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The correlation between the clinical competency and empathy of

ORIGINAL ARTICLE

nurses: Case study, Intensive Care Units of the educational hospitals


of Kerman Medical Sciences University, Iran
Zohre Jahanshahi, Alireza Ghahri Sarabi1, Fariba Borhani2, Malihe Nasiri3, Sima Zohari Anboohi3
Departments of Nursing, 1Faculty of Operation Room and Anesthesiology, College of Nursing and Midwifery, Shahid Beheshti University
of Medical Sciences, 2Medical Ethics and Law Research Center, College of Nursing and Midwifery, Shahid Beheshti University of Medical
Sciences, 3Department of Biostatistics, Faculty of Paramedical Sciences, College of Nursing and Midwifery, Shahid Beheshti University of
Medical Sciences, Tehran, Iran

ABSTRACT
Background and Purpose: Special nursing is considered an expertise in nursing profession and requires a special
competency. Empathy is complementary to the skills and knowledge needed to effectively treat a patient. Clinical
competency and empathy are followed by effective health cares. The aim of this study was to assess the correlation
between clinical competency and empathy of nurses employed in Intensive Care Units (ICUs). Methodology: This
descriptive, correlational study was carried out on 231 nurses employed in the ICUs of the educational hospitals of
Kerman University of Medical Sciences that were selected through a census. The data collection tools included an
intensive care nursing competency scale and a nursing empathy assessment questionnaire. Data were analyzed using
the SPSS version 20 software and the independent t‑test, ANOVA, Pearson’s correlation coefficient and regression.
Results: The study results indicated that the mean score of nurses’ clinical competency was 574.08 ± 86.51, and
the mean score of empathy was 150.12 ± 17.04. The highest level of clinical competency belonged to the field of
knowledge, and the lowest level belonged to the field of skill. The highest level of empathy was related to the behavioral
area, and lowest level was related to the emotional area. There was a correlation between the two variables of clinical
competency and empathy and all of their areas (the overall correlation coefficient r = 0.7 and P < 0.001). Conclusion:
Given the relationship between clinical competency and empathy, it can be concluded that a higher clinical competency
in nurses makes them more likely to establish an empathetic relationship with patients. According to the findings of
this research, nursing managers and nursing education planners can provide appropriate conditions to enhance the
clinical competency of nurses and improve their chance of establishing empathetic relations.

Key words: Clinical competency, empathy, intensive cares, nurse

Introduction professional position.[2] According to the opinion of the


International Council of Nurses, the knowledge, skills,
One of the controversial topics in the field of health and competency of nurses are vital to ensure the quality
is clinical competency.[1] Competency is introduced of patient care.[3] Assessment of clinical competency
as a special adjective for judgment of the quality has a very important role in the management of the
or capability of individuals and is a reflection of the
knowledge, critical thinking, individual, and technical This is an open access article distributed under the terms of the
skills that lead professional individuals to a clinical and Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0
License, which allows others to remix, tweak, and build upon the
work non‑commercially, as long as the author is credited and the
Access this article online new creations are licensed under the identical terms.
Quick Response Code: Website:
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Cite this article as: Jahanshahi Z, Sarabi AG, Borhani F, Nasiri M,


DOI: Anboohi SZ. The correlation between the clinical competency and
10.4103/ATMPH.ATMPH_233_17 empathy of nurses: Case study, Intensive Care Units of the educational
hospitals of Kerman Medical Sciences University, Iran. Ann Trop Med
Public Health 2017;10:694-701.

Correspondence:
Prof. Alireza Ghahri Sarabi, Department of Operation Room and Anesthesiology, College of Nursing and Midwifery, Shahid Beheshti University of
Medical Sciences, Tehran, Iran. E‑mail: args1340@yahoo.com

694
694 © 2017 Annals of Tropical Medicine and Public Health | Published by Wolters Kluwer - Medknow
Jahanshahi, et al.: Clinical competency and empathy of nurses

process of providing care, ensuring the appropriate creation and maintenance of interpersonal relations.[16]
provision of cares, achievement of care provision When an empathetic nurse cares for a patient, outcomes
goals, identification of fields requiring promotion, such as relief from tension, a high level of physical and
determination of the educational needs of nurses, and mental well‑being, reception of emotional responses
safety of care.[4] to conditions, increased conformity and increased
cooperation with the medical team will be provided
Clinical competency in nursing has a high relationship to patients.[17] An empathetic relationship between a
with increased safe performance, quality of care, nurse and a patient not only improves the experience
patient satisfaction, decreased medical errors, hospital of the patient as the receiver of the care but will also
infections, mortality, postoperative complications, and lead to positive medical outcomes.[14] Empathy can
accidental dislocation of endotracheal tube, particularly increase patient satisfaction, lead to a more correct
in Intensive Care Units (ICUs).[5,6] A competent person diagnosis and treatment[18] and it particularly influences
improves and guarantees the quality of care and patient adherence to care recommendations and decreases care
satisfaction.[7] Since patients in ICUs are responsible errors[19] and has a direct relationship with the positive
for the provision of specialized cares to patients clinical outcome of patients, decreased exhaustion, and
with severe conditions with potential and active dissatisfaction.[20,21] A lack of empathy in the relationship
complications in their vital organs and are subject to a between the medical personnel and a patient can disrupt
high risk of complications threatening their health, it the processes of diagnosis, treatment, and care.[14] Given
is significantly important to have clinical competency the necessity of the empathetic relationship of nurses
for the provision of care to these patients in the with patients to access medical goals and promote the
complicated environments of the ICU.[8] quality of care and also the importance of the relationship
between a patient and a nurse in ICUs, it is necessary to
Conceptually, clinical competency and empathy are investigate the empathy of nurses with these patients.
followed by more effective medical cares. A relationship Nurses’ empathetic attitude has a special place for the
between a medical team and a patient based on empathy adhesion of patients to treatment and prediction and
compliments the skills and knowledge required for the rating of clinical competency and correct diagnosis by
effective treatment of the patient.[9] Researchers believe nurses.[22]
that although there have been many developments in
the field of physical cares in the ICU, but in general, Currently, despite the importance of the subject,
care of all the human aspects that include the mental there is little awareness about the status of nurses’
and spiritual care of patients is neglected.[10] Therefore, competency and empathy in ICUs, and few studies have
nurses of ICUs should not only provide for the been performed in this area in Iran, and even in these
physiological needs of patients but also provide the few studies, nurses’ clinical competency has not been
mental needs of the patients by establishing a correct measured with specialized tools for clinical competency.
relationship.[11] In ICUs, the relationship with a patient However, the results of studies performed about the
is of special importance and priority because nurses in relationship between clinical competency and empathy
the ICU are responsible to provide care for patients who area contradicting. Casas et  al. (2016)  indicate the
may die at any moment. An appropriate relationship existence of a relationship between empathy and
with a patient in these units, decrease their anxiety clinical competency,[21] while in Maleki, no significant
and worries and improves the treatment process of the relationship was seen between empathy and clinical
patients. One way of establishing a relationship with a competency.[23] Ogle et  al. concluded in their study
patient is to create empathy with him.[12] Empathy is that there is a strong relationship between clinical
a fundamental component in the relationship between competency and empathy assessed by a supervisor,
a nurse and a patient, and nurses are expected to use but there is no relationship between self‑assessed
this ability in providing medical care.[13] Empathy empathy and clinical competency.[9] Given the issues
includes the ability to understand the experiences, mentioned about clinical competency, empathy and
worries, and opinions of others and the capability to the importance of evaluating them and also limited
establish a relationship based on this understanding,[14] studies about the investigation of the correlation
and in a general, it is the ability to place oneself in the between clinical competency and empathy, existence
position of others to better understand the experiences of contradicting results in previous studies, it seems
and feelings in a mutual interaction.[15] Empathy has necessary to perform this study and by performing this
a fundamental role in interpersonal commitments, study, it is possible to assess the relationship between
social interactions, friendship and maintenance of various areas of clinical competency and empathy,
it, improved health, increased possibility of receiving and investigate the synergic or decreasing effect of the
or giving assistance, altruism, social cohesion, and desired areas.
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Jahanshahi, et al.: Clinical competency and empathy of nurses

Methodology the range of 38–190 and a higher score means a higher


sympathy with an individual patient.
This is a descriptive, correlational study. The study
population consists of nurses employed in ICUs and In this research, to determine the validity of the tool of
cardiac care units (CCUs) of the educational hospitals empathy, a content validity index (CVI), and content
of Kerman University of Medial Sciences who at least validity ratio (CVR) were used. For this purpose, the
had a bachelor’s degree in nursing. empathy assessment questionnaire was given to ten
professors of this field who were of the professors of
In this study, sampling was performed through a Shahid Beheshti University of Medical Sciences. Next,
census. Such that the questionnaires were given to all they were asked to determine the necessity level of each
the nurses employed in ICU and CCU, with a total term based on the CVI (level of clarity, relevance, and
number of 260 nurses, out of this number, 231 nurses simplicity based on a 4‑part score criterion) and CVR.
completed the questionnaire. The attrition rate was The CVI of each question was determined which for
11% which is statistically acceptable. all the questions amounted to a value higher than 0.8,
and the overall value of it for all the tools was 0.89. The
For data collection, three questionnaires were used: CVR of each question was determined which ranged
(1) Demographic data questionnaire consisting from 0.8 to 1 and the overall value of it for all the tools
of 14 questions about age, gender, marital status, was 0.94.
employment status, level of education, overall years
of service, work background in ICU, work shift, To determine the reliability of the questionnaire,
average weekly work hours, overtime, history of internal consistency, and re‑testing were used. To
illness and history of drug use, history of the stay of measure the internal consistency, the questionnaire
a family member, or friend in an ICU. (2) Farsi scale was given to twenty nurses working in an ICU, and
of ICU nursing competency used to assess the clinical its Cronbach’s alpha was calculated. The overall
competency of nurses. This scale was designed by Cronbach’s alpha coefficient of the empathy assessment
Lakanema et al. in 2012 and underwent psychometry questionnaire was 0.94, and the Cronbach’s alpha
and introduced as a valid and reliable scale for the coefficient of the ICU nursing competency scale was
assessment of ICU nursing competency. This scale has 0.97. Also to measure external consistency using retest,
the four areas of knowledge base, skill base, attitude the questionnaire was given 20 nurses working in an
and value base, and experience base and 144 items with ICU, and 2 weeks later, the questionnaire was given to
each area including 36 items. Each item is investigated the same individuals again, and then, its reliability was
in a 5‑point Likert Scale with the scores ranging from calculated through an intraclass correlation coefficient.
1 = very poor to 5 = very good. The tools’ scores are The intraclass correlation coefficient in the cognitive,
categorized as poor competency (144–288), average emotional, behavioral, and ethical fields of the
competency (289–432), good competency (433–576), empathy assessment questionnaire were 0.90, 0.85,
and excellent competency (577–720). These tools were 0.78, and 0.92, respectively, and in the dimensions of
translated by Shouryabi in 2014 in Iran and underwent knowledge, skill, attitude, and value and competency
psychometry.[24] (3) The questionnaire of nurses’ scale experience this value was 0.90, 0.88, 0.83, and
empathy was prepared by Rahmatizadeh in 2015 under 0.92, respectively.
the supervision of Hojjat by adopting his tools.[25]
This questionnaire consists of 38 questions, out of In this research, after receiving the approval of the Ethics
which twenty questions were taken from the standard Committee in Shahid Beheshti School of Nursing and
20‑item questionnaire of Jefferson which was created Midwifery and also receiving permissions from the study
by Hojat et al. to investigate the level of physiologists’ hospitals, to collect the data, the researcher visited the
empathy, and 18 questions were added to it after ICU and CCU of the educational hospitals of Kerman
consultation with nursing and psychology professors. in the three work shifts of morning, evening, and night
The advantage of this questionnaire over the standard while carrying the questionnaire and after going through
20‑item questionnaire of Jefferson is that the questions the stages of self‑introduction, statement of research
of this questionnaire are categorized in the four areas goals, ensuring the participants of the confidentiality
of cognitive, emotional, behavioral, and ethical. The of the information and receiving a written permission
scores obtained are based on a Likert scale (5 = very from the nurses participating in the research, and
much, 4 = much, 3 = almost, 2 = little, and 1 = very attempted to collect the data. The participants were
little) which are given to the areas of cognitive, asked to complete the questionnaires (utmost within
emotional, behavioral, and ethical empathy of nurses 3 days) any time that they consider appropriate and
with patients. The total score of the individuals is at return them.
696
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Jahanshahi, et al.: Clinical competency and empathy of nurses

The SPSS version 20 statistical software developed 150.12 ± 17.04. Since the number of the questions of
by IBM Corporation was used for data analysis. First the four fields are not equal, therefore in order for it
descriptive indices such as mean and standard deviation to be clear that, in which field the lowest or highest
were reported and to determine the correlation between empathy levels are, the mean of empathy with the
clinical competency and empathy; the Pearson’s number of the questions must be considered. The
correlation coefficient was used. Mutual relations highest mean of empathy belonged to the behavioral
between clinical competency, empathy, and effective category, and the lowest mean of empathy belonged to
variables were investigated using ANOVA, t‑test, and the emotional category [Table 3].
linear regression. In the tests performed, a confidence
coefficient of 95% and degree of significance of (α = The result of the Pearson’s correlation coefficient test
0.05) were considered. The Kolmogorov–Smirnov test showed that since r = 0.7 and P < 0.001, therefore,
was used to investigate the normality of the data and there is a direct relationship between the amount of
all the variables were normal (P > 0.05). nurses’ clinical competency and their empathy level,
which was statistically significant. This means that a
Results higher clinical competency of nurses indicates that they
are more likely to establish an empathetic relationship
The results showed that out of the 231 participating with patients. There is a direct relationship between
nurses, 67.96% (157 individuals) worked in an ICU and all the fields of clinical competency (knowledge,
32.04% (74 individuals) worked in a CCU. Most of the skill, attitude and value, and experience) and all the
nurses were in the age range of 31–38. The overall service categories of empathy (cognitive, ethical, emotional,
years of most of the nurses ranged from 6% to 10. 90.5% and behavioral). The highest level of correlation
of the nurses (209 individuals) were female, 74.9% (173 was between the field of attitude and value and
individuals) were married, 95.2% (220 individuals) had the behavioral category, and the lowest amount of
a bachelor’s degree, 32.5% (75 individuals) had contract correlation was between the field of attitude and value
employment, 91.3% (211 individuals) had rotational and the emotional category [Table 2].
shiftwork, 66.2% (153 individuals) had compulsory
overtime, 92.2% (213 individuals) had no history of In investigating the demographic components related
illness. 90.9% (210 individuals) had no history of drug to clinical competency, findings suggested that there
use. 58% (134 individuals) had no history of the stay of was a relationship between clinical competency and
a family member or friend in an ICU. The weekly work variables such as marital status, compulsory overtime,
hours of the majority of the nurses ranged from 41 to 60. history of drug use, history of the stay of a family
member or friend in an ICU, the type of ICU that
The overall minimum and maximum mean clinical nurses are employed in, employment status, work
competency of the nurses were 144 and 720, shift, work background in ICUs, overall years of service
respectively, 574.08 ± 86.51, which is good. The in an ICU, age and number of weekly work hours, and
score of the clinical competency of the majority of the factors such as gender, different levels of education, and
nurses (56.7%) was excellent [Table 1]. The highest history of illness had no effect on the amount of the
competency score belonged to the field of knowledge, clinical competency of nurses.
and the lowest competency score belongs to the field of
skill [Table 2]. Factors such as the type of employment of nurses,
overall years of service in an ICU, number of weekly
The overall empathy mean of the nurses ranged work hours, age, marital status, compulsory overtime,
from 38 at the minimum to 190 at the maximum the type of ICU that the nurses are employed in,
history of the stay of a family member or friend in
Table 1: Frequency distribution of nurses employed in an ICU and work shift affected the level of empathy
the Intensive Care Units of the educational hospitals of in nurses but a history of the presence of illness,
Kerman University of Medical Sciences in 2016 based on history of drug use, different levels of education,
the scores obtained in clinical competency and gender did not affect the level of the empathy
The score obtained in clinical Level of clinical n (%) of nurses.
competency competency
144-288 Poor 4 (1.7) In the present study, regression analysis of the study
289-432 Average 13 (5.7) variables showed that clinical competency affects the
433-576 Good 83 (35.9) level of empathy in nurses such that for each 1 score
577-720 Excellent 131 (56.7) increase of clinical competency, the score of empathy
Total 231 (100)
increases by a value of 0.11 [Table 4].
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Table 2: The correlation between the categories of clinical competency and the categories of empathy of nurses employed
in the Intensive Care Units of the educational hospitals of Kerman University of Medical Sciences in 2016
Empathy Clinical competency
Knowledge (r, P) Skill (r, P) Attitude and value (r, P) Experience (r, P)
Cognitive 0.49, <0.001 0.53, <0.001 0.51, <0.001 0.50, <0.001
Emotional 0.44, <0.001 0.40, <0.001 0.34, <0.001 0.40, <0.001
Ethical 0.57, <0.001 0.58, <0.001 0.53, <0.001 0.55, <0.001
Behavioral 0.57, <0.001 0.60, <0.001 0.63, <0.001 0.58, <0.001

Table 3: Clinical competency, empathy, and their their study (empathy is relate to clinical competency
categories in nurses employed in the Intensive Care Units in medical cares) showed that the observed behavioral
of the educational hospitals of Kerman University of criteria of empathy measured by the supervisor, are
Medical Sciences in 2016 greatly related to clinical competency, and a strong
Categories Number of Mean±SD Mean±SD of a score by relationship was seen between empathetic behaviors
questions taking into account the and clinical competency in medical positions. However,
number of questions
a self‑assessed empathy is not related to clinical
Clinical
competency
competency.
Knowledge 36 149.37±23.20 4.14±0.64
Skill 36 140.09±22.57 3.89±0.62 The overall mean of clinical competency of nurses
Attitudes 36 142.86±24.85 3.96±0.69 employed in the ICUs of the educational hospitals of
and values Kerman University of Medical Sciences in 2016 was
Experience 36 141.74±21.28 3.93±0.59 574.08 ± 86.51 which was at a good level. The clinical
Total 144 574.08±86.51 3.98±0.60 competency score of the majority of nurses (56.7%)
Empathy was excellent. Since the present study is the first study
Cognitive 11 43.77±6.31 3.97±0.57 performed to investigate the clinical competency of
Ethical 7 27.46±3.76 3.92±0.53 nurses employed in ICUs using these tools; therefore,
Emotional 8 30.90±4.70 3.86±0.58 it was not possible to compare the results of this study
Behavioral 12 47.99±6.82 3.99±0.56
with other studies for different categories. In the study
Total 38 150.12±17.04 3.95±0.44
of Maleki performed to assess the clinical competency
SD=Standard deviation
of nurses employed in the cancer wards of the selected
hospitals of Tehran University of Medical Sciences, Iran,
Discussion the value of clinical competency in 72.3% of the nurses
was assessed as being good. The study by Bahreini et al.
There is a direct relationship between the mean of the in 2010 performed on the self‑assessment of clinical
overall clinical competency of nurses and the mean competency of nurses employed in various wards of
of their overall empathy. This means that a higher Shiraz Hospital Iran, indicated a good level of clinical
clinical competency in nurses makes them more likely competency where the greatest clinical competency
to establish an empathetic relationship with patients. belonged to the nurses of CCU. The research findings
The results of this research are in alignment with the of the study of Shatery performed to investigate the
results of the studies of Hojat et  al. in 2002[26] and clinical competency of nurses in the ICUs of Tehran
Ogle et  al. and contradict the results of Maleki. The University of Medical Sciences, showed that the
results of the study of Maleki showed that there is level of clinical competency of 22.8% of ICU nurses
no relationship between the amount of empathy and was poor, 67% was average, and 9.8% was strong.[27]
clinical competency of nurses employed in the cancer Ghalgeh et al. in their study performed to investigate
wards of the selected hospitals of University of Tehran, the correlation between the clinical competency of
Iran. Hojat et  al. in 2002 in their study (with the nurses and patients’ satisfaction of nurses’ services,
title: investigating the empathy of medical students reported the clinical competency of 82.9% of the
and its relation to gender, academic performance, and nurses of the clinical wards participating in their study
clinical competency) concluded that samples with a as being at the expected level.[28] The study of Karimi
higher empathy enjoyed a higher clinical competency. Moneghy et  al. showed that the clinical competency
However, it cannot be certainly said that a person of nurses employed in general, special, specialized,
with a high empathy will doubtlessly have the best and emergency wards as begin good.[29] In this study,
performance and a high level of clinical competency. there is a relationship between the clinical competency
Ogle et  al. in 2013 in Australian Medical School in and number of overall service years of nurses and their
698
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Table 4: Investigating the linear regression of empathy with relevant factors in nurses employed in the Intensive Care Units
of the educational hospitals of Kerman University of Medical Sciences in 2016
Regression factors Nonstandardized Standardized beta coefficients t statistic P
coefficient
B coefficient SE
Constant factor 69.962 14.107 ‑ 4.959 0.001
Clinical competency 0.109 0.012 551 9.140 0.001
Marital status −0.783 2.073 −0.020 −0.378 0.706
Compulsory overtime −1.138 1.865 −0.032 −0.610 0.543
Type of ICU −1.115 1.854 −0.031 −0.602 0.548
History of hospitalization of a family member or close friends in an ICU 1.286 1.699 0.037 0.757 0.450
Work shifts 2.044 1.638 0.065 1.248 0.213
Employment status −0.401 1.177 −0.023 −0.341 0.733
The work experience of nurses −0.043 0.033 0.172 1.307 0.193
Work experience in an ICU −0.005 0.023 −0.019 −0.221 0.825
Weekly working hours −0.123 0.113 −0.059 −1.096 0.274
Age 0.435 0.345 0.150 1.263 0.208
SE=Standard error, ICU=Intensive Care Units

number of service years in ICUs, given that the mean as a valuable factor in improving clinical competencies
overall work years and overall work years in ICUs of which places individuals in a real test with all the
the nurses participating in the study are 9.62 and 7.51, associated challenges and difficulties, and considered
respectively, their enjoyment of clinical competency the continuous repetition of care, especially in technical
is at a good and reasonable level because nurses with areas as an effective method in the acquisition of skills
a longer work experience can better adapt themselves in this area. According to some nurses, the role of
with different circumstances and feel more competent practice and repetition in improving competency is not
due to their use of past experiences. only limited to technical measures but also includes
fields such as establishing a relationship with a patient
Conclusion or making a decision. An experience is in fact the
process of refining past opinions and knowledge of an
In this study, in addition to the overall mean of individual through encountering several real‑life cases.
clinical competency, the scores in each category were The understanding obtained from each experience is
calculated individually. The greatest mean score of accumulated with past experiences, and at the end,
competency is related to the field of knowledge, and they collectively lead to the understanding of details.[33]
the lowest score of competency is related to the field of
skill. ICU nurses must have sufficient theoretical and The mean of overall empathy of nurses employed
clinical knowledge because they deal with patients with in ICUs is 150.12 ± 17.04. The greatest mean of
bad health conditions and ethical challenges. Advanced empathy was related to the behavioral category, and the
and complete knowledge about equipment and subjects lowest mean of empathy was related to the emotional
related to special cares are the necessary and strong category. The results of the study of Ouzouni and
conditions for supporting nursing care which results in Nakakis on nursing students in Greece performed with
the provision of quality care.[30] One of the important the 20‑item questionnaire of Jefferson showed that
and key elements in the development of nurses’ the empathy of students was 20 at the minimum and
competency is education which leads to the provision 140 at the maximum, 88.63 ± 8.93.[34] The results
of high‑quality care.[31] In regards with professional of the study of Rahmatizadeh, 2015[25] performed
skills, nurses as a part of the human resources in the to investigate the empathy of nurses employed in
health system play an important role in improving an oncology ward using the empathy assessment
the health of the individuals in society. Education of tool of the present study showed that the empathy
nurses must take place in coordination with the new score of nurses was 38 at the minimum and 190 at
knowledge and findings related to the method of the the maximum 149.24 ± 16.63. The greatest amount
provision of health services, so nurses can fully exhibit of the empathy of nurses of the oncology ward was
their job abilities, skills, and competency.[32] In 2011 in related to the ethical category, and the lowest amount
his study, Khodayarian called experience as the most of empathy was related to the emotional category. The
important factor affecting the acquisition of competency cognitive and behavioral empathy of nurses were equal.
through feeling realities and called direct experiences O’Connell and Landers (2008) in their study state that
Annals of Tropical Medicine and Public Health | Volume 10 | Issue 3 | May - June 2017 699
Jahanshahi, et al.: Clinical competency and empathy of nurses

the emotional aspect of care is more important than all Financial support and sponsorship
the other aspects.[35] Maybe the reason for the low level Nil.
of emotional care in Iran is due to cultural factors or
nurses’ little opportunity to express their emotions for Conflicts of interest
patients. A nurse will establish a relationship with a There are no conflicts of interest.
patient by the amount that she understands the feelings
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