Using the Topic: Therapeutic Approaches in Psychiatric Nursing Care Article title: Examining the association between evidence-based practice and the

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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