementioned review (McAllister
et al., 2019) plus other relevant studies, such as those by Reynolds and Scott (1999), Forchuk

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 et al. (1998) or the previously cited study by Gerace et al. (2018). Likewise, certain studies
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use a quantitative perspective to explain the important relationship and influence of empathy
on numerous aspects, both regarding interpersonal relationships as well as the experiences of
health professionals in different fields of practice. Thus, the association of empathy with the
attitudes regarding severe mental illnesses in health professionals has been analyzed
(Economou et al., 2019) and the effects of different training interventions on therapeutic
communication in empathy towards mental health illnesses of nursing students (Vaghee,
Lotfabadi, Salarhaji, Vaghei, & Hashemi, 2018). Other studies have analyzed the relationship
between empathy and burnout among health professionals (Yuguero et al., 2017; Wilkinson,
Whittington, Perry, & Eames, 2017) and the influence of compassion and the quality of
interpersonal relationships in work performance and the mental health of professionals (Chu,
2017). More specifically, empathy in mental health nurses has been associated with nurses’
perceptions of family participation in practice (Hsiao & Tsai, 2015). In line with these
studies, although from the perspective of the theoretical framework by Davis (1983; 1994)
and his multidimensional model, our research attempts to shed light on the contribution and
concrete influence of each of the different dimensions of empathy in nursing care proposed
by Davis (perspective taking, empathic concern, personal distress and fantasy) on the
construction of the therapeutic alliance and its dimensions throughout the different phases of
the therapeutic relationship. This will enable us to obtain more specific knowledge regarding
the role played by the different types of empathic tendencies in the relationship that nurses
establish with patients in mental health units (Gerace, 2020). Undoubtedly, being able to gain
a deeper knowledge regarding the relationship between these constructs deemed essential in
mental health nursing, will help to identify elements for improving the relational competence
of mental health nurses.

Aim and Objectives

This study is part of a larger research project in Catalonia (Spain). The main aim of this
project is to improve the therapeutic relationship in acute mental health units implementing
evidence-based practice via a three-stage design using mixed methods. Nurses from 18 of the
21 mental health units participated in this project. These units formed part of the Catalonian
Mental Health Network (Red Catalana de Salud Mental), which follow the same quality
indicators and guidelines as the Health Department of the Government of Catalonia.

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 The aim of this study was to examine the relationship between the dimensions of empathy
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and mental health nurses’ social and professional factors and the establishment of a
therapeutic relationship.

METHODS

Design and participants

A cross-sectional design was used for data collection. The 21 mental health units belonging
to the Catalonian Mental Health Network were contacted, of which 18 centers agreed to
participate. All the nurses from the units were invited to participate in the study (n=235) of
whom, ultimately, 198 participated. Specialist trainee nurses were excluded from the study.

Data collection

Procedure

First, the director of each institution, plus the research team, selected a nurse coordinator for
each center who fulfilled the conditions of leadership and credibility and agreed to participate
voluntarily in the study. Thereafter, in order to recruit participants from each unit, the
principal investigator presented the research project and its aims at each center in
informational sessions with nurses. Thereafter, the nurse coordinators were placed in charge
of recruiting the participating nurses and gathering the informed consent forms and email
addresses in order to provide them with a confidential participant code, together with a link to
the electronic form via the google forms platform in order to gather the data during the first
phase of the study. The data collection for this part of the study was performed from February
2018 to April 2018.

Measures

The electronic form included a questionnaire containing sociodemographic and professional

data of nurses and the assessment tools, including the Work Alliance Inventory – Short
(WAI-S: Horvath & Greenberg, 1989) and the Interpersonal Reactivity Index (IRI: Davis,
1983).

The level of the therapeutic relationship was measured using the Working Alliance
Inventory-Short (WAI-S: Horvath & Greenberg, 1989). The short version of this scale
contains 12 items and each item is evaluated by the health professional using a scale that
ranges from 1 (never) to 7 (always). This questionnaire is comprised of three subscales of
four items each: a) bonding: the development of an affective bond between patient and nurse,

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 which includes aspects such as empathy, mutual trust and acceptance: (e.g. ‘I feel that my
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patient appreciates me’), b) goals: the agreement between the patient and nurse in terms of
goals (in other words, mutual acceptance on what the intervention hopes to achieve (e.g. ‘My
patient and I are working towards agreed upon goals’), and c) tasks or activities: the
agreement between the patient and nurse on tasks or activities which should be performed
(e.g. ‘My patient believes the way we are working with the problem is correct’). In the form,
nurses were asked to think generally about their patients. The greater the score, the stronger
the therapeutic relationship. The Spanish version of the WAI-S has shown good reliability
and validity, with Cronbach’s alpha values of 0.85 for the bonding subscale, 0.81 for the
goals subscale, 0.90 for the tasks subscale and 0.93 for the total scale (Andrade-González &
Fernández-Liria, 2015).

Empathy was measured following the theoretical framework by Davis (1983; 1994) via the
Spanish adaptation of the Interpersonal Reactivity Index (IRI) (Mestre Escrivá, Dolores,
Navarro, & García, 2004): this scale measures the empathic capacity of an individual across
four dimensions. Two dimensions are centered on the cognitive aspects of empathy: the
perspective taking subscale estimates the individual’s tendency to see things from the point of
view of the other person, when relating to that person; the fantasy subscale measures the
respondents’ tendencies to transpose themselves imaginatively into the feelings and actions
of fictitious characters. The other two dimensions evaluate emotional reactions: the empathic
concern subscale measures the individual’s tendency to respond with compassionate feelings
of concern in light of the difficulties and anguish experienced by another person; the personal
distress subscale examines the level of anxiety and other self-oriented negative effects which
occur based on experiences of suffering of other people in difficult situations or crises. Each
dimension comprises seven items using a Likert scale based on five points. The scores on
each subscale can vary from 0 to 27. This instrument has been validated in Spanish and the
Cronbach’s alpha values vary between 0.63 and 0.71 across the four factors (Mestre Escrivá
et al., 2004).

Statistical analysis

The quantitative variables were expressed as the mean and the standard deviation or the
median and interquartile range. The categorical variables were expressed as the frequency
and percentage. The reliability of the instruments in our sample was verified using the Omega
coefficient based on the polychoric correlation matrix. In the bivariate analysis, the
association between the quantitative variables was evaluated using the Pearson’s correlation

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 coefficient. Finally, linear regression models were used for the analysis of the therapeutic
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relationship according to the level of empathy and by introducing the sociodemographic
profile and professional variables of nurses as covariates. The choice of covariates was made
based on possible theoretical associations between the main factor (empathy) and these
variables. The sociodemographic and professional variables introduced in each of the models
were gender, years of mental health experience, mental health specialty, highest education
and type of contract. Age was not included to avoid redundancy and multicollinearity. In
addition, the educational level variable was dichotomized as PhD or master’s degree and
bachelor’s degree. The type of contract variable was dichotomized in full-time and other
contracts. Statistically significant results were established with a p-value of<0.05. The
statistical analyses were performed using the SPSS V 22.0 statistical package (SPSS Inc.,
Chicago, IL).

Ethical considerations

This study was coordinated at the institution of the principal investigator which was the first
Ethics Committee to grant approval for this research. Thereafter, the remaining Ethics
Committees of the participating institutions also granted approval. All study participants
signed a consent form prior to data collection. The consent forms and the completed
questionnaires were separated to ensure anonymity, and all data were treated confidentially.

RESULTS

In total, 235 nurses from 18 psychiatry units were eligible to participate in this study. Of
these, 198 subsequently formed part of this study. The mean age of participants was 33.8
years (SD=9.23), 72.5% were women and only 20.2% of nurses were specialized in mental
health nursing. Up to 34.2% held a diploma, 32.6% had a four-year degree and 33.2% had
postgraduate studies. The median experience in mental health was 6.5 years (IQR=10.1) and
nurses had been in the unit for a median duration of 2.4 years (IQR=7.0). Approximately
60% of nurses (n=118) held a fulltime contract, 20% (n=43) held a part-time contract and the
remaining had temporary work contracts.

Regarding the reliability of the instruments used in our sample, the Omega coefficient (ω)
for the total WAI score was 0.81 and for the bond, goals and tasks subscales, this was 0.64,
0.43 and 0.76, respectively. In the case of the IRI subscales, Omega (ω) coefficients of 0.77
were obtained for fantasy, 0.81 for perspective taking, 0.78 for empathic concern and 0.77 for
personal distress.

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 In the bivariate analysis of the empathy and therapeutic relation dimensions, all the
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empathy dimensions significantly predicted perceptions of greater scores in therapeutic
relationships. Positive associations were highlighted for perspective taking and empathic
concern of nurses with an improved therapeutic relationship. However, among nurses who
experienced a greater personal distress, there was a decrease in the therapeutic relationship
(Table 1).

A linear regression was performed to determine whether the level of the therapeutic
relationship could be explained by the dimensions of empathy and nurses’ social and
professional factors, such as gender, the experience working in mental health, academic
education and specialty (Table 2). The initial model was significant (F (9, 188) = 6.700, P<
0.001), with these factors representing 20.7 % of the variation in the level of the therapeutic
relationship. It is worth noting that, in this first model, besides the experience (β =0.170, P<
0.01) and the educational level (β =1.820, P=0.024), all empathy dimensions were
significant, with the exception of fantasy (perspective taking: β= 0.336, P< 0.01; empathic
concern: β= 0.336, P< 0.01; personal distress: β= -0.216, P= 0.027) (Table 2).

To explain the relationship between the dimensions of empathy and each of the factors of
the therapeutic relationship, linear regressions were again performed, adjusted by the social-
professional variables of nurses, such as gender, experience in mental health, academic
training and specialty. Model 2, which was performed to explain the association between
empathy and bonding, was significant (F (9, 188) = 5.959, P< 0.001), with the factors
included in the model representing 18.5% of the variation in the nurses’ level of bonding.
Concretely, the empathy factor which achieved significance was perspective taking (β=
0.180, P< 0.001) (Table 2). Concerning the third model, used to explain the relationship of
empathy with the agreement on goals, this was also significant (F (9, 188) = 3.615, P<
0.001), with the factors included in the model 10.7 % of the variation in the level of
agreement on goals. In this case, the significant factors of the model were empathic concern
(β= 0.163, P= 0.011) and personal distress (β= -0.107, P= 0.026) (Table 2). Finally, the
fourth model was used to determine whether the level of agreement on tasks can be explained
due to the dimensions of empathy. Once again, the model was significant (F (9, 188) = 2.964,
P= 0.003), with the factors included representing 8.2 % of the variation in the level of
agreement on the nursing tasks. In this model, none of the empathy factors were significant,
only the nurses’ experience was significant (β= 0.090, P< 0.01) (Table 2).

DISCUSSION

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 The overall aim of this study was to quantitatively examine the association between the
Accepted Article
dimensions of empathy and the therapeutic relationship and their components among nurses
working at mental health units. The results revealed a significant relationship between both
constructs. Although we were unable to find any study which directly examined the
association between therapeutic relationship and empathy, studies in the field of mental
health nursing have shown the importance of empathy for the relationship and therapeutic
commitment between patients and nurses in hospitalization units (McAllister et al., 2019).
Indeed, both from the point of view of mental health nurses, as well as that of patients,
empathy is viewed as being an essential element of mental health nursing care (Moreno-
Poyato et al., 2016).

It is important to underline that, overall, the results revealed that all the dimensions of
empathy were associated with the therapeutic relationship. Furthermore, all the dimensions of
empathy were positively associated with the therapeutic relationship, except for personal
distress for which a negative association was found. This dimension was inversely associated,
in line with theoretical frameworks (Davis, 1983) and empirical results which reveal that
presenting higher levels of stress and personal distress as a response to a patient’s situation
means that the professional is conditioned to make decisions rapidly with less time for
reflection (Haas, Anderson, & Filkowski, 2015). In this sense, several studies have used
different intervention strategies, such as mindfulness, to improve empathy and feelings of
personal distress (Lamothe, McDuff, Pastore, Duval, & Sultan, 2018) or even movies
(Zeppegno, Gramaglia, Feggi, Lombardi, & Torre, 2015). Furthermore, as in other studies,
our findings indicate that the experience of nurses and training in the specialty of mental
health are factors which significantly condition empathy and the therapeutic relationship
(Alhadidi, Abdalrahim, & Al-Hussami, 2016; McAndrew et al., 2014; Roche et al., 2011).

Furthermore, the results of the analysis of the influence of empathy on each of the
components of the therapeutic relationship revealed that the model which best explained the
changes was the one which studied the influence of empathy on the nurse-patient bond.
Concretely, a relationship was found between a greater level of perspective taking, and more
extensive professional experience, resulting in the establishment of a stronger nurse-patient
bond. This finding confirms the importance of empathy to generate trust and, therefore, build
a strong bond with patients. In addition, the results reveal that, in order to create a stronger
patient bond, the cognitive components of empathy are also necessary. This means that in this
first part of the therapeutic relationship, the nurse must cognitively assume the patient’s

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 perspective due to the need to be understood and recognized as a person (Beyene,
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Severinsson, Hansen, & Rørtveit, 2019; Eldal et al., 2019).

In contrast, the influence of empathy on nurses in relation to the level of agreement

regarding goals and tasks, was far more limited. This was only found in the case of agreeing
on treatment goals, where the affective dimensions of empathy of nurses explained part of
their changes. This finding is especially interesting as, in line with the model by Batson
(2011) which proposes the fact that empathic concern mobilizes and leads one to desire to
help people, these results indicate the importance of the empathic concern of nurses in order
to progress from the orientation phase to the working phase in the context of the therapeutic
relationship (Forchuk et al., 1998; Peplau, 1988). Thus, it is important to highlight that the
personal distress of the nurses, limits and conditions the joint agreement on goals with service
users. This finding is evident in acute mental health units, where the situations of non-
voluntary events and conflict are more common, and where nurses subconsciously maintain
an emotional distance in order to avoid suffering (Gerace et al., 2018). These results confirm
that empathy is an important construct in order to establish a good connection with the
patient, in our case, it influences the establishment of mutual goals with patients however it
did not influence the agreement in tasks, which are considered as being important parts of the
therapeutic relationship. Interestingly, a recent meta-analysis revealed that these two factors
of the TR are the least considered by professionals in clinical practice (Tryon, Birch, &
Verkuilen, 2018). This is, indeed, an aspect that warrants further research. Ultimately, the
achievement of an optimal level of bonding with patients is important, however, shared
decision making should not be overlooked, and should be based on the mutual agreement on
goals and tasks to encourage the therapeutic commitment in mental health hospitalization
units (Beyene et al., 2019; McAllister et al., 2019).

What the study adds to the existing evidence

Although multiple studies are available in the published literature which examine the
phenomenon of the patient-nurse relationship in acute mental health units, this study
quantitatively analyses the relationship between the different dimensions of nurses' empathy
proposed in Davis's theoretical model (1983; 1994) and the construction of the therapeutic
alliance and its dimensions throughout the various phases of the nurse-patient relationship.

In this sense, the results of this study show that the nurses' perspective taking regarding the
patient's situation improves the bond and therefore this skill is especially useful in the

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 orientation phase. However, during the working phase of the therapeutic relationship, the
Accepted Article
affective components of empathy are specifically associated to a greater empathic concern,
together with less personal stress among nurses. This improves the joint establishment of
goals with patients, and therefore supporting shared decision making. This has been widely
studied in other areas and in mental health units via the use of qualitative approaches
(Forchuk et al., 1998; Gerace et al., 2018; McAllister et al., 2019; Reynolds & Scott, 1999).

Limitations and strengths

This study has several limitations. First, the cross-sectional design did not allow us to detect
changes in nurses’ perceptions over time, nor make causal inferences. Second, it is important
to consider that empathy was evaluated as a general measure, and, this was related with the
overall perceptions of nurses on TR, which could have differed from those of their patients if
these had been specifically measured. Third, another possible limitation is that in our sample,
the subscales for agreement on goals and the development of a bond had internal consistency
results of less than 0.7. Nonetheless, this study has obtained appropriate validity in terms of
the factorial structure, which, added to the theoretical relevance of the original dimensions in
clinical practice, lead us to consider maintaining the factorial structure of the instrument used
in our study. This is a matter that warrants consideration as it conditions the interpretation of
results and invites the need for a greater psychometric study in the future regarding the WAI
scale, the most widely used scale on an international level for the measurement of therapeutic
alliance (Harris & Panozzo, 2019). In contrast, one of the study strengths was the rate of
participation among nurses in the participating institutions. Furthermore, we identified
specific relationships between the dimensions of empathy and the TR, and, although this
degree of influence was not high from the associative point of view, these findings suggest
the need to perform further in-depth studies of the factors which influence a quality
therapeutic relationship.

IMPLICATIONS FOR PRACTICE

Empathy and its dimensions are generally related with the establishment of the TR among
nurses and patients in mental health units. According to the phase of the therapeutic
relationship, certain dimensions influence empathy more than others, therefore nurses must
be aware of this and adapt to this in their daily clinical practice. Perspective-taking skills are
one of the components which most strongly influence the nurse-patient bond, which is an
essential starting point in the orientation phase of a therapeutic relationship. Also, knowing

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 that empathic concern and personal distress are more influential than other dimensions of
Accepted Article
empathy in the working phase of the therapeutic relationship could be especially important
for mental health nurses to become aware of the importance of personal self-awareness and
emotional management in the establishment of therapeutic relationships of quality with
patients. This specific finding is both relevant and striking, considering the tendencies of
current mental health care which are centered on the paradigm of autonomy and the model of
recovery. Thus, according to this model, to facilitate patient empowerment, health
professionals should constantly generate spaces for shared decision making (Newman,
O’Reilly, Lee, & Kennedy, 2015; Smith & Williams, 2016). This may help gain awareness
among nurses of these factors, as well as inform educational programs, by including the
training of empathic strategies and emotional management. Likewise, these findings, together
with the existing literature, indicate the need for further research on the factors which predict
the establishment of therapeutic relationships, in order to improve the quality of care
provided at mental health hospitalization units.

RELEVANCE STATEMENT

This article features the results of a study analyzing the association between the dimensions
of empathy and the therapeutic relationship of nurses in mental health units. After controlling
the influence of nurses’ social and professional characteristics, we found that the changes that
occurred in the therapeutic relationship were significantly related with certain dimensions of
empathy in nurses. Perspective taking is the factor which most strongly influences the bond
between the patient and nurse, constituting an essential starting point in the orientation phase
of a therapeutic relationship. Also, the fact that empathic concern and personal distress are
more influential than other dimensions of empathy in the work phase of the therapeutic
relationship is important, as mental health nurses must be aware of the importance of
personal self-awareness and emotional management in the establishment of greater quality in
the nurse-patient therapeutic relationships. These factors are directly related with shared
decision making, and the basic practice of person-centered care, which, in turn is recognized
as being an essential component of recovery-oriented care.

REFERENCES

Alhadidi, M. M. B., Abdalrahim, M. S., & Al-Hussami, M. (2016). Nurses’ caring and
empathy in Jordanian psychiatric hospitals: A national survey. International Journal of
Mental Health Nursing, 25(4), 337–345. https://doi.org/10.1111/inm.12198

This article is protected by copyright. All rights reserved

 Andrade-González, N., & Fernández-Liria, A. (2015). Spanish Adaptation of the Working
Accepted Article Alliance Inventory-Short (WAI-S). Current Psychology, 35(1), 169–177.
https://doi.org/10.1007/s12144-015-9365-3

Batson, C. D. (2011). Altruism in Humans (Vol. 10). New York: Oxford University Press.
https://doi.org/10.1093/acprof:oso/9780195341065.001.0001

Beyene, L. S., Severinsson, E., Hansen, B. S., & Rørtveit, K. (2019). Being in a space of
sharing decision‐ making for dignified mental care. Journal of Psychiatric and Mental
Health Nursing, (July), jpm.12548. https://doi.org/10.1111/jpm.12548

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working

alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260.
https://doi.org/10.1037/h0085885

Chu, L.-C. (2017). Impact of Providing Compassion on Job Performance and Mental Health:
The Moderating Effect of Interpersonal Relationship Quality. Journal of Nursing
Scholarship, 49(4), 456–465. https://doi.org/10.1111/jnu.12307

Davis, M. H. (1983). Measuring individual differences in empathy: Evidence for a

multidimension approach. Journal of Personality and Social Psychology, 44(1), 113–
126.

Davis, M. H. (1994). Empathy: A social psychological approach. Dubuque, IA: Brown &
Benchmark Publishers.

Economou, M., Peppou, L. E., Kontoangelos, K., Palli, A., Tsaliagkou, I., Legaki, E.-M., …
Papageorgiou, C. (2019). Mental Health Professionals’ Attitudes to Severe Mental
Illness and Its Correlates in Psychiatric Hospitals of Attica: The Role of Workers’
Empathy. Community Mental Health Journal, (0123456789).
https://doi.org/10.1007/s10597-019-00521-6

Eldal, K., Natvik, E., Veseth, M., Davidson, L., Skjølberg, Å., Gytri, D., & Moltu, C. (2019).
Being recognised as a whole person: A qualitative study of inpatient experience in
mental health. Issues in Mental Health Nursing, 40(2), 88–96.
https://doi.org/10.1080/01612840.2018.1524532

Forchuk, C., Westwell, J., Martin, M. Lou, Azzapardi, W. B., Kosterewa-Tolman, D., & Hux,
M. (1998). Factors influencing movement of chronic psychiatric patients from the
orientation to the working phase of the nurse-client relationship on an inpatient unit.

This article is protected by copyright. All rights reserved

 Perspectives in Psychiatric Care, 34(1), 36–44. https://doi.org/10.1111/j.1744-
Accepted Article 6163.1998.tb00998.x

Gerace, A. (2020). Roses by other names? Empathy, sympathy, and compassion in mental
health nursing. International Journal of Mental Health Nursing.
https://doi.org/10.1111/inm.12714

Gerace, A., Oster, C., O’Kane, D., Hayman, C. L., & Muir-Cochrane, E. (2018). Empathic
processes during nurse–consumer conflict situations in psychiatric inpatient units: A
qualitative study. International Journal of Mental Health Nursing, 27(1), 92–105.
https://doi.org/10.1111/inm.12298

Haas, B. W., Anderson, I. W., & Filkowski, M. M. (2015). Interpersonal reactivity and the
attribution of emotional reactions. Emotion, 15(3), 390–398.
https://doi.org/10.1037/emo0000053

Harris, B. A., & Panozzo, G. (2019). Therapeutic alliance, relationship building, and
communication strategies-for the schizophrenia population: An integrative review.
Archives of Psychiatric Nursing, 33(1), 104–111.
https://doi.org/10.1016/j.apnu.2018.08.003

Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working
Alliance Inventory. Journal of Counseling Psychology, 36(2), 223–233.

Hsiao, C. Y., & Tsai, Y. F. (2015). Factors Associated With the Perception of Family
Nursing Practice Among Mental Health Nurses in Taiwan. Journal of Family Nursing,
21(4), 508–528. https://doi.org/10.1177/1074840715606543

Kelley, J. M., Kraft-Todd, G., Schapira, L., Kossowsky, J., & Riess, H. (2014). The influence
of the patient-clinician relationship on healthcare outcomes: a systematic review and
meta-analysis of randomized controlled trials. PloS One, 9(4), e94207.
https://doi.org/10.1371/journal.pone.0094207

Lamothe, M., McDuff, P., Pastore, Y. D., Duval, M., & Sultan, S. (2018). Developing
professional caregivers’ empathy and emotional competencies through mindfulness-
based stress reduction (MBSR): Results of two proof-of-concept studies. BMJ Open,
8(1), 1–9. https://doi.org/10.1136/bmjopen-2017-018421

Luborsky, L., Barber, J. P., Siqueland, L., Johnson, S., Najavits, L. M., Frank, A., & Daley,
D. (1996). The revised helping alliance questionnaire (HAq-II): Psychometric

This article is protected by copyright. All rights reserved

 properties. Journal of Psychotherapy Practice and Research, 5(3), 260–271.
Accepted Article
Marmar, C. R., Weiss, D. S., & Gaston, L. (1989). Toward the validation of the California
Therapeutic Alliance Rating System. Psychological Assessment, 1(1), 46–52.
https://doi.org/10.1037//1040-3590.1.1.46

McAllister, S., Robert, G., Tsianakas, V., & McCrae, N. (2019). Conceptualising nurse-
patient therapeutic engagement on acute mental health wards: An integrative review.
International Journal of Nursing Studies, 93, 106–118.
https://doi.org/10.1016/j.ijnurstu.2019.02.013

McAndrew, S., Chambers, M., Nolan, F., Thomas, B., & Watts, P. (2014). Measuring the
evidence: reviewing the literature of the measurement of therapeutic engagement in
acute mental health inpatient wards. International Journal of Mental Health Nursing,
23(3), 212–220. https://doi.org/10.1111/inm.12044

McGuire-Snieckus, R., McCabe, R., Catty, J., Hansson, L., & Priebe, S. (2007). A new scale
to assess the therapeutic relationship in community mental health care: STAR.
Psychological Medicine, 37(1), 85–95. https://doi.org/10.1017/S0033291706009299

Mestre Escrivá, V., Dolores, M., Navarro, F., & García, S. (2004). La medida de la empatía :
análisis del Interpersonal Reactivity Index. Psicothema, 16(2), 255–260.

Moreno-Poyato, A. R., Montesó-Curto, P., Delgado-Hito, P., Suárez-Pérez, R., Aceña-

Domínguez, R., Carreras-Salvador, R., … Roldán-Merino, J. F. (2016). The Therapeutic
Relationship in Inpatient Psychiatric Care: A Narrative Review of the Perspective of
Nurses and Patients. Archives of Psychiatric Nursing, 30(6), 782–787.
https://doi.org/10.1016/j.apnu.2016.03.001

Newman, D., O’Reilly, P., Lee, S. H., & Kennedy, C. (2015). Mental health service users’
experiences of mental health care: an integrative literature review. Journal of
Psychiatric and Mental Health Nursing, 22(3), 171–182.
https://doi.org/10.1111/jpm.12202

Peplau, H E. (1997). Peplau’s theory of interpersonal relations. Nursing Science Quarterly,

10(4), 162–167. https://doi.org/10.1177/089431849701000407

Peplau, H. E. (1988). Interpersonal relations in nursing : a conceptual frame of reference for

psychodynamic nursing. Houndmills: Macmillan.

Reynolds, W. J., & Scott, B. (1999). Empathy: A crucial component of the helping

This article is protected by copyright. All rights reserved

 relationship. Journal of Psychiatric and Mental Health Nursing, 6(5), 363–370.
Accepted Article https://doi.org/10.1046/j.1365-2850.1999.00228.x

Roche, M., Duffield, C., & White, E. (2011). Factors in the practice environment of nurses
working in inpatient mental health: A partial least squares path modeling approach.
International Journal of Nursing Studies, 48(12), 1475–1486.
https://doi.org/10.1016/j.ijnurstu.2011.07.001

Rogers, C. R. (1972). El proceso de convertirse en persona (On becoming a person) (17th

ed.). Barcelona: Paidós.

Smith, G. P., & Williams, T. M. (2016). From providing a service to being of service:
Advances in person-centred care in mental health. Current Opinion in Psychiatry, 29(5),
292–297. https://doi.org/10.1097/YCO.0000000000000264

Staniszewska, S., Mockford, C., Chadburn, G., Fenton, S. J., Bhui, K., Larkin, M., … Weich,
S. (2019). Experiences of in-patient mental health services: Systematic review. British
Journal of Psychiatry, 214(6), 329–338. https://doi.org/10.1192/bjp.2019.22

Tryon, G. S., Birch, S. E., & Verkuilen, J. (2018). Meta-analyses of the relation of goal
consensus and collaboration to psychotherapy outcome. Psychotherapy, 55(4), 372–383.
https://doi.org/10.1037/pst0000170

Turkel, M. C., Watson, J., & Giovannoni, J. (2018). Caring Science or Science of Caring.
Nursing Science Quarterly, 31(1), 66–71. https://doi.org/10.1177/0894318417741116

Vaghee, S., Lotfabadi, M. K., Salarhaji, A., Vaghei, N., & Hashemi, B. M. (2018).
Comparing the effects of contact-based education and acceptance and commitment-
based training on empathy toward mental illnesses among nursing students. Iranian
Journal of Psychiatry, 13(2), 120–128.

Wilkinson, H., Whittington, R., Perry, L., & Eames, C. (2017). Examining the relationship
between burnout and empathy in healthcare professionals: A systematic review. Burnout
Research, 6, 18–29. https://doi.org/10.1016/j.burn.2017.06.003

Yu, J., & Kirk, M. (2008). Measurement of empathy in nursing research: Systematic review.
Journal of Advanced Nursing, 64(5), 440–454. https://doi.org/10.1111/j.1365-
2648.2008.04831.x

Yuguero, O., Forné, C., Esquerda, M., Pifarré, J., Abadías, M. J., & Viñas, J. (2017).
Empathy and burnout of emergency professionals of a health region. Medicine (United

This article is protected by copyright. All rights reserved

 States), 96(37). https://doi.org/10.1097/MD.0000000000008030
Accepted Article
Zeppegno, P., Gramaglia, C., Feggi, A., Lombardi, A., & Torre, E. (2015). The effectiveness
of a new approach using movies in the training of medical students. Perspectives on
Medical Education, 4(5), 261–263. https://doi.org/10.1007/s40037-015-0208-6

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 TABLE 1 Relationship between the IRI and the level of the therapeutic relationship among nurses
Accepted Article
Variable PT F EC PD IRI

Bond 0.364*** 0.209** 0.287*** -0.104* 0.266***

Goals 0.194** 0.054 0.226** -0.190** 0.095

Tasks 0.159* 0.138 0.177* -0.089 0.145*

WAI-S 0.306*** 0.170* 0.299*** -0.184** 0.216***

*P <0.05, **P <0.01, ***P <0.001. WAI-S, Working Alliance Inventory – Short; IRI, Interpersonal Reactivity Index;

PT, Perspective Taking; F, Fantasy; EC, Empathic Concern; PD, Personal Distress

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 TABLE 2 Association between nurses’ characteristics and IRI subscales with therapeutic relationship (n
Accepted Article
= 198)

Dependent variables WAI Bond Goals Tasks

Independent variables β (95% CI) β (95% CI) β (95% CI) β (95% CI)

Gender 0.30 0.15 -0.23 0.69

(female) (-1.40 to 2.01) (-0.83 to 0.53) (-1.08 to 0.61) (-0.15 to 1.53)

Years of MH experience 0.17** 0.04 0.04 0.09**

(0.05 to 0.29) (-0.01 to 0.08) (-0.02 to 0.11) (0.03 to 0.15)

Highest education 1.81* 0.64* 0.52 0.66

(PhD or master’s degree (0.24 to 3.38) (0.01 to 1.26) (-0.26 to 1.29) (-0.12 to 1.43)
versus bachelor’s degree)

MH Nursing Specialty 1.17 0.28 -0.08 0.97

(no) (-0.91 to 3.24) (-0.55 to 1.11) (-1.11 to 0.94) (-0.05 to 2.00)

Type of contract -0.86 -0.31 -0.43 -0.12

(Full-time versus other (-2.56 to 0.84) (-0.99 to 0.37) (-1.27 to 0.41) (-0.95 to 0.72)
contracts)

PT 0.34** 0.18** 0.09 0.07

(0.11 to 0.57) (0.09 to 0.27) (-0.03 to 0.20) (-0.05 to 0.18)

F 0.09 0.05 -0.01 0.05

(-0.09 to 0.26) (-0.02 to 0.12) (-0.10 to 0.07) (-0.04 to 0.14)

EC 0.31* 0.10 0.16* 0.05

(0.06 to 0.57) (-0.01 to 0.20) (0.04 to 0.29) (-0.07 to 0.18)

PD -0.22* -0.06 -0.11* -0.05

(-0.41 to -0.03) (-0.14 to 0.01) (-0.20 to -0.01) (-0.14 to 0.05)

Adjusted R2 0.21 0.18 0.11 0.08

IRI. Interpersonal Reactivity Index; PT. Perspective Taking; F. Fantasy; EC. Empathic Concern; PD. Personal Distress; CI.
Confidence interval; MH. Mental health; WAI. Working Alliance Inventory; *P˂ 0.05; **P ˂ 0.01

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