Forgiveness and Empathy as Predictors of Psychological Wellbeing among Nurses

The purpose of the study was to examine whether forgiveness and empathy have a significant correlation with psychological wellbeing among nurses. The present research will enable the theorist to develop measures that will cultivate empathy, forgiveness and psychological wellbeing in nurses. This was a correlational, survey based research. A sample of 151 nurses of age range 20-55 was selected via purposive sampling technique from Karachi, Pakistan. The participants were approached through online medium. The study variables were assessed through Toronto Empathy Questionnaire (Spreng et al., 2009), The Heartland Forgiveness scale (Thompson et al., 2005) and Ryff’s Psychological Well-Being Scales (Ryff, 1989). Statistical Package for Social Sciences (SPSS- Version 22) was used for analyzing the data, the results revealed that empathy and forgiveness are significant predictors of psychological wellbeing. Further findings of the research highlighted significant differences in empathy, forgiveness and psychological wellbeing with respect to nurse’s age, gender, education and family structure. The results of the present study could be useful for enhancing nurse’s psychological.

Nursing profession has a significant contribution in the health care sector of all times. Nursing is considered to be one of the old and noble professions which started to get noticed and gain popularity by the efforts of Florence Nightingale. Since then nursing is perceived as a profession of providing care, being helpful and kind to others.  But in today’s era nursing is not just limited to these pro-social behaviors, nursing is beyond that.
International Council Nurses defines “Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management and education are also key nursing roles” (Nursing Definitions, 2002, para. 1).
It is a commonly known fact that nurses are taught, trained and practiced to be empathetic. And with empathy individuals become forgiving as well. Because when a person is able to understand others they forgive the hurt caused by others. Thus, the negativity of hurtful feelings is reduced by generating positive or neutral feeling. The formation of neutral or positive feelings and the reduction of negative feelings lead to better mental health. Literature supports that forgiving behavior has a significant relationship with empathy (Reza et al., 2021).
This situation highlights the importance to look into the forgiveness, empathy and psychological wellbeing of nurses.

Problem Statement

Nursing is always seen a profession that is stressful and demanding. Areas that lead towards job satisfaction and work related stress were comprehensively explored by researchers. Yet, the most important thing that is the psychological wellbeing of nurses is something that is rarely looked upon. It is a common knowledge that nurses have jobs that are emotionally intense, related to people’s sufferings and illness. The constant exposure of seeing humans in pain affects an individual’s mental health. This makes it important for psychologist to explore the factors that can be the possible predictors of psychological wellbeing among nurses and can be helpful in improving the psychological wellbeing.

Research Question

1. Would forgiveness and empathy predict psychological well-being among nurses?

Objective of Research

1. To find out whether forgiveness and empathy are predictors of psychological wellbeing among nurses.

Rationale

Nurses have a significant position in health care sector since forever. Without nurses taking care of the patients is nearly impossible. Nurses, being such an important professionals of our society face huge challenges on daily basis, such as being exposed to diseases which effects their physical health; taking care of patients, seeing people dying, witnessing humans in their worst conditions after accidents; all this makes it important to look upon nurses wellbeing. In Pakistan less work has been done on investigating the forgiveness, empathy and psychological wellbeing of nurses. Therefore, the need on improving or cultivating forgiveness, empathy and psychological wellbeing of nurses is not considered.
This study helps us to know the relation of the two positive qualities of nurses, i.e. forgiveness and empathy as predictors of psychological wellbeing. This study is also beneficial for the theorists, psychologists and teachers, as it will enable the theorist to develop theories that will better explain the relationship of forgiveness, empathy as predictors of psychological wellbeing among nurses, will enable the psychologist develop and implement the interventions accordingly and teachers of nursing schools can add these variables as important and significant part of their curriculum.

Literature Review

Nurses create an atmosphere that results in better healing through their caring and helping nature. To care and help others it is important for nurses to have a good psychological wellbeing which will not only have a positive impact on their professional life but also helps them to have an improved lifestyle.
It is commonly known that nurses have an extremely demanding job and with this managing their personal life too becomes tough and so for these professionals it is difficult to keep up their mental health thriving.
Work load, non-supportive family and peers do effect an employed individual’s life but there are people who have the capacity to cope with their stressful environment and effectively deal with it. Study demonstrates that an individual’s virtues positively contribute towards better mental health outcomes (Lim, 2015).
Virtues are the good qualities that every individual possess. According to positive psychology there are 6 virtues that make up 24 character strengths. Character strengths are encouraged and valued by society, these are considered good traits of a person. Forgiveness is one of the character strength that comes under the virtue that protects people from excess (Peterson & Seligman, 2004).
Forgiving others is significant for health care professionals. Studies have shown that people who are hurt emotionally on their jobs, when practiced forgiveness to cope with the hurt, proved to have better wellbeing, increased productivity and improved health (Toussaint et al., 2018).
Forgiveness is seen as a healing component for both the victim and transgressor, it is considered to be a relationship repairing mechanism that is natural. Theorists have explained the process of letting go the negative feelings to take revenge or hold grudges for the offender through REACH model of forgiveness which helps in restoring friendly relationships with others (Worthington et al., 2005). The REACH model is a six step process; the acronym REACH stands for:

1. Recalling the incident that has caused you the hurt as truthfully as possible,
2. Empathizing with the person who has harmed you by putting yourself in the offender’s shoes,
3. being Altruistic by forgiving someone as a gift, and remember the time when someone else has forgiven you and how good it felt to you,
4. Committing to the experience of forgiveness
5. Holding on yourself that you have forgiven by reminding oneself.

This explains the process to forgive someone by changing your negative feelings towards the transgressor (Worthington, 201 4).The REACH model represents the importance of empathy when forgiving someone. Study reveals that when individuals consciously empathize with an offender their forgiveness towards the offender is increased (Cornish et al., 2018). Forgiving others and being able to empathize with others contribute towards better mental health.
Empathy plays a significant role in nursing profession. The higher the levels of empathy a nurse possess the higher wellbeing they have (Bourgault et al., 2015). Practicing empathy not only benefits other to whom one is being empathetic but it is also beneficial to one’s own self as empathy is related to wellbeing. Manczak et al. (2016) research reveals that empathy has positive physiological and psychological effects on the provider and recipient. 
Researches shows that in Pakistan, nurses face stressful work environment on daily basis due to a number of reasons including lack of value of nursing profession (Hamid, 2016). Nurses psychological wellbeing is negatively impacted by the poor support they get and the nature of job they are into. Lack of social support and job demand is negatively linked with nurses work outcomes and psychological well-being (Burke et al., 2012).
However, literature is full of evidences that prove that nurses psychological wellbeing is positively linked to a good workplace environment, the positive characteristics they possess and the social support they get. Moreover, Nurses have a significant positive relationship with psychological wellbeing and job satisfaction (Olatunde & Odusanya, 2015).
Harzer and Ruch (2015) study on nurses show that nurses who have enhanced interpersonal strengths are better at coping and nurses with intellectual strengths are good at managing work related stress. Nurses with greater psychological wellbeing are good at dealing with the daily stresses. Individual’s that have high psychological wellbeing are found to have low psychological distress (Winefield et al., 2012). Empathy and forgiveness are both positive qualities of a human being that are found to be associated with psychological wellbeing, together and alone. 

Association between Forgiveness and Empathy

Studies have shown positive relationship between forgiveness and empathy. Researches reveal that nurses who are more likely to forgive are the ones that possess greater level of empathy. Study on medical and nursing student’s shows that forgiveness has a significant positive association with empathy and patient relationship (Khodabakhsh & Mansuri, 2012).
Aragon (2016) reveals that empathetic individuals are more likely to forgive the offender without having a similar experience of harm. Forgiving others is also found to be associated with the activation of brain networks that are related to empathy, mind theory and the regulations of emotions (Ricciardi et al., 2013). Moreover, Empathy is found to be significant predictor of forgiveness of others (Turnage et al., 2012).

Association between Forgiveness and Empathy and Psychological Wellbeing

Studies reveal that psychological wellbeing is closely related to forgiveness and empathy. Raj et al., (2016) investigated the impacts and indicators of practicing forgiving behavior. The results reveal that individual’s religiosity, empathy, positive emotional state and perspective taking are the indicators of forgiving behavior. Moreover, forgiving behavior increases physical and psychological wellbeing, ability to handle challenges and self-acceptance.
In a nutshell, results from previous research studies have established that empathy and forgiveness are important element in nursing profession and contributes in living a healthy life, it not only increases personal wellbeing but also increase the wellbeing on the community level.

Theoretical Framework

Nurses have a tough work environment as they are responsible to take care of multiple patients at a time. The overly demanding job of nurses negatively effects their personal life and psychological wellbeing (Metwaly & El-Maksoud, 2018). It is known that long term stress causes a number of physical and psychological health issues that includes, irritability, negative emotions, depression, heart issues and many other health related problems which also influences a person’s interpersonal relations.
Overcoming one’s negative emotions is very important in order to live a happy and satisfied life. Forgiveness helps an individual to reduce their stress and improve mental health, forgiveness is seen as an emotion focused coping strategy (Worthington & Scherer, 2004).
In the present study forgiveness means, to not hold grudges or desire to take revenge from the offender even if the transgressor does not asks for forgiveness or admit the hurt  that he/she gave you; to let go one’s own mistakes; forgive oneself, another person and the situation that has harmed you; to move beyond experiencing negative about the transgression towards feeling positive or neutral (Thompson et al., 2005).
Researches have shown that forgiveness and empathy work together as a process (Ulus, 2015). Empathy in this study is defined as an affective insight into the feeling state of another person, empathy is seen largely as an emotional process (Spreng et al., 2009).
Being a nurse involves interacting and dealing with a number of people regularly, a nurse with good mental health will be able to better deal with the patients, patients’ families, their own family and their own personal self. This helps in understanding that a nurse who practices forgiveness and is empathetic towards themselves and their environment will be having an increased level of psychological wellbeing. As both empathy and forgiveness helps in maintaining an individual’s psychological wellbeing by making people feel satisfied and happy from themselves and the world around them. In the present study psychological wellbeing is defined as positive psychological functioning; including six dimensions namely, personal growth, autonomy, environmental mastery, self-acceptance, positive relations with others and purpose in life (Ryff, 1989).

1. Autonomy. Involves being self-reliant when evaluating others or self, resisting the social pressures when thinking or behaving and being a completely independent individual. 
2. Self-Acceptance. Refers to accept all your qualities and yourself fully, and have a positive attitude regarding one’s own self and past life.
3. Purpose in Life. Involves being aware of the aims of life and to be goal oriented. Seeing life as a meaningful journey in which past and present life are well integrated.
4. Personal Growth. Having a potential to seek experiences from life and grow from them, able to recognize the self-improvements.
5. Environment Mastery. Having the potential to use, create and manage your environment. Being able to choose and master your surroundings as per your demands and values.
6. Positive Relations. Involves understanding others, building warm, trusting and positive relations with others and having the capacity to maintain relationships.

The sixth component of this model as per Ryff’s (1989) explanation is engaging in meaningful relationships with others which includes empathy, intimacy, and affection. If a person is unable to empathize with others it leads towards lack of understanding of others. Hence, results in poor relationships which decreases a person’s psychological wellbeing as the need of belongingness is impacted. This shows how empathy contributes in an individual’s psychological wellbeing, the more a person is empathetic the greater psychological wellbeing they have.
In the existing theoretical perspective empathy and forgiveness are seen as essential components, empathy helps nurses to understand, communicate and help others. Forgiveness works in helping nurses overcome their negative experiences. This clarifies how closely and positively forgiveness and empathy are linked to one another and to the psychological wellbeing of an individual. The above mentioned studies establishes that in nursing professionals, empathy, forgiveness and psychological wellbeing have a significant value. And both forgiveness and empathy are found to be significant predictors of psychological wellbeing among nurses.

Figure 1
Theoretical Framework of the Study.

Hypothesis
H1: Empathy and forgiveness will be significant predictors of psychological wellbeing among nurses.

Method

Correlational research design and quantitative research method has been used in this study. For assessing the empathy, forgiveness and psychological wellbeing of nurses, structured self-report measures were used.

Sample

A sample of 151 nurses both male and female, ranging in age 20-55 were selected for this study through purposive sampling technique which is a technique of non-probability sampling. The participants were approached through online medium via social media applications.

Inclusion Criteria

1. Participants who were 20-55 years were selected.
2. Participants must have at least done 12 year education i.e. Intermediate.
3. Participant can read and understand English to fill the questionnaires.
4. Participants must be working in a hospital.
5. Participants must not have taken or are not taking any psychological treatment.

Table 1
Demographic Characteristics of Participants (N=151)

Table 1 depicts the main demographic variables of the present study. It shows the distribution of the demographic variables into sub categories based on demographic information of the participants of the study (N = 151).

Measures

Informed Consent Form
The consent form consists of all the necessary details of the study that should be known to the participants to make an informed decision to whether or not participate in this study. It also explains the purpose of the current study, participant’s confidentiality, and their choice to voluntary participate. 

Demographic Form
The demographic form of the present study includes factual information about the participant’s age, gender, birth order, family structure, marital status, educational level, hospital name where they are working and socio economic background. Additionally, the form also investigates whether the participants have taken or are taking currently any sort of psychological treatment.

The Toronto Empathy Questionnaire
To measure empathy of the participants, Toronto Empathy Questionnaire developed by Spreng et al. (2009) was used. The scale was developed by using factor analysis on a combination of empathy scales to form a brief, valid and reliable scale. This questionnaire is based on 16 items, each item rated on a 5- point scale ranging from ‘never’ to ‘often’. TEQ is a brief and strong scale that has high test-retest reliability, convergent and construct validity, and internal consistency.

The Heartland Forgiveness Scale
Heartland forgiveness scale was developed by Thompson et al. (1999) and was published in positive psychological assessment in 2003. The scale has three subscales, making a total of 18 items. Each item is answered on a seven- point Likert scale. For total scale test retest reliability was .83 and for subscales ranged from .72 to .77. The Cronbach alpha value ranges from .84 to .87 for the total scale and Cronbach alpha for subscales ranges from .71 to .83 this supports an adequate internal consistency reliability of the HFS (Thompson & Snyder, 2003).

Psychological Wellbeing Scale
This scale was developed by Ryff (1989) and comprises of 18 items. Those 18 items are divided into six subscales, each subscale represent a dimension of the psychological model. Each statement is rated on a seven- point scale ranging from strongly agree to strongly disagree. Inter item reliability has been revealed by the Cronbach alpha value of 0.85 with standardized item alpha value of .855.

Procedure

Permission from the concerned authorities of Institute of Professional Psychology, Bahria University was taken to conduct this study. The participants were contacted through online medium applications for both reaching them and sending questionnaires as the study was conducted during Covid’19 so to ensure safety of both researcher and participant’s online medium was the best approach.
The participants were required to read the consent form which briefly explains the purpose of the study, if the participants agreed to the consent form then they proceeded to participate in this research. A total of 300 nurses were approached but as the study was conducted during covid’19 therefore, a large number data could not be gathered. The number of nurses who responded back with filled questionnaires were 151.
Demographic form, The Toronto Empathy Questionnaire (Spreng et al., 2009), The Heartland Forgiveness Scale (Thompson et al., 2005) and Psychological wellbeing scale (Ryff, 1989) were provided to the participants to fill online. Participants were instructed about each questionnaire in the written form.  To assess the statistical significance of the relationship among variables, statistical package for social sciences- version 22 (SPSS-22) was used to analyse the results obtained from self-report questionnaires.

Results

To test the hypotheses of the study the data was compiled and analysed by using Statistical Package for Social Sciences (SPPS-version 22). A series of inferential and descriptive statistics were used to test the hypotheses which includes, Mean, Standard Deviation, Skewness, Kurtosis, ranges of study variables, one way Anova, simple linear regression analysis and independent sample t-test.

Descriptive Analysis

Mean, Standard Deviation, Skewness, Kurtosis along with the potential and actual ranges of the scales have been outlined in Table 2 and Table 3. Potential range is the maximum and minimum scores specified by the scale while actual range is the minimum and maximum scores of the current participants on the scale.

Table 2
Cronbach Alpha of the Scale’s Psycho metric properties of scales (N=151)

Note. HFS = Heartland forgiveness scale; TEQ = Toronto Empathy Questionnaire; PWB = Psychological Well-being Scale.

Reliability tests shows the validity of scales used in this study. The Cronbach alpha of HFS is .964, TEQ is .938 and PWB is .912 which indicates that these scales have strong reliability.

Table 3
Descriptive Analysis Included Mean, Standard Deviation, Skewness, Kurtosis and Ranges of the Study Variables (N=151)

Note. M = Mean; SD = Standard Deviation; SK = Skewness; K = Kurtosis; TEQ = Toronto empathy questionnaire; HFS = Heartland forgiveness scale; HFS- self = forgiveness of self; HFS-Others= forgiveness of others; HFS-Situation= forgiveness of the situation; PWB = Psychological wellbeing Scale; AU = Autonomy; EM = Environment Mastery; PG = Personal Growth; PR = Positive relations with others; PL = Purpose in life; SA = Self-Acceptance.

Table 3 represents mean, standard deviation, skewness value, kurtosis value, actual and potential ranges. The value of skewness and kurtosis shows that the data is normally distributed.

Hypothesis

Empathy and forgiveness will be significant predictors of psychological wellbeing among nurses.

Table 4
Simple Linear Regression Showing Empathy and Forgiveness as Significant Predictors of Psychological Wellbeing Among Nurses (N=151)

Note. TEQ = Toronto empathy questionnaire, HFS = Heartland forgiveness scale, β = Regression Coefficient, R2 = R square, ΔR2 = R, CI = Confidence Interval, LL = Lower Limit, UL = Upper Limit.

The Table 4 above shows simple linear regression. It was conducted to find out the role of empathy and forgiveness in predicting psychological wellbeing among nurses. The results show that empathy and forgiveness acts as a strong predictor of psychological wellbeing among nurses.

Table 5
Independent Sample t-test for the Variables of Forgiveness, Empathy and Psychological Among Nurses Belonging to Different Genders (N=151)

Note. n = Number of participants; M = mean; SD = Standard deviation; LL = lower limit; UL = Upper limit; t = t-test;frequency; p = Significance.

Table 5 represents the independent sample t-test of variables of empathy, forgiveness and psychological wellbeing among male and female nurses. It represents a statistically significant (p < 0.05) difference of forgiveness among male (M = 99.60) and female nurses (M = 89.47).

Table 6 represents one way ANOVA of the variables of forgiveness, empathy and psychological wellbeing among nurses belonging to different age groups. It shows that nurses of age 20-31 have significant (p < 0.05) difference in empathy (M = 12.86) and psychological wellbeing (M = 99.94) as compared to other age groups. Whereas, nurses belonging to 32-43 age range have a significant difference in forgiveness (M = 97.22) as compared to the nurses of other age ranges. 

Table 6
One-way ANOVA for the Variables of Forgiveness, Empathy and Psychological Among Nurses of Different ages (N=151)

Note. n = Number of participants; M = mean; SD = Standard deviation; LL = lower limit; UL = Upper limit; t = t-test; frequency; p = Significance.

Table 7
One-way ANOVA for the Variables of Forgiveness, Empathy and Psychological Among Nurses Belonging to Different Family Structures (N=151)

Note. n = Number of participants; M = mean; SD = Standard deviation; LL = lower limit; UL = Upper limit; t = t-test; frequency; p = Significance.

Table 7 shows the one way ANOVA of the variables of forgiveness, empathy and psychological wellbeing among nurses of different family structures. The table demonstrates a statistically significant (p < 0.05)  difference in empathy (M = 12.96), forgiveness (M = 99.71) and psychological wellbeing (M = 99.86) of nurses belonging to joint family as compared to nurses living in nuclear or extended families.

Table 8
One-way ANOVA for the Variables of Forgiveness, Empathy and Psychological Among Nurses Having Different Education Levels (N=151)

Note. n = Number of participants; M = mean; SD = Standard deviation; LL = lower limit; UL = Upper limit; t = t-test; frequency; p = Significance.

Table 8 demonstrates One-way ANOVA of the study variables among nurses having different academic qualifications. This shows that nurses having education other than BS and MS have statistically significant difference (p < .05) in the level of empathy (M = 13), forgiveness (M = 101.22) and psychological wellbeing (M = 101).

Discussion

Empathy and forgiveness are positive and prosocial psychological strengths that are closely related with psychological wellbeing. In this study an assumption was made that empathy and forgiveness will be significant predictors of psychological wellbeing among nurses, which has been proved through simple linear regression analysis. The result shows that empathy and forgiveness are statistically significant and strong predictors of psychological wellbeing among nurses. The finding is similar to previous study which shows that forgiveness and empathy are significant predictors of psychological wellbeing (Vinayak & Judge, 2018).
A detailed demographic analysis of the research shows significant relationship of demographic factors with the study variables. It has been found out that men are more forgiving than women. Root and Exline (2011) study has similar findings that males have an increased level of forgiveness as compared to females.
Nurses of age 20-31 are more empathetic and have increased psychological wellbeing as compared to nurses of other age ranges, whereas for forgiveness of nurses of age 32-43 are found to be more forgiving. Previous studies have also identified that as individual’s age their forgiveness is increased (Tao et al., 2021).
Nurses belonging to joint family system have increased forgiveness, empathy and psychological wellbeing as compared to nurses living in nuclear and extended family. It is evident that family systems provide people with a different experience ever since they are born. Gul (2017) explored that children belonging to joint family systems have greater psychological wellbeing as compared to those who belong from nuclear family.
Furthermore, the study reveals that there’s a significant difference among nurse’s academic qualification. Nurses who have education level of MS and BS are less empathetic, forgiving and have decreased psychological wellbeing as compared to nurses having other academic qualification. Past research reveals that nursing students of Master’s Program showed lower empathy levels as compared to the students of undergraduate programme (Eklund et al., 2019).

Conclusion

This study suggests that empathy and forgiveness are significant predictors of psychological wellbeing among nurses which is supported by past literature. Additionally, this research highlights the significant differences in empathy, forgiveness and psychological wellbeing with respect to nurse’s age, gender, education, income group and family structure; stress and student’s positivity and their academic achievement.

Limitations

The study is limited to nurses who are only working in hospitals, who are able to understand English and had access to social media applications. The research was conducted during Covid’19 and data was collected from Karachi, Sindh, Pakistan due to limited resources in terms of time, money and human resource.  

Recommendations

Sample size should be large, data from both practicing and non-practicing nurse, and scales constructed in English and Urdu language should be used in future researches for generalizability of results.

Implications

The findings of this research can be used by educationist in designing the curriculum of nursing programs in such a way that it includes and emphasizes on forgiveness and empathy. Furthermore, these findings can be used by counsellors of nursing schools to teach their clients to be more understanding, practicing forgiveness and making them use such skills that will enhance their psychological wellbeing.
Additionally, the findings are useful for hospitals. Hospitals can provide their staff such trainings and sessions that bring awareness of psychological wellbeing, practicing forgiveness and being empathetic. Moreover, these findings will facilitate the theorists to develop interventions and theories on improving empathy, enhancing forgiveness and increasing psychological wellbeing; both independently and by combining these together.

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Received 8 September 2021
Revision received 26 November, 2022