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JournalofAdvancedNursing-2020-MorenoPoyato-Examiningtheassociationbetweenevidencebasedpracticeandthe.pdf
1762 | wileyonlinelibrary.com/journal/jan J Adv Nurs. 2021;77:1762–1771.© 2020 John Wiley & Sons Ltd
Received: 12 August 2020 | Revised: 28 October 2020 | Accepted: 24 November 2020 DOI: 10.1111/jan.14715
O R I G I N A L R E S E A R C H : E M P I R I C A L R E S E A R C H - Q U A N T I T A T I V E
Examining the association between evidence-based practice and the nurse-patient therapeutic relationship in mental health units: A cross-sectional study
Antonio R. Moreno-Poyato1,2 | Georgina Casanova-Garrigos3 | Juan F. Roldán- Merino4 | Óscar Rodríguez-Nogueira5 | MiRTCIME.CAT working group
1Department of Public Health, Mental Health and Maternal and Child Health Nursing, Nursing School, Universitat de Barcelona, Ĺ Hospitalet de Llobregat, Barcelona, Spain 2IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain 3School of Nursing, Universitat Rovira i Virgili, Tarragona, Spain 4Campus Docent Sant Joan de Déu Fundació Privada. School of Nursing, University of Barcelona, Barcelona, Spain 5Nursing and Physical Therapy Department, SALBIS Research Group, Health Sciences School, Universidad de León, Ponferrada, León, Spain
Correspondence Juan F. Roldán-Merino, Campus Docent Sant Joan de Déu Fundació Privada. School of Nursing, University of Barcelona, Spain. Email: [email protected]
Abstract Aims: To examine the relationship between the dimensions of evidence-based prac- tice and the therapeutic relationship and to predict the quality of the therapeutic relationship from these dimensions among nurses working in mental health units. Design: A cross-sectional design. Methods: Data were collected between February–April 2018 via an online form com- pleted by nurses working at 18 mental health units. Multiple linear regressions were used to examine the relationship between the dimensions of evidence-based prac- tice and therapeutic relationship. Questionnaires were completed by 198 nurses. Results: Higher levels of evidence-based practice were a significant predictor of a higher-quality therapeutic relationship (β: 2.276; 95% CI: 1.30–3.25). The evidence- based practice factor which most influenced an improved therapeutic relationship was the nurses’ attitude (β: 2.047; 95% CI: 0.88–3.21). The therapeutic relationship dimension which was most conditioned by evidence-based practice dimensions was agreement on tasks, which was most favourable with a better attitude (β: 0.625; 95% CI: 0.09–1.16) and greater knowledge and skills for evidence-based practice (β: 0.500; 95% CI: 0.08–0.93). Conclusion: In mental health settings, the therapeutic nurse–patient relationship is positively enhanced by evidenced-based practice and the nurse's level of experience, with a great influence on shared decision-making. Impact: This research sought to examine the relationship between the evidence- based practice and the therapeutic relationship in mental health nursing. This study demonstrates that an improved attitude and knowledge of evidence-based practices of mental health nurses increases shared decision-making with patients, which is a basic requirement for person-centred care. Because the therapeutic relationship is considered the backbone of nursing practice in mental health units, this research will have an impact on both mental health nurses and mental health unit managers.
K E Y W O R D S
evidence-based practice, mental health, nurse–patient relationships, practice nursing, quantitative approaches
| 1763MORENO-POYATO ET Al.
1 | I N T R O D U C T I O N
The international literature recognizes that the therapeutic re- lationship is an essential component of mental health nursing (Moreno-Poyato et al., 2016; Peplau, 1988; Vahidi et al., 2018) im- proving person-centred care and shared decision-making (Hamovitch et al., 2018). Furthermore, it is known that evidence-based practice enables the best clinical decisions to be made about patient care, considering factors such as nurses' experience and users' expecta- tions (DiCenso et al., 1998). In this regard, it seems clear that nurses with greater competence in evidence-based practice should estab- lish a better therapeutic relationship with patients.
1.1 | Background
Via the therapeutic relationship, nurses are able to positively make an impact on the health of people with mental health problems (McAndrew et al., 2014; Moreno-Poyato et al., 2019). Furthermore, the establishment of an appropriate therapeutic relationship has been empirically demonstrated to be associated with improved health outcomes for patients (Kelley et al., 2014). Furthermore, the therapeutic relationship also increases the effectiveness of any clini- cal practice intervention performed by nurses in acute mental health units (McAndrew et al., 2014). In terms of therapeutic value, via their interactions, nurses can provide a safe place, allowing the patient to overcome emotional resistance and move toward deep self-knowl- edge that often results in change (McAndrew et al., 2014). Along these lines, it was Peplau (1988) in the 1950s who referred to the role of the nurse as a leader who should help the patient to take on tasks through a relationship of cooperation and active participation, thus representing a true therapeutic alliance (Bordin, 1979). In turn, Bordin (1979) pointed out that the main components of the thera- peutic alliance are the agreement between the therapist and the patient on the treatment objectives, the tasks to be carried out and, finally, the affective bond that is established between the patient and the therapist. To build effective interpersonal relationships, Peplau (1988, 1997) described nursing care as an interpersonal process of therapeutic nature. Concretely, Peplau (1988, 1997) described nurs- ing care as a human relationship between a sick person or a person in need of help and a nurse who is properly trained to recognize and respond to the person's need for help. The therapeutic interpersonal relationship described by Peplau (1988) is based on three phases: orientation, working and termination. During the orientation phase, the individual perceives a need and seeks professional assistance. In this case, the nurse helps the patient to recognize, understand and assess his or her problem and situation. Subsequently, the work- ing phase represents most of the time that the nurse spends with the patient, where the nurse facilitates the exploration of feelings to help the patient cope with the illness and to be able to move on to the last phase, the resolution phase, which marks the satisfac- tion of old needs and the emergence of new needs to be fulfilled (Peplau, 1988).
Multiple studies provide evidence of the attributes required for the therapeutic relationship and their meaning (Felton et al., 2018; Harris & Panozzo, 2019; Hartley et al., 2019; McAllister et al., 2019; Moreno-Poyato et al., 2016). However, there is evidence of underuse of the same by mental health nurses (Hamaideh, 2017; Youssef et al., 2018). Clearly, it follows that knowledge and implementation of evidence-based empirical and theoretical precepts of the thera- peutic relationship should facilitate and improve the implementation of therapeutic relationship in clinical practice in mental health units.
Evidence-based practice has been defined as the organized use of the best available evidence (DiCenso et al., 1998). Some authors consider this as being an essential element in the provision of opti- mal high-quality care (Ramos-Morcillo et al., 2015; Stevens, 2013). Indeed, the implementation of EBP has been associated with im- proved health outcomes, decreased healthcare expenditure and increased nursing staff satisfaction (Moore, 2017; Ramos-Morcillo et al., 2015). Over recent years, certain difficulties have been ob- served in the implementation of this empirical knowledge in the complex clinical reality of health services (Correa et al., 2020). Thus, limitations have been identified for its use both at the individual level and by organizations at large. For professionals, lack of time, a heavy workload and lack of knowledge represent major difficulties (Correa et al., 2020; Stevens, 2013). Furthermore, the lack of human and material support and insufficient leadership resources are the main organizational limitations identified (Correa et al., 2020; Warren et al., 2016). In this regard, it should be noted that mental health nurses must overcome certain barriers that they encounter on a daily basis to implement EBP (Yadav & Fealy, 2012; Youssef et al., 2018). According to Alzayyat (2014), these barriers are due to the nature of the evidence, the contribution of mental health nurses involved in research, the personal characteristics of these nurses and organizational factors.
In the field of mental health, nursing studies have shown that the incorporation of evidence-based practice in clinical practice in- creases the empathy of nurses and improves the factors that con- tribute towards establishing a therapeutic alliance with patients (Moreno-Poyato et al., 2018), and increasing the nurses' self-confi- dence, allowing them to reflect on their practice, present ideas and acquire new knowledge (Moreno-Poyato et al., 2019). However, these studies have not specifically evaluated the contribution be- tween the EBP and its dimensions and the therapeutic relation- ship from a quantitative point of view (Moreno-Poyato et al., 2019; Moreno-Poyato et al., 2018).
Considering the impact of EBP on the therapeutic relationship in nursing practice in general and understanding the therapeutic rela- tionship as the essence of nursing practice in mental health (Felton et al., 2018; Moreno-Poyato et al., 2016), it is imperative to study the impact of EBP on this relationship in mental health units. Further knowledge is clearly necessary, considering that the work performed by mental health nurses in the context of the therapeutic relation- ship must be translated into practice following the established guidelines of empirical-theoretical precepts based on EBP. No stud- ies to date have evaluated the relationship between both constructs.
1764 | MORENO-POYATO ET Al.
It is therefore essential to research the association between the dif- ferent dimensions of EBP and the therapeutic relationship and its factors, while considering the relationship between EBP and the socio-demographic and professional characteristics of nurses, to develop strategies to improve the quality of the nurse–patient ther- apeutic relationship in mental health units.
2 | T H E S T U DY
2.1 | Aims
The aims of this study were to examine the relationship between the dimensions of evidence-based practice and the therapeutic relation- ship and to predict the quality of the therapeutic relationship from these dimensions among nurses working in mental health units.
2.2 | Design
This cross-sectional, correlational study sought to explore the asso- ciation between dimensions for EBP and the level of the therapeutic relationship among mental health unit nurses. The data collected for this study were part of the first phase of a mixed-method project entitled MiTRCIME.CAT, which aimed to improve the therapeutic re- lationship by implementing evidence-based practice in acute mental health units in Catalonia (Spain).
2.3 | Sample/Participants
The 21 mental health hospitalization units forming part of the Catalonian Network of Mental Health were informed of this study, of which 18 units agreed to participate. All the nurses employed at the collaborating units were invited to participate in the study (n = 235). Resident nurses who were on clinical placements were excluded from the study. Finally, 198 nurses participated in the study. Considering that, to perform a multiple linear regression, it is recommended to introduce one variable for every 10–15 individuals (Austin & Steyerberg, 2015; Green, 1991) and that in our study, nine variables were collected for each individual, the final sample size was considered appropriate.
2.4 | Data collection
First, the director of each institution, plus the research team, selected a nurse coordinator for each centre who fulfilled the conditions of leadership and credibility and agreed to participate voluntarily in the study. Thereafter, to recruit participants from each unit, the principal investigator presented the research project and its aims to each cen- tre via informational sessions with nurses. Thereafter, the nurse coor- dinators were placed in charge of recruiting the participating nurses
and gathering the informed consent forms and email addresses to provide them with a confidential participant code, together with a link to the electronic form via the google forms platform to gather the data during the first phase of the study. The data collection for this part of the study took place between February and April 2018. The electronic form included a questionnaire which gathered nurses' socio-demographic and professional data and measurement tools, including the Work Alliance Inventory – Short (WAI-S: Horvath & Greenberg, 1989) and the Evidence-Based Practice Questionnaire (EBPQ-19: Upton & Upton, 2006).
2.5 | Ethical considerations
This study was approved by the Research Ethics Committees of all the participating hospitals and participating nurses signed a con- sent form. The consent forms and the completed questionnaire were given to participants as separate forms and data were treated confidentially.
2.6 | Data analysis
The quantitative variables were expressed as the mean and the standard deviation. The categorical variables were expressed as the number and percentage. In the bivariate analysis, the association be- tween the quantitative variables was evaluated using the Pearson's correlation coefficient. The relationship between quantitative and categorical variables was determined using the Student's t-test. Finally, multiple linear regression models were used for the analy- sis of the therapeutic relationship according to the EBPQ and by in- troducing the socio-demographic profile and professional variables of nurses as covariates. The choice of covariates was made based on possible theoretical associations between the main factor (EBP) and these variables. The socio-demographic and professional vari- ables introduced in each of the models were gender, years of mental health experience, mental health specialty and highest education. Age was not included to avoid redundancy and multicollinearity. Statistically significant results were established with a p-value of <.05. The statistical analyses were calculated using the SPSS V 22.0 statistical package (SPSS Inc., Chicago, IL).
2.7 | Validity and reliability
The level of the therapeutic relationship was measured using the Working Alliance Inventory-Short (WAI-S). The short version of this scale contains 12 items, and each item is assessed by the health professional based on a scale ranging from 1 (never) to 7 (always). The scoring range of the overall WAI-S is 12–84 points. The higher the score, the higher the therapeutic relationship. This question- naire has three dimensions: (a) bond: the bond between patient and nurse, which includes aspects such as empathy, mutual trust
| 1765MORENO-POYATO ET Al.
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and acceptance; (b) objectives: the agreement between patient and nurse on the goals of therapy (i.e., mutual acceptance of what the in- tervention aims to achieve); and (c) tasks or activities: the agreement between patient and nurse on the tasks or activities to be carried out. The Spanish version of the WAI-S has good reliability and valid- ity, with a Cronbach alpha of 0.93 (Andrade-González & Fernández- Liria, 2015). In the case of our sample, the Cronbach's alpha value for the total scale was 0.71, the subscales for tasks and bonding pre- sented internal consistencies of 0.73 and 0.56, respectively, whereas the subscale objectives had a lower internal consistency of 0.31.
Evidence-based practice was measured using the Evidence- Based Practice Questionnaire (EBPQ-19) developed by Upton and Upton (2006). The EBPQ-19 Questionnaire consists of 19 items, structured in three dimensions: (a) practice, which includes six items (e.g. ‘Formulated a clearly answerable question as the begin- ning of the process towards filling this gap or ‘Tracked down the relevant evidence once you have formulated the question’); (b) atti- tude with three items (e.g., ‘I welcome questions on my practice’ or ‘Evidence-based practice is fundamental to professional practice’); and (c) professional knowledge and skills for evidence-based prac- tice with 10 items (e.g., ‘Knowledge of how to retrieve evidence’ or ‘Ability to critically analyze evidence against set standards’). Each item scores from 1–7, with 1 being the least favourable value and 7 the most favourable in terms of competence in the application of EBP. The scale ranges from 19–133 points. We used the Spanish adaptation of this questionnaire validated by Pedro Gómez et al. (2009) with Cronbach's alpha values of 0.89, 0.72 and 0.92 for each of the factors. In our sample, the Cronbach's alpha values were 0.92 for the total scale and 0.88, 0.50 and 0.92 for each of the factors.
3 | R E S U LT S
Of the 235 nurses who were invited to participate, 198 nurses agreed to participate in the study and answered the form. The aver- age age of participants was 33.8 years (SD 9.23). Only 27.5% were male and almost 80% of the nurses lacked the official qualification of mental health nurse. One third of the nurses (33.2%) had offi- cial postgraduate training (Masters or PhD studies). The mean num- ber of years’ experience in mental health was 7.9 years (SD 7.45). Regarding the relationship between the nurses' socio-demographic and professional variables and the EBPQ and WAI, experience in mental health was associated with a greater therapeutic alliance (r = 0.221, p = .002) whereas no association was found with a greater EBPQ. Furthermore, associations between higher academic level and greater competence for EBP were found (t = -2.957, p = .003).
T A B L E 2 Relationship between the EBPQ and the level of therapeutic relationship of nurses
Variable Practice Attitude Knowledge/ Skills EBPQ
Bond 0.194** 0.273*** 0.244*** 0.287***
Objectives 0.089 0.189** 0.058 0.127
Tasks 0.250*** 0.265*** 0.308*** 0.340***
WAI-S 0.233*** 0.317*** 0.264*** 0.328***
Note: EBPQ, Evidence-Based Practice Questionnaire; WAI-S, Working Alliance Inventory Short. *p < .05, **p < .01, ***p < .001.
Variable β
Model 1 (Adj R2 = 0.161)
P-value β
Model 2 (Adj R2 = 0.175)
P-value95% CI 95% CI
Gender (female)
1.135 −0.554-2.823 .187 1.142 −0.538-2.822 .181
Years of MH experience
0.222 0.107-0.336 <.0001 0.224 0.111-0.338 <.0001
Highest education (PhD or master's degree)
1.355 −0.277-2.987 .103 1.427 −0.225-3.079 .090
MH Nursing Specialty (no)
1.430 −0.698-3.557 .187 1.473 −0.658-3.604 .174
EBPQ 2.276 1.303-3.250 <.0001
Practice 0.285 −0.484-1.054 .465
Attitude 2.047 0.876-3.217 .001
Knowledge/ Skills
0.619 −0.312-1.550 .191
Note: Abbreviations:EBPQ, Evidence-Based Practice Questionnaire; CI, confidence interval; MH, mental health
T A B L E 3 Multiple linear regression examining the association between the EBPQ and the therapeutic relationship (N = 198)
| 1767MORENO-POYATO ET Al.
Likewise, higher academic level was associated with greater thera- peutic alliance (t = -2.222, p = .027). In contrast, specific training as a mental health nurse specialist was not related with either EBP or the therapeutic alliance (Table 1).
A bivariate analysis was conducted to study the association be- tween the dimensions of the EBP competence of nurses and the therapeutic alliance and associated factors. A significant positive correlation was observed between most dimensions and the total scores of both scales. Particularly noteworthy were the positive as- sociations between competence for EBP and the relationship of the same with the level of the therapeutic alliance, specifically regarding the factor for agreement on tasks (Table 2).
To determine whether the level of therapeutic alliance could be explained, firstly, by the competence for EBP and the socio-profes- sional factors of the nurses and secondly, incorporating the dimen- sions of competence for EBP and the socio-professional factors, two linear regressions were calculated (Table 3). Model 1 was significant (F (5, 192) = 8.568, p < .0001), with the variables incorporated into the model representing 16.1% of the variation in the level of nurses' therapeutic alliance. It should be noted that competence for EBP was the most influential variable in this first model (β = 2,276, p < .0001). The second model (F (7, 190) = 6,972, p < .0001) revealed that the most influential dimension for therapeutic alliance was the attitude towards EBP (β = 2,047, p = .001). This model explained 17.5% of the variation of the level of the therapeutic relationship.
Subsequently, we examined the influence of the competence dimensions for EBP and each of the factors of the therapeutic al- liance. For this purpose, linear regressions were calculated once again, adjusted for nurses’ socio-professional variables. The models that emerged from examining the influence of EBP on the bond and the agreement on therapy goals between nurses and their patients, were also significant, although they only explained 10% and 5% of the changes in the bond (F (7, 190) = 4.034, p < .0001) and in the
agreement on therapy goals (F (7, 190) = 2.558, p = 0,015). In both models, the only influential dimension was attitude towards EBP, with β = 0.686 (p = .005) and β = 0.735 (p = .014) respectively. However, when examining the influence of EBP dimensions on task agreement, once again a model was obtained which explained over 16% of the changes in the agreement on tasks (F (7, 190) = 6.610, p < .0001). In this model, experience (β = 0.096, p < .0001) and gender (β = 0.872, p = .027) were significant socio-professional variables for nurses. In addition, in this model it is noteworthy that attitude (β = 0.625, p = .023) and knowledge/skills for EBP (β = 0.500, p = .022) were predictor variables (Table 4).
4 | D I S C U S S I O N
The aim of this study was to examine the relationship between the dimensions of EBP among mental health nurses and the therapeutic relationship they establish with their patients. According to our find- ings, it is worth highlighting that a greater EBP improves the thera- peutic relationship established by nurses in mental health units. Although this relationship appears to be evident from a theoretical- conceptual point of view, since therapeutic relationship has tradi- tionally been considered as the axis of care in mental health nursing (Felton et al., 2018; Harris & Panozzo, 2019; Peplau, 1988), this find- ing enables us to confirm the association between both constructs, from a quantitative point of view. This reinforces the statement that the therapeutic relationship is not only based on an experiential con- struction of a relationship between nurse and patient (McAndrew et al., 2014), rather it also improves when the nurse shows greater competence for EBP.
In terms of the specific characteristics of nurses, it should be noted that, unlike other studies, the nurses who showed the great- est competence for EBP were those with the highest educational
T A B L E 4 Association between nurses’ characteristics and EBPQ’s subscales with WAI’s subscales (N = 198)
Dependent variables
Bond (Adj R2 = 0.097)
Goals (Adj R2 = 0.052)
Tasks (Adj R2 = 0.166)
Independent variables β 95% CI
P- value β 95% CI P-value β 95% CI P-value
Gender (female) 0.240 −0.452 to 0.931 .495 0.031 −0.808 to 0.870 .943 0.872 0.099 to 1.645 .027
Years of MH experience
0.050 0.003 to 0.097 .037 0.079 0.022 to 0.135 .007 0.096 0.044 to 0.148 <.001
Highest education (PhD or master's degree)
0.529 −0.151 to 1.209 .126 0.564 −0.261 to 1.389 .179 0.333 −0.426 to 1.093 .388
MH Nursing Specialty (no)
0.383 −0.495 to 1.260 .391 0.112 −0.952 to 1.176 .836 0.978 −0.002 to 1.958 .05
Practice 0.058 −0.258 to 0.375 .718 0.071 −0.313 to 0.455 .715 0.156 −0.198 to 0.510 .385
Attitude 0.686 0.204 to 1.168 .005 0.735 0.151 to 1.320 .014 0.625 0.087 to 1.164 .023
Knowledge/ Skills
0.267 −0.117 to 0.650 .172 −0.147 −0.612 to 0.318 .533 0.500 0.072 to 0.928 .022
Note: Abbreviation:EBPQ, Evidence-Based Practice Questionnaire; WAI, Working Alliance Inventory; CI, confidence interval; MH, mental health
1768 | MORENO-POYATO ET Al.
level (Wonder et al., 2017; Moore, 2017; Rojjanasrirat & Rice, 2017). However, in line with other previous studies, the nurses' experi- ence was not associated with improved EBP (Wonder et al., 2017; Moore, 2017; Rojjanasrirat & Rice, 2017). This fact is remarkable given that experience is a factor associated with EBP from a the- oretical point of view (DiCenso et al., 1998) and some studies have also confirmed this association (Hamaideh, 2017; Zhou et al., 2016). Likewise, no differences were found regarding whether the nurses had training in the specialty of mental health nursing. We were un- able to compare this finding with other studies due to a lack of liter- ature in this area, however, it raises the question of whether training for mental health specialists in our context is including content on EBP.
Regarding the association between EBP dimensions and the therapeutic relationship, the dimension which most influenced the overall therapeutic relationship was the attitude of nurses to- wards EBP. In fact, the attitude towards EBP is often the highest rated factor by nurses in most settings and specialties (Cavazos- Rehg et al., 2014; Wonder et al., 2017; Moore, 2017; Ramos- Morcillo et al., 2015; Zhou et al., 2016). In addition, nurses' beliefs and attitudes about the importance and value of EBP have been identified as one of the most important attributes for implement- ing EBP (Schaefer & Welton, 2018). When nurses have positive attitudes on this topic, it is easier for them to implement changes in their daily practice (Saunders & Vehviläinen-Julkunenb, 2016). The attitude of the nurse towards the recipient of their care is an inherent part of the profession, which must be focused on pa- tients’ needs, as negative attitudes prevent the establishment of a quality therapeutic relationship (Wahl & Aroesty-Cohen, 2010). Teaching future professionals should not reinforce certain nega- tive attitudes but rather create strategies in the studies that help generate attitudes of greater acceptance and understanding of the person. However, neither practice nor knowledge explained im- provements in the overall therapeutic relationship. Indeed, both knowledge and practice of EBP were the dimensions that scored the lower mean scores by the nurses. These results could be due to the difficulties described in the literature affecting EBP in men- tal health nursing such as lack of training, lack of time and lack of resources for EBP, factors that directly affect both nurses' knowl- edge and the use of evidence in clinical practice (Alzayyat, 2014; Hamaideh, 2017; Yadav & Fealy, 2012).
The analysis of the association between EBP dimensions and each of the dimensions of the therapeutic relationship, revealed a significant association between the attitude towards EBP and experience and each of the dimensions of the therapeutic relation- ship. The results indicate that a better attitude towards EBP al- lows the establishment of a greater bond of trust with the patient in the context of the therapeutic relationship, an element with a strong attitudinal component (Bordin, 1979) and basic in the first phase of the therapeutic relationship (Peplau, 1997). In this sense, a higher score in the attitude towards EBP represents nurses who are open to dialogue and change, who do not judge others when they criticize their actions and who try to integrate opinions and
knowledge as part of a possible improvement. In short, a nurse who accepts comments and does not judge these, who adopts the patients’ perspective and accepts it, strengthening the link formed in the nurse–patient therapeutic relationship (Moreno-Poyato & Rodríguez-Nogueira, 2020). However, the nurses' experience had more weight in explaining the improvements in factors such as agreement on goals and tasks. It should also be noted that a better agreement on the tasks was influenced by attitude and by a greater knowledge and skills for EBP. Consequently, a higher level of knowledge and skills of EBP nurses is more relevant in the working phase during the therapeutic relationship process (Peplau, 1997). This finding is particularly relevant as it confirms that knowledge and skills for EBP are necessary for person-cen- tred care and shared decision-making. These are aspects that positively condition the therapeutic relationship and are directly related to the trend in current mental health care that focuses on the paradigm of autonomy and the recovery model which recog- nizes the importance of person-centred care. The main elements of the recovery model include a greater involvement of the service users, a vision of the person beyond his or her illness and the fa- cilitating treatment selection. In short, the recovery model aims to reverse the role of the service user from being a follower to another where they can lead, change and direct their own care (Newman et al., 2015; Smith & Williams, 2016).
4.1 | Limitations
This study has several limitations. First, the cross-sectional de- sign did not allow us to detect changes in nurses’ perceptions over time, nor make causal inferences. Second, it is important to consider that the therapeutic relationship was assessed as a gen- eral measure and, this was related with nurses’ overall percep- tions of the therapeutic relationship, which could have differed from those of their patients. Finally, although the purpose of the study was not to validate the scales used, it should be noted that the internal consistency of the objectives subscale of the WAI-S in our study was low. In contrast, one of the study strengths was the rate of participation among nurses in the participating institu- tions. Therefore, the results can be generalized to the nurses of mental health units in Spain. It is likely that the results can be ex- trapolated to other countries where the training plans for nurses and the care settings in mental health units are similar to those of this study. Furthermore, we identified specific relationships between the dimensions of EBP and the therapeutic relationship and, although the degree of influence from the predictive point of view was not high, it should be considered that taking into ac- count that the therapeutic relationship is a multifaceted construct, the amount of explained variance is significant and could be con- sidered to be high. These findings suggest the need to perform further in-depth studies of the factors that influence the quality of the therapeutic relationship. In addition, it would be advisable to replicate the study on an international level to confirm the results
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and to elaborate strategies to improve EBP and, consequently, im- prove the quality of the therapeutic relationship.
5 | C O N C L U S I O N
The results of our study contribute to a greater understanding of the relationship between the dimensions of evidence-based practice and therapeutic relationship in nurses working in mental health units. The results confirm that increased evidence-based practice improves the establishment of the nurse–patient therapeutic relationship in mental health units. In general, the association of nurses' attitudes with their experience in therapeutic relationship is noteworthy. Specifically, an improved nurse attitude and knowledge of evidence-based practice increases shared decision-making with patients, which is basic to per- son-centred care. An improved attitude towards EBP is likely to help nurses working in mental health units to apply the knowledge acquired in daily clinical practice, improving care through new evidence-based practices.
A C K N O W L E D G M E N T S We would like to acknowledge all the participants of MiRTCIME. CAT project and the College of Nurses of Barcelona for financial support (PR-218/2017). We also thank Dr. Xavier Duran from the Methodological and Biostatistical Advisory Service of the IMIM, Barcelona, for his cooperation.
C O N F L I C T O F I N T E R E S T No conflict of interest has been declared by the authors.
A U T H O R C O N T R I B U T I O N S ARMP, JFRM and GCG made substantial contributions to the con- ception or design of the work; or the acquisition, analysis or inter- pretation of data for the work. JFRM contributed the main part of the data analysis. ARMP, JFRM, GCG and ORN helped in drafting the work or revising it critically for important intellectual content. ARMP, JFRM, GCG and ORN 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.
F U N D I N G I N F O R M AT I O N College of Nurses of Barcelona (PR-218/2017).
P E E R R E V I E W The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.14715.
O R C I D Antonio R. Moreno-Poyato https://orcid.org/0000-0002-5700-4315 Georgina Casanova-Garrigos https://orcid.org/0000-0002-3652-9745 Juan F. Roldán-Merino https://orcid.org/0000-0002-7895-6083
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How to cite this article: Moreno-Poyato AR, Casanova- Garrigos G, Roldán-Merino JF, Rodríguez-Nogueira Ó; MiRTCIME.CAT working group. Examining the association between evidence-based practice and the nurse-patient therapeutic relationship in mental health units: A cross- sectional study. J Adv Nurs. 2021;77:1762–1771. https://doi. org/10.1111/jan.14715
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