Commentary: Psychometric properties of the Turkish version of the therapeutic relationship assessment scale for nurses

The therapeutic relationship is at the heart of mental health nursing, underpinning a person-centred approach which fosters recovery and optimism (Hartley et al., 2020). The paper reported on the psychometric properties of a Turkish translation of the Therapeutic Assessment Scale for Nurses. The scale consists of 25 statements addressing factors of empathy, self-knowledge, participation (involvement in patient care) and orientation (introducing oneself and getting to know the patient). The researchers followed a thorough translation procedure with bilingual academics who had expertise on the topic translating the scale to Turkish; having a Turkish linguistics academic check the translated version for clarity and linguistic correctness; then carrying out a back translation to English by bilingual speakers whose first language is English, verifying the items against the original scale. The scale was then tested for content and construct validity over two stages, firstly with a small group of academics and clinicians, and secondly with a larger group of nurses. Exploratory and confirmatory factor analytic techniques were used to check the underlying four factors. The translation was carried out as the authors report that there is currently no instrument in Turkish which evaluates the therapeutic relationship between nurses and their patients.

The ability to measure the therapeutic relationship between nurses and patients is challenging but important. It is challenging because it is argued that the skills associated with therapeutic relationships are implicit and difficult to quantify (Hartley et al., 2020; Zugai et al., 2015). However, this undermines the importance of developing the evidence base for identifying the factors that promote therapeutic relationships as well as those that hinder them. Measures for therapeutic relationships can help to provide an evidence base for the skills and qualities required to build positive relationships and therapeutic milieus in psychiatric settings. The paper discusses the importance of the therapeutic relationship in relation to nursing and in particular mental health nursing. In psychiatric inpatient units, it is nurses who spend most time with patients; so, these relationships are fundamental to quality of care and the recovery approach (Hartley et al., 2020). The therapeutic relationship in mental health nursing has been linked with improved outcomes for patients in terms of promoting autonomy, improved well-being, better engagement with services, achievement of personal goals, insight into own mental health, greater self-care and increased progress towards recovery (Zugai et al., 2015). The therapeutic relationship has been described not just as contributing to good treatment but being ‘the treatment’ (Hartley et al., 2022: 23).

In addition to the benefits for patients, the therapeutic relationship also impacts staff job satisfaction and burnout. The therapeutic relationship requires the nurse to show warmth, friendliness, and interest in the patient (Kornhaber et al., 2016). The ability to show these qualities requires self-awareness, good emotion regulation, adept communication skills and in theory the ability to be authentic (Edward et al., 2017). In order to achieve this, nurses must be able to regulate their emotions and behaviours and adapt to the needs of their patients who may present in emotionally challenging ways (Gulsen and Ozmen, 2020). Hochschild (1983) referred to the effort involved in portraying this professional persona as ‘emotional labour’. The greater the gap between real feelings and portrayed feelings, the greater the effort or emotional labour involved (Grandey & Sayre, 2019) and the higher the level of emotional exhaustion which impacts the worker both in their personal and professional roles (Gulsen and Ozmen, 2020). Self-awareness has been found to reduce emotional labour in that people are better able to manage feelings if they are aware of them than if they are not (Edward et al., 2017).

Despite its associated importance with patient outcomes and professional fulfilment, there is a lack of research into the topic (Hartley et al., 2020). Measures that evaluate therapeutic relationships can identify the skills required that could be developed and honed throughout nursing education and practice (Harris and Panozzo, 2019). Importantly, measures of therapeutic relationships may also be used to assess associations with organisational factors which are protective of such relationships such as support, training and supervision (Edward et al., 2017).

Biography

Manuela Jarrett, RMN, PhD is Assistant Professor in Mental Health Nursing. Her research is focused on mental health of people in the criminal justice system.