Empathy, emotional intelligence, and communication in Nursing: The moderating effect of the organizational factors*

Objective: to evaluate the relation and the moderating effect of the organizational factors on the attitudes towards communication, empathy, and emotional intelligence in the nurses. Method: a cross-sectional study was conducted with a convenience sample of 268 nurses from Valencia, Spain. The attitudes towards communication were evaluated by means of the specifically designed instrument, those towards empathy with the Jefferson’s Scale of Empathy for Nursing Students, and those towards emotional intelligence by means of the Trait Meta-Mood Scale, consisting of 24 items. The effect of the studied variables was assessed by means of ANOVA, multiple linear regression models were applied, and the moderating effect was analyzed using PROCESS. Results: there are statistically significant differences based on the type on contract (permanent); and statistically significant differences were found in the cognitive dimension of the attitudes towards communication. Regarding the regression models, the perspective taking dimension of empathy was the main predictive variable tn the dimensions of the attitudes towards communication. Finally, a moderating effect of the type of contract was evidenced in the effect of emotional reparation over the cognitive dimension of the attitudes towards communication. Conclusion: the organizational factors exert an influence on the attitudes towards communication, empathy, and emotional intelligence.


Introduction
Communication is a complex, multi-dimensional, and dynamic process, which refers to developing the means of interaction in an effective and efficient way (1) ; it constitutes itself as one of the most important indicators to assess the quality of Nursing care (2)(3) . It is for this reason that the Joint Commission International (JCI), as a governmental organization for the global accreditation of the best practices related to quality and to patients' safety, identifies inadequate communication among the most common causes of adverse events. Effective communication helps to improve the care actions (4) and the patients' health results (1,5) , as well as it contributes to the team's satisfaction and to organizational effectiveness (6) .
However, despite its importance, studies have barely been developed on the nurses' communication with the patients in the hospital general context (6) , in clear opposition to the case of Oncology and in long-term care settings (7) , ignoring other situations or realities.

Studying communication as a human conduct
inevitably lies on evaluating the attitudes towards such conduct (8) . Additionally, in developing communication, Emotional Intelligence (EI from now on) (9) and empathy (10) play a fundamental role. In this sense, there are studies on the relations of the attitudes towards communication, EI, and empathy (11)(12) . These variables can be influenced by intrinsic and extrinsic factors, like the type of service where the nurses work (general hospitalization or special services) and the type of contract (permanent or temporary) (13)(14) . Work uncertainty (15) , related to the type of contract, as well as the stress level in the service (general hospitalization or special services), can hinder communication; but EI and empathy facilitate communication even in stressful moments (16) , hence their study is considered fundamental. However, despite their importance, we have not found in the literature any study which analyses the relation and moderating effect of these extrinsic factors (type of service and the nurses' contracts) on the attitudes towards communication, empathy, and EI in the nurses. It is for this reason that the main objective of our paper is to analyze the impact of these factors.

Method
A cross-sectional study was designed, with a convenience sample consisting of 286 nurses from 3 hospitals in Valencia, Spain. The calculation for the sample size was performed according to the population of 2,000 nurses who worked in the participating hospitals, taking into account a 95% confidence interval and an alpha error of 5.9%, a sample size of 243 nurses being necessary. Eventually, the study's sample size was 286 nurses. The inclusion criteria were the following: being an active working nurse in the selected hospitals and having expressed their informed and voluntary consent to participate. The exclusion criteria were the following: being on vacation, time-off, and leave periods during the three weeks of data collection. In the active working situation of the nurses, the type of contract (temporary and permanent) was considered. In Spain, a permanent contract offers more stability because the nurses have passed a selective process, thus obtaining an appointment to perform their duties permanently.
In addition, the nurses who hold this condition can participate in internal promotion and staff mobility processes. In the case of temporary contracts, the nurse is appointed by the health services due to need or urgency, or for developing programs of a temporary nature; the job, therefore, is performed for a limited period of time (17) .
Data collection was conducted by means of a selfapplied instrument. The participants had to answer based on a Likert format with five options, ranging from 1 = Totally disagree to 5 = Totally agree. The instrument contained the following scales: • Sociodemographic data: work center, service, gender, age, and working situation.

Discussion
The communication, empathy and EI skills had a direct repercussion on the quality of care (2)(3) . It was important to consider external factors which were more related to the organizational aspects, like the type of contract and services, which could have exerted an influence on those skills (13)(14) . However, there are still no studies which analyze these relations; so the objective of this research was to know how the type of contract and service affected the attitudes towards communication, empathy, and EI in the nurses.
The Nursing literature presents studies on the influence of the organizational aspects on their work satisfaction and on the nurses' intention to leave their profession, together with the appearance of negative feelings of impotence and uselessness (25)(26) .
Other studies assess quality of life in the work of the Nursing personnel based on the type of contract and on the type of institution where they work (6) , as well as the psychosocial factors and the mental burden of the nurses related to the care unit where they work (27) . These The results of our study show that there only seems to be statistically significant differences in the case of the cognitive dimension from the ACO scale considering the type of contract; those professionals with a permanent contract seem to present slightly higher levels than those with a temporary contract.
Likewise, the empathy and EI dimensions are better predictors of the attitudes towards communication in the case of individuals with a permanent contract than in those with a temporary contract. Similarly, those variables were also better predictors in the case of the general hospitalization services compared to the special services. In general, the variable which best seems to predict the attitudes towards communication is perspective taking (JSNE), followed by emotional clarity.
Finally, a moderating effect of the working situation on the effect of emotional reparation was observed over the cognitive dimension of the ACO instrument; in this sense, emotional reparation seems to be a better predictor in the case of the permanent contracts.
These results might indicate that work uncertainty (15) , related to the type of contract, as well as the stress level in the service (general hospitalization or special services), can hinder communication. In this study we found studies which relate work insecurity and stress level in the service as negative factors for providing quality Nursing care and for the nurses' wellbeing (6,(25)(26) . The results of this research also showed that empathy and EI constitute themselves as protection elements in these situations (16) . professionals, which hinders the generalization of the results found. In the future it is proposed to conduct a stratified probabilistic sampling, considering different geographical areas, thus improving data generalization.

Conclusion
Nurses with a permanent contract seem to present slightly higher levels in the cognitive dimension from the ACO scale, which evidences the importance given to the communication with the patients and/or families.
In the case of the permanent contracts and of the general hospitalization services, the empathy and EI dimensions are better predictors of the attitudes towards communication.
Our study shows that the type of contract and service exert an influence on the attitudes towards communication, empathy, and EI, with the consequent possibility of arising as risk or protection factors.
Thus, improving the working conditions of the Nursing professionals will translate into the improvement of their attitudes towards communication and, therefore, of the quality of the Nursing care.