Yearbook on Journal of the Japan Society of Nursing Research 2015

Development of An Intervention Scale Measuring Psychiatric Patient-Nurse RelationshipShibata Yuko1), Satoru Sugita2)
Key Words :scale development
patient-nurse relationship
Peplau’s nursing theory

ABSTRACTThe purpose of this paper is to develop a scale that measures the formation of a patient-nurse relationshipin psychiatry and examine its reliability and validity. The scale was constructed by reviewing literature
on Peplau’s nursing theory and interviewing 8 nurses who had worked at psychiatric wards for at least 5
years. Then, we conducted a questionnaire survey of nurses who work on psychiatric wards in university
hospitals in Japan and developed scale items by statistical methods. The scale was composed of 24 items and
4 subscales – “cooperative and supportive intervention,” “cognitive, analytical, and communicative skills,”“receptive attitude,” and “readiness for intervention.” Statistical analysis showed that Cronbach’s coefficientalpha was above .70, indicating high internal consistency. We also compared these results with results on
the earlier study of involvement necessary for establishing the patient-nurse relationship. It showed that
construct validity, and the emotional empathy scale and the opener scale on criterion-related validity wereadequate, yet we consider that it is still necessary to enhance the validity for its practical application.

Introduction

to develop nurses’ professional skills.

Okaya (1995) noted that “nursing is the work involved inpatients’ daily life and sometimes their whole life, making it
difficult to offer them effective care without good relationshipwith them.” Hildegard E. Peplau (1952/1999), a pioneer ofpsychiatric nursing, also discussed the importance of anurse’s involvement with a patient. She defined nursing
as a “significant, therapeutic, interpersonal process” andrevealed that patients had come to actively deal with theirown problems and develop themselves through the nursepatient interaction.
Yet, there are some previous studies that showed that
nurses sometimes are “afraid of patient’s response” and feel
“helplessness,” revealing that there is a difficulty in dealing
with patients (Nishikiori, et al., 2005). Makino (2005) also
unveiled that nurses’ lack of experience and their upset overpatients’ words and actions were an influence factor causing
their confusion of therapeutic situations and orientation due
to the maintenance of their negative feelings toward patients(“unintended involvement”).
In addition, Abo (1994) notes that it is difficult to express
nurse-patient relationship in an objective and conscious
way. This is because nurses’ own characteristics can’t help
but affect their involvement with patients, therefore, it isdifficult to see their own involvement objectively and tovisualize relationship between them, uncertain factors suchas patients’ disease and conditions affect the construction of
their relationship, and their interpersonal skills depend on
their own abilities.
However, some scales have been developed for measuring
a patient-nurse relationship objectively, for instance, Okaya(1995)’s Patient Trust Scale, which measures the level of trust
between a patient and a nurse, and Client-Nurse Relationship
Scale (CNRS) (Fukai, Shinmi, and Okura, 2000). Yet, thesescales are not constructed specifically for psychiatric services.
They are measured by asking patients to evaluate nurses’
involvement but in psychiatry it is especially difficult toimprove the patient-nurse relationship, making it necessary

I. The Purpose and Framework of the Research
The purpose of this research is to develop a scale thatmeasures the formation of a patient-nurse relationship in
psychiatry. We relied on Peplau’s theory of interpersonal
relations, which is used in previous studies focusing on apatient-nurse relationship (Forchuck and Brown, 1989),
as the theoretical basis of scale construction. Patient-nurse
relationship is defined as “relationship in which it is aimed tochange subject’s behaviors by nurse’s exploratory approach(the attempt to talk together for clarifying patient’s needs
and to collaborate for resolving problems)” by referring toPeplau’s description of patient-nurse relationship in her
article (1989/2010).
It is expected that this scale can be used as a measure toevaluate nurses’ intentional involvement for constructing
patient-nurse relationship and as a tool to review how theirinvolvement helps to construct a supportive relationshipbetween them.
II. Research Methods

1. The Construction of Items on “Intervention Scales for
Forming Patient-Nurse Relationship in Psychiatric Wards”
a. Construction Process

Provisional scale items were constructed by reviewing
relevant literature and interviewing some psychiatric nurses.
Then, a questionnaire survey was conducted with nurses
who had worked on psychiatric wards in national university
hospitals which agreed to participate in this research, andscale items were developed by statistical methods.
b. Literature Review

With the supervision by a psychiatric nursing specialist weread Hildegard E. Peplau’s Theory of Interpersonal Relations
thoroughly and extracted factors which were necessary forforming nurse-patient relationship on “four phases of nursepatient relationship.” We then assigned numbers to data
extracted from the literature.

1) Fukuoka Jogakuin Nursing College
2) Oita University Faculty of Medicine School of Nursing

Corresponding author. Tel.: +81 92 940 2488; Fax: +81 92 940 2341.
E-mail address: y_shibata@fukujo.ac.jp (Y. Shibata)1
This paper was published at “the Japan Society of Nursing Research” Vol.36 No.1 in 2013.

Yearbook on Journal of the Japan Society of Nursing Research 2015

c. Interview Survey

anger,” an empathic attitude is considered to be a necessary
stance a nurse must take as a condition to form relationshipbetween them.
Gail W. Stuart (2007) pointed out that nurse’s self-disclosure
elicits patient’s self-disclosure which is necessary for bringing
about favorable outcomes of treatment. Therefore, we focused
attention on empathy and self-disclosure, and decided to
employ an “emotional empathy scale” as an external criterion
for scale development and an “opener scale” which measures
a sensibility toward self-disclosure.

We conducted semi-structured interviews with nurses
working in psychiatric wards in order to extract their concrete
involvement.
(1) Subjects

Subjects were 8 nurses who had worked at psychiatric wards
for at least 5 years in hospitals which agreed to cooperate inthis research project.

(1) Emotional Empathy Scale(2) Implementation Period

Emotional empathy scale was developed by Kato and Takagi(1980) for measuring the level of empathy on emotional
aspects. Its scales are composed of Scale I (emotional-warmth,
10 items), Scale II (emotional-coolness, 10 items), and Scale
III (emotional-susceptibility, 5 items). The reliability andvalidity of these scales have already been verified. High scoresof Scale I (emotional-warmth), Scale II (emotional-coolness),
and Scale III (emotional-susceptibility) show that a subject
is emotionally warm, emotionally cool, and susceptible toemotions, respectively.

From June to August in 2009.
(3) Data Collection Methods

A ward administrator selected those who met the conditions
necessary for the research. Subjects were those who agreed
to participate in this research from among them. In a semistructured interview we explained the definition of “patientnurse relationship” and “Peplau’s interpersonal process” inthis research and asked them to talk about freely “cases inwhich they made a patient change their behaviors in some
way or could realize that they formed ties with a patient.”
We conducted interviews with each subject once for 20 to
60 minutes in a separate room. The content of interviews wasrecorded using an IC recorder with subject’s consent and wastranscribed verbatim.

(2) Opener Scale

An opener scale was developed to measure the sensibility to
self-disclosure (Miller, Berg & Archer, 1983; Oguchi, 1989).
This scale is composed of two subscales: a “relaxing” factor (5items) which measures the extent to which a subject can makeothers feel comfortable and open up and an “empathetic”
factor (5 items) which measures the extent to which a subject
listens to another person with interest. The coefficient of
reliability was .65 for all items, .64 for the “relaxing” factor, and.62 for the “emphatic” factor. Construct validity was assured
on its correlation with Revised-Jourard’s Self-Disclosure
Questionnaire (R-JSDQ).

(4) Methods of Analysis

Accounts supposed to be an involvement necessary forforming patient-nurse relationship was transcribed verbatim
with one meaning in one sentence. One context was treated asa unit of records and factors extracted from Peplau’s nursing
theory were numbered serially. Data obtained from interview
surveys were put into numerical order (A001 to H010) basedon subjects and data. In order to enhance the validity of ouranalysis we classified every unit of records and extracted
questionnaire items under the supervision of a psychiatricnursing specialist.

3. The Implementation of a Questionnaire Survey
a. Facilities That Participate in the Research

We asked national university hospitals in Japan to participate
in this research and 39 facilities agreed to it.

2. Questionnaire Items

b. Subjects

a. Attributes of Nurses

Subjects were 718 nurses working in psychiatric wards of 39
national university hospitals.

Sex, age, years of nursing experience, and years of psychiatricnursing experience.

c. Periodb. The Number of Questionnaire Items and Point Allocation

From June to November 2009.

Thirty two questionnaire items were extracted from literature
review and survey content of interviews (Figure 1). Each item
was scored from 1 (do not at all) to 10 (never fail to do).

d. Methods

A confidential self-administered questionnaire survey was
conducted with psychiatric nurses in 39 national university
hospitals. The questionnaire sheets were sent to directors of
nursing in each facility. We asked them to distribute sheets tosubjects and tell them to mail the survey sheets to us by mailor submit sheets to a director of nursing.

c. Examination of Criterion-related Validity

As Ito (1999) notes that “patient-nurse relationship which
has gone through the phase of empathy leads to importantunderstanding of patients for carrying out skilled help and the
reduction of patient’s distress such as anxiety, depression, and2This paper was published at “the Japan Society of Nursing Research” Vol.36 No.1 in 2013.

Yearbook on Journal of the Japan Society of Nursing Research 2015

Figure 1. Questionnaire Items Classified by Literature Review and Content of an Interview Investigation
Number
1
2
3
4
5
6
7
8
9

10
11
12
13
14

Extracted Item

Literature No.3
A005
A007
A008
A016
C011

A026
C009
Literature No.12
D014
D013
D002
D001
D005
D025
E003

C006
D006

F017
H010
Literature No.15
D004
D010
D024
F016
F018

A010
C018
C019
D009
D019
E010
Literature No.11
A003
C005
F022
Literature No.7
A024
B007
B008
C014

15

D019

17

Literature No.21

16

F001
F004
F005
F019

18

A018
B017
Literature No.23

20

D008
F013

22

B012
B016
C002
D007
D023
E012
H008

19
21

23

A029
A030

D015
E025

B004
B014
E029
G005

24

B009
H014

26

A014
E001
E005
E017

25

G007
G009

27

A009
B018
C007
Literature No.4

29

C001
C017

28
30
31
32

A012
B006
E018
B012
E004
E005

Literature No.19
Literature No.27

Extracted Content
Explaining rules and restrictions on hospital service available to a patient.
Telling that a nurse would help a patient to be well and to solve problems.

Being involved for constructing relationship through casual conversation such as patient’s concerns.
Listening to patient’s opinions fully without telling nurses’ opinions unilaterally.
Listening to patient’s complaints and trying to understand his/her feelings.
Listening to patient’s complaints without interrupting him/her.
Telling a patient about the things nurses worry about.

Telling a patient about nurse’s own thoughts and opinions.

Understanding patient’s experience and accepting it as it is.

Being involved with a patient patiently whatever situation he/she faces.

Being involved with a patient without expecting too much from him/her until reliable relationship is formed.
Being involved with a patient so that he/she can express his/her feelings and troubles.
Being involved so that a patient can recognize that he/she is a nurse in charge.

Setting an appropriate time and place when talking to a patient in order to listen to him/her talking in arelaxed way.
Trying to clarify positive and negative emotions a nurse has toward a patient.

Judging how to be involved with a patient (e.g., whether I should ask a patient about his/her private mattersor make only a general talk) from his/her glance, expression, atmosphere, and attitudes.

Being involved with a patient by which a nurse can understand the needs he/she requires in a step-by-stepmanner and supply them sufficiently.
Noticing patient’s small changes and the things they can do in order to give feedback to him/her in a positive
way.
Being involved with a patient in order to make him/her understand the significance of treatment by mentioning
the things he/she could do by treatment.
Being involved with a patient while recognizing one’s own roles and maintaining an appropriate distancefrom him/her.
Trying to understand patient’s psychosocial conditions.

Listening to patient’s hopes and goals which he/she wants to achieve in the future.
Thinking together about how to achieve patient’s goals.

Telling a patient that a nurse would like to solve problems he/she faces together.

Sharing problems with a patient and encouraging him/her to evaluate them together.
Explaining the necessity of treatment while evaluating patient’s conditions.

Understanding patient’s anxieties and being involved with him/her for relieving them.

Thinking together about what a patient should do when he/she is in trouble, feels sick, or needs help after
discharge.
Looking back on the past conditions together in order to make a patient notice the effect of treatment.

Taking care of patient’s conditions and trying to let him/her make own decisions by approaching him/her
in a step-by-step manner.
Clarifying expectations that both a nurse and a patient have with each other.
Analyzing one’s own tendency and recognizing own behavioral pattern.

note.
1. The number of each datum is recorded and each interview subject is named A to H.
2. Each datum extracted from literature is name Literature No. ~.

3This paper was published at “the Japan Society of Nursing Research” Vol.36 No.1 in 2013.

Yearbook on Journal of the Japan Society of Nursing Research 2015

e. Methods of Analysis

3. Exploratory Factor Analysis
a. Excluded Items

Exploratory factor analysis was conducted for identifying
items on Intervention Scales for Forming Patient-Nurse
Relationship in Psychiatric Wards and a Cronbach’s alpha ofsubscales was calculated to examine reliability of each item.
We also calculated Spearman’s rank correlation coefficientfor the examination of criterion-related validity and performed
a Mann-Whitney U test for testing the differences between thesexes. The Kruskal-Wallis test and Scheffe’s test of multiple
comparisons were conducted on the years of nursing
experience and years of psychiatric nursing experience. PASW
Statistics 18 for Windows was used for statistical analysis.

In order to construct appropriate subscales on 32 intervention
scales for building the relationship between a patient and anurse, inappropriate items were identified and excluded in
the following way.
(1) Items excluded from the analysis due to ceiling effect(Figure 2)

Oshio (2004) pointed out that “when a ceiling effect (orfloor effect) occurs the distribution is skewed positively(negatively), making it inappropriate to use as a scale item.”
Therefore, we calculated the average score and standard
deviation of 32 items and set the score of 10 (the averagescore + standard deviation) as the upper limit. Item 7 was
excluded because its score (8.45+1.46=9.91) was close to thescore of 10. After excluding 5 items (Item Number 2, 3, 5, 7,13) out of 32 items, 27 items remained for analysis.

4. Ethical Considerations

Those who agreed to participate in this research signed aletter of consent after receiving the following explanation:
your participation in the research is voluntary and you canquit it at any time; interviews can be suspended according tointerviewee’s convenience; information on individuals andhospitals remains confidential; we do not use acquired data forother purposes; data were kept in the secure possession of theresearchers; data on individual information were discarded
after the study had been completed; and the article written
based on acquired data is not used for other than conference
presentation and the publication to an academic journal.
In addition, the following explanation was made in a
written form: the submission of a questionnaire is treated as
the acceptance of this research; participation in this research
is voluntary and non-participation does not bring any
disadvantages to them; subject’s workplaces and attributes
are confidential; and personal data acquired through theinterview are managed strictly. This research protectedsubjects’ human rights and was approved by and conductedunder the guidance of Ethics Committee of Faculty of Medicine,
Oita Univesrity.

(2) Items whose value of correlation coefficient was .70 andover (Figure 3)

Item Number 4 was included because Item Number 5 was
excluded from the analysis due to ceiling effect. Item Number
22 was also excluded from the analysis because Item Number
23, involvement in which a nurse thinks together for goal
achievement subsumes Item Number 22, involvement in whicha nurse asks a patient about his/her desire in the future andgoals. Item Number 24 was similar to Item Number 23 but not
excluded from the analysis because it was about involvementin which a nurse tells a patient about his/her intention tocooperate for problem solving, which was different from thecontent of Item Number 23. Both Item Number 18 and 19
were not excluded from the analysis because giving positive
feedback to a subject (Item Number 18) and involvement
which can notice the meaning of treatment (Item Number19) were different in content. The content of attaching ameaning to treatment by looking back on physical conditions(Item Number 29) and involvement through which patient’s
conditions are observed and for which a patient can makehis/her own decisions (Item Number 30) were different incontent, so that both items were not excluded. Then, a totalof 26 items were retained for factor analysis.

III. Results
1. Subjects

Questionnaires were sent to 718 nurses and 414 questionnaires
were recovered (response rate 57.7%), among which 410
questionnaires were valid, with the effective response rate of
99.0%.
2. Background of Subjects

Figure 2. Items Excluded from the Analysis due to Ceiling
EffectSubjects were 64 males (15.6%) and 346 females (84.4%) andtheir average age was 35.85±11.34. According to age brackets,
160 subjects (39%) were in their twenties, followed by 106
subjects (25.9%) in their thirties and 68 subjects (16.6%)in their forties. The average years of nursing experience
was 12.83±0.98. Their distribution was 184 (44.9%) in 10
years and over, 97 (23.7%) in 5 to 10 years, 96 (23.4%) in
2 to 4 years, and 33 (8.0%) in the first year. The average
years of psychiatric nursing experience was 4.93±4.66. Their
distribution was 203 (49.5%) in 2 to 4 years, 92 (22.4%) in 5
to 10 years, and 79 (19.3%) in the first year.

Number2
3
5
7

13

Questionnaire Item

Telling that a nurse would help patients to be well and to solve problems.
Being involved for constructing relationship through casual conversationsuch as patient’s concerns.
Listening to patient’s complaints
and trying to understand his/herfeelings.
Telling a patient about the things
nurses worry about.
Being involved so that a patient canrecognize that he/she is a nurse incharge.

4This paper was published at “the Japan Society of Nursing Research” Vol.36 No.1 in 2013.

Sum(the mean + SD)
10.39(9.17+1.22)
10.04(8.64+1.40)
10.04(8.82+1.22)

9.91(8.45+1.46)

10.08(8.43+1.65)

Yearbook on Journal of the Japan Society of Nursing Research 2015

together toward goals such as Item Number 24 (“Telling apatient that a nurse would like to solve problems he/she faces
together.”) and Item Number 28 (“Thinking together about
what a patient should do when he/she is in trouble, feel sick,or needs help after discharge.”).

Figure 3. Items Whose Value of Correlation Coefficient was .70
and Over Number
Number

Questionnaire Item

Listening to patient’s opinions fully without telling nurses’ opinions unilaterally.
Listening to patient’s complaints and trying
5
to understand his/her feelings.
(excluded) Listening to patient’s hopes and goals which22
he/she wants to achieve in the future.
Thinking together about how to achieve
23
patient’s goals.
Telling a patient that I would like to solve
24
problems he/she faces together.
Noticing patient’s small changes and the18things they can do in order to give feedback to him/her in a positive way.
Being involved with a patient in order tomake him/her understand the significance19of treatment by mentioning the things he/she could do by treatment.
Looking back on the past conditions to29
gether in order to make a patient noticethe effect of treatment.
Taking care of patient’s conditions andtrying to let him/her make own decisions
30
by approaching him/her in a step-by-step4manner.

Correlation
Coefficient.71

b. Factor 2

Factor 2 was composed of 8 items. It was named “cognitive,
analytical, and communicative skills” because it was related
to “cognition” which recognizes and evaluates patient’s nonverbal behaviors such as Item Number 20 (“Being involved
with a patient while recognizing one’s own roles andmaintaining an appropriate distance from him/her.”) and Item
Number 16 (“Judging how to be involved with a patient [e.g.,whether I should ask a patient about his/her private mattersor make only a general talk] from his/her glance, expression,
atmosphere, and attitudes.”), content which recognizes and“analyzes” situations such as Item Number 21 (“Trying tounderstand patient’s psychosocial conditions.”) and Item
Number 17 (“Being involved with a patient by which a nurse
can understand the needs he/she requires in a step-by-stepmanner and supply them sufficiently.”), and intentional
linguistic approach leading to the enhancement of one’s
feelings of self-esteem such as Item Number 18 (“Noticing
patient’s small changes and the things they can do in orderto give feedback to him/her in a positive way.”).

.79
.72
.75

.75

Figure 4. Excluded Items after the First Exploratory Factor
Analysis
Number1

8

Questionnaire It
Explaining rules and restrictions
on hospital service available to apatient.
Telling a patient about nurse’s own
thoughts and opinions.

Factor Loadingsc. Factor 3.18

Factor 3 was composed of 4 items. It was named “receptive
attitude.” Item Number 6 (“Listening to patient’s complaints
without interrupting him/her.”) and Item Number 4 (“Listening
to patient’s opinions fully without expressing nurse’s opinions
unilaterally.”) show the attitude on which a nurse keeps whentalking to a patient. Item Number 9 (“Understanding patient’s
experience and accepting it as it is.”) and Item Number 10(“Being involved with a patient patiently whatever situation
he/she faces.”) were about nurse’s attitudes on accepting
subjects unconditionally.

.29(3) Excluded items after the first exploratory factor analysis(Figure 4)

An exploratory factor analysis using maximum likelihood
estimation and a promax rotation was performed on the 26
items. The Kaiser-Guttman rule suggested that four factors
were sufficient. Through factor analysis, Item Number 1(.18) and 8 (.29) whose factor loading was below .30 weredeleted.

d. Factor 4

Factor 4 was composed of 4 items. Item Number 31 (“Clarifying
expectations that both a nurse and a patient have with eachother.”) refers to involvement for which a nurse prepares
to cooperate with a patient. Item Number 15 (“Trying toclarify positive and negative emotions a nurse has toward apatient.”) shows how a nurse analyzes one’s own emotions
and behaviors in order to understand oneself. This factor wasnamed “readiness for intervention” because factor loadings ofitems showing readiness to be involved were high.

b. Factor Structure of Scales (Figure 5)

Eight items were finally deleted from the earlier results. Then,factor analysis was conducted again, resulting in subscales of
4 factors and 24 items.
c. Reliability of Scales

Internal consistency of the whole scales of 24 items (Cronbach’s
alpha) was .95. The alpha coefficient of each subscale was .92(Factor 1), .92 (Factor 2), .80 (Factor 3), and .72 (Factor 4).

5. Criterion-related Validity (Figure 6)

To establish criterion-related validity, we calculated thescore of each factor and obtained a correlation coefficient
between an emotional empathy scale and an opener scale. The
Shapiro-Wilk test for normality showed that data were notnormally distributed, therefore, Spearman’s rank-correlation
coefficient, a non-parametric measure of correlation, wasused to determine the relationship between 4 subscales, anemotional empathy scale and an opener scale.

4. Evaluation of Four Factors
a. Factor 1

Factor 1 was composed of 8 items. It was named “cooperativeand supportive intervention” because its components hadhigh factor loadings on involvement necessary for working
5This paper was published at “the Japan Society of Nursing Research” Vol.36 No.1 in 2013.

Yearbook on Journal of the Japan Society of Nursing Research 2015

Figure 5. Results of Factor Analysis of “Intervention Scales for Forming Patient-Nurse Relationship in Psychiatric Wards”(Maximum Like lihood Estimation and a Promax Rotation)

24. Telling a patient that I would like to solve problems he/she faces together.

28. Thinking together about what a patient should do when he/she is in trouble,
feels sick, or needs help after discharge.
26. Explaining the necessity of treatment while evaluating patient’s conditions.

29. Looking back on the past conditions together in order to make a patient noticethe effect of treatment.
27. Understanding patient’s anxieties and being involved with him/her for relievingthem.
23. Thinking together about how to achieve patient’s goals.

25. Sharing problems with a patient and encouraging him/her to evaluate them
together.

Factor Loadings

Factor 1 Factor 2 Factor 3 Factor 4
.788

.093

.100

-.209

.759

-.006

-.047

.067

.652

.136

.174

.766
.709
.650

.022

-.093
.254

.015

-.048

.023
.313

.006

.373

-.019

.888

-.084

-.007

21. Trying to understand patient’s psychosocial conditions.

.215

.678

-.074

.035

17. Being involved with a patient by which a nurse can understand the needs he/she requires in a step-by-step manner and supply them sufficiently.
19. Being involved with a patient in order to make him/her understand the significance of treatment by mentioning the things he/she could do by treatment.

18. Noticing patient’s small changes and the things they can do in order to give
feedback to him/her in a positive way.

-.047
.070
.321

.763
.65

.627

.326

-.200

10. Being involved with a patient patiently whatever situation he/she faces.

-.066

.182

32. Analyzing one’s own tendency and recognizing own behavioral pattern.

.158

31. Clarifying expectations that both a nurse and a patient have with each other.

15. Trying to clarify positive and negative emotions a nurse has toward a patient.

14. Setting an appropriate time and place when talking to a patient in order to listen
to him/her talking in a relaxed way.
Factor Contribution(After Rotation)

Contribution Ratio (%)(Before Rotation)

Cumulative Contribution Ratio (%)(Before Rotation)

.133

.466

-.021

9. Understanding patient’s experience and accepting it as it is.

.292

.005

6. Listening to patient’s complaints without interrupting him/her.

.172
.042

.000
.061

.857

.688
.586
.699

.077

.617

.098

.636

.000

.473
.520

.696

.504

.134

.251

-.208
.151

.154

.233

.487
.421
.383

9.74

9.55

7.24

6.90

47.66

52.76

55.92

58.56

5.10

.565

.611

.573

.014

47.66

.663

.549

-.074

.151

.725

-.259

-.078

.208

.641

.744

.408

-.105

.091

-.048

-.015

.509

.159

-.029

.523

-.207

4. Listening to patient’s opinions fully without telling nurse’s opinions unilaterally.

.007

.273

11. Being involved with a patient without expecting too much from him/her until
reliable relationship is formed.
12. Being involved with a patient so that he/she can express his/her feelings andtroubles.

-.119

.718

.530

-.088

20. Being involved with a patient while recognizing one’s own roles and maintaining an appropriate distance from him/her.
16. Judging how to be involved with a patient (e.g., whether I should ask a patient
about his/her private matters or make only a general talk) from his/her glance,
expression, atmosphere, and attitudes.

.596

.292

.007

-.008

.045

.650

.623

-.154

.524

.640

-.14

.621

30. Taking care of patient’s conditions and trying to let him/her make own decisions
by approaching him/her in a step-by-step manner.

Communality

3.16

.547

.565
.259
.482
.407

2.65

Figure 6. The Association Between “Intervention Scales for Forming Patient-Nurse Relationship in PsychiatricWards,” an Emotional Empathy Scale, and an Opener Scale

Emotional-Warmth
Emotional-Coolness
Emotional-susceptibility
Relaxing Factor
Empathic Factor

Cooperative andSupportive Intervention.16 **-.16 **-.08.17 **.18 **

note. *:p<.05 **:p<.01
note. Spearman’s rank correlation coefficient

Cognitive, Analytical, andCommunicative Skills.14 **-.15 **-.12 *.11 *.15 **

Receptive Attitude.20 **-.20 **-.13 **.15 **.30 **

6
This paper was published at “the Japan Society of Nursing Research” Vol.36 No.1 in 2013.

Readiness forIntervention.05-.03-.22 **-.13 *.09

Yearbook on Journal of the Japan Society of Nursing Research 2015

Figure 7. The Association Between “Intervention Scales for Forming Patient-Nurse Relationship in Psychiatric Wards” andNurses’ Attribution

Male
FemaleMean Value

Significance
Probability
Year of Nursing Experience
1st Year
Mean Value
2 to 4 Years
5 to 10 Years
11 Years And OverYears of sychatric Nursing Experience
1st Year
Mean Value
2 to 4 Years
5 to 10 Years
11 Years And Over

Cooperative andSupportive Intervention
-.10
.02
.31

Cognitive, Analytical,
and Communicative Skills
-.05
.01

-.71
-.11 **
**
.08
.15

-.45
**
.02
**
**
.24
.32

Receptive Attitude
-.31
.06

.49

.000*

-.66
**
-.24
**
.07
**
.22

-.13
-.28
.05 **
.15

-.44
**
-.01
**
**
.22
.52

-.21
-.07
*
.24
.29

Readiness forIntervention
.00
.00

note.
1. Factor score is used for calculating the mean value.
3. Significant difference between the sexes; the Mann-Whitney U test.
4. Significant difference between years of nursing experience and years of psychiatric nursing experience; Scheffe’s method.

“Cooperative and supportive intervention” (Factor 1) was
associated positively with “emotional-warmth” (r=.16, p<.01)
and negatively with “emotional-coolness” (r=-.16, p<.01) in
Emotional Empathy Scale. There was no association with“emotional-susceptibility.” It was also associated positively
with a “relaxing” factor (r=-.17, p<.01) and an “empathic”
factor (r=-.18, p<.01) in an opener scale.
“Cognitive, analytical, and communicative skills” (Factor 2)
and “receptive attitude” (Factor 3) were associated positively
with “emotional-warmth” (r=.14, p<.01; r=.20, p<.01) andnegative with “emotional-coolness” (r=-.15, p<.01; r=.20,
p<.01) and “emotional-susceptibility” (r=-.12, p<.05; r=.13,
p<.01) , respectively. They were also associated positively
with a “relaxing” factor (r=-.11, p<.05; r=.15, p<.01) and a“empathic” factor (r=-.15, p<.01; r=.30, p<.01), respectively.
“Readiness for intervention” (Factor 4) was associatedpositively with “emotional-susceptibility” (r=-.22, p<.01)
while there was no association with “emotional-warmth” and“emotional-coolness.” It was also associated negatively with a“relaxing” factor (r=-.13, p<.05) but there was no association
with an “empathic” factor.

.87

-.38
-.22
-.22 **
.20

-.39
**
-.05
**
.22
*
.57

among those who worked for “two to four years.” On both“receptive attitude” and “readiness for intervention” the scoreof those whose years of nursing experience were “eleven years
and over” was significantly higher than that among those who
worked for “two to four years.”
In addition, on “cooperative and supportive intervention”
and “cognitive, analytical, and communicative skills” the scoreof those whose years of psychiatric nursing experience were
“two to four years,” “five to ten years”, or “eleven years andover” was significantly higher than that “less than one year.”On “receptive attitude” the score of those whose years of
psychiatric nursing experience were “eleven years and over”
was significantly higher than that among those who worked
for “less than one year.” On “readiness for intervention” thescore of those whose years of psychiatric nursing experience
were “five to ten years” and “more than ten years” weresignificantly higher than that among those who worked for“less than one year.”, and the score of those whose years of
psychiatric nursing experience were “eleven years and over”
was significantly higher than that among those who worked
for “two to four years.”
IV. Discussion

6. The Association Between “Intervention Scales for Forming
Patient-Nurse Relationship in Psychiatric Wards” and the
Attributes of Nurses (Figure 7)

1. Reliability of ScalesComparison between sexes revealed that the score of“receptive attitude” among female nurses was significantly
higher than that among male nurses.
On “cooperative and supportive intervention” the score ofthose whose years of nursing experience were either “five toten years” or “eleven years and over” was significantly higher
than that among those who worked “less than one year.” On“cognitive, analytical, and communicative skills” the score ofthose whose years of nursing experience were either “five toten years” or “eleven years and over” was significantly higher
than that among those who worked for “less than one year.”
The score of those whose years of nursing experience were
“eleven years and over” was also significantly higher than that

Oshio (2004) noted that “it is evaluated that scales areinternally consistent when a coefficient alpha is over somelevel (.70 or .80).” In this research every coefficient alpha wasover .70, showing that its internal consistency was found to
be good.
2. Validity of Scalesa. Construct Validity

The first factor - “cooperative and supportive intervention”
refers to participatory approach of nursing in which a nurse
shares problems with a patient by supportively relating
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Yearbook on Journal of the Japan Society of Nursing Research 2015

to patients. Psychiatric care tended to be paternalistic,necessitating an effort to construct cooperative relationshipaiming for the improvement of patient’s autonomy. Peplau’s
Interpersonal Relations in Nursing also maintains the necessity
to construct cooperative relationship between a nurse and apatient.
Therapeutic alliance, a concept of psychotherapy, shows
relationship between a client and a therapist for making
cooperative work possible by focusing on the health ofpatients. Previous studies have revealed that therapeutic
alliance between a patient and a nurse brings about patient’s
behavioral changes (Kanemoto, Okamoto & Kishitani, 2009).
The Working Alliance Inventory which Adam O. Horvathand Leslie S. Greenberg (1989) invented for measuring
the formation of therapeutic alliance also pointed out thenecessity to construct cooperative relationship for solving avariety of problems as suggested that its subscales are “theemotional bond of trust and attachment between patient
and therapist,” “agreement concerning the overall goals oftreatment” and “agreement concerning the tasks relevant forachieving these goals.”
The second factor - “cognitive, analytical, and communicativeskills” shows nurse’s skills for recognizing, analyzing, andcommunicating phenomena arising when a nurse interacts
with a patient. In the study of interaction on communication
between patient and nurse S. Janzen (1980) treats coding,translating, and screening received messages in conducting
assessment through communication as basic skills. In
addition, the second factor mainly contains the content
gained from interview investigations of nurses, implying thatit shows nurses’ “practical knowledge” necessary for forming
relationship between nurse and patient.
The third factor - “receptive attitude” shows nurses’
attitudes which accept patients as they are. C.B. Rogers(1959/1966) noted that pure interest in clients and accepting
them as one human being are one of the basic characteristicsof therapeutic relationship. It is considered that nurses
must have an interest in subjects who feel loneliness or fearaccording to their mental state and accept them as they are.
The fourth factor - “readiness for intervention” is about
insight on mutual expectations and nurse’s own feelings aspreconditions for intervention. Katsuki (2009) notes that
“interacting with patients in a warm feeling is an importantquality of nurses but its excess might encourage patient’s
dependence and inhibit their potential for self-reliance.”
Trasference or countertransference may occur in therelationship between nurse and patient, impeding patients’treatment. Therefore, it is considered that “readiness forintervention” is a necessary involvement because nurses mustsee their own involvement in patients’ treatment objectively
and get to know themselves better.
For the reasons stated above, it is suggested that 4
subscales extracted in this study are about part of factors of
involvement necessary for forming patient-nurse relationshipin psychiatry.

relationship is not the same thing as sympathizing out of pity.
A.W. Combs (1985/1990) argues that empathy is a willingness
to accept that the other’s perception is the reality for him/her,suggesting that empathy in supportive relationship is “closer”
to “cognitive aspects” of empathy. There is a possibility thatstatistically significant difference was not found in some items
because empathy does not necessarily lead to sympathy.
Some association was found on subscales of an opener
scale - a “relaxing factor” and an “empathetic factor” andfactors extracted in this research (“cooperative and supportive
intervention,” “cognitive, analytical, and communicative skills,”
and “receptive attitude”) probably because it was necessary
to make a patient open up and disclose himself/herself whensharing problems and evaluating implemented nursing
practice and to listen to a patient with interest.
c. Cross Validity

It was examined whether 4 subscales extracted in thisresearch differed according to the attributes of subjects.
The results showed that although differences were foundin each subscale, the scores of those who worked as nurses
or psychiatric nurses for a long time tended to high. There
was a statistically significant difference between those who
worked as psychiatric nurses for less than 1 year and those
who worked as psychiatric nurses for 11 years and over.
C. Forchuk (1995), who had conducted research on factors
affecting the development of patient-nurse relationship,clarified that experienced nurses were quicker to form a
relationship than inexperienced nurses by examining ages,
years of nursing experience, years of psychiatric nursing, andhours of dialogue in a month. Therefore, “Intervention Scales
for Forming Patient-Nurse Relationship in Psychiatric Wards”
were affected by years of nursing experience, failing to secure
universality.
This result reaffirms that nurse’s experience is necessary
for constructing patient-nurse relationship and it would taketime to master necessary skills.
d. The Use of “Intervention Scales for Forming Patient-Nurse
Relationship in Psychiatric Wards”

It is possible to make use of the factors in this scales whena nurse wants to know which intervention is lacking whenforming relationships with a patient. Yet, it is necessary tokeep in mind that some questions in Factor 1 (cooperativeand supportive intervention) are not good at evaluating its
usefulness on nursing intervention during recover process(e.g., Question 28: Thinking together about what a patient
should do when he/she is in trouble, feels sick, or needs help
after discharge.).
3. The Limitation of This Research and Future Tasks

The application of research is limited to nurses dealing
with patients who can use verbal communication becausesome scale items include involvement for sharing goals
with patients. This research also examined validity only on“self-disclosure” and “empathy,” therefore, as future tasks,
it is considered to be necessary to examine the association
with other factors affecting the formation of nurse-patient
relationship.

b. Criterion-related Validity

Statistically significant relationship was found out between
intervention scales and emotional empathy scale but there wasno association in some items. Empathy falls roughly into two
categories: those that emphasize “cognitive aspects” and thosethat emphasize “emotional aspects.” Empathy in supportive
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Yearbook on Journal of the Japan Society of Nursing Research 2015

Conclusion

Fukai, K., T. Niimi, M. Okura (2000). Taishou: Kangosha kankei hyoka
shakudo (CNRS) no kaihatsu (The Development of a Client-Nurse
Relationship Scale (CNRS)), Kawasaki Iryo Fukushi Gakkai-shi,
10(2), 285-291.
Horvanth, A.O. and L.S. Greenberg (1989) . Development andValidation of the Working Alliance Inventory. Journal of Counseling
Psychology, 36(2), 223-233.
Ito, Y. (1999). “Kyokan” ni motozuku kanjya: Kangoshi enjyo kankei
no kentou (Empathy in Patient-Nurse Relationships), Hokkaido Iryo
Daigaku Kango Fukushi Gakubu Kiyo, 6, 115-121.
Janzen, S. (1980). Taxonomy for Development of Perceptual Skills.
Journal of Nursing Education, 19(1), 33-40.
Katsuki, F. (2009). Seishinka ni okeru kangoshi no kanjya ni taisuru
shinriteki kyori no kanren youin (The Influence Factors for
Psychological Distance of Psychiatric Nurses to Patients in a ClinicalSetting), Nihon Kango Kenkyu Gakkai Zasshi, 32(1), 105-110.
Kato, T. and H. Takagi (1980). Seinenki ni okeru jyoudouteki
kyoukansei no tokushitsu (Characteristics of the Emotional
Empathy in Adolescence), Tsukuba Daigaku Shinrigaku Kenkyu, 3,
51-70.
Kanamoto, J., M. Okamoto, and J. Kishitani J. (2009). Jinkaku shogai tozenshin toutsuu ni yoru kutsuu no tame insurin dounyuu konnan
de atta tounyoubyou kanjya no kango de manandakoto, Nihon
Tounyuubyou Kyouiku/Kangogaku Kaishi, 13(2), 158-163.
Miller, L.C., J.H. Berg, and R.L. Archer (1983). Openers: Individuals
Who Elicit Intimate Self-disclosure, Journal of Personality and Social
Psychology, 44, 1234-1244.
Oguchi, K. (1989). Jiko kaiji no ukete ni kansuru kenkyuu: Opener
scale, R-JSDQ to SMI o mochiite, Ouyou Shakaigaku Kenkyuu, 31,
49-64.
Nishikiori, R., K. Yoneyama, K. Moriyama, M. Nagira, Y. Furuyama(2005). Seishinka byotou Kangoshi no mensetsu chousa kara, Nihon
Seijinka Kango Gakkaishi, 48(1), 292-293.
Makino, K. (2005). Seishinka kango ni okeru kangoshi no “makikomare”
taiken no kousei youso to sono kanren youin (The Nurse’s
Involvement with a Psychiatric Patient: Positive and Negative Aspectsof Involvement and How to Maintain a Therapeutic Relationship witha Patient), Ningen Kangogaku Kenkyuu, 41-51.
Okaya, K. (1995). Kangofu-kanjya kankei ni nyuuin kanjya henokakawari no konnansa:

Intervention scales for forming patient-nurse relationship in
psychiatric wards were composed of 24 items and 4 factors(“cooperative and supportive intervention,” “cognitive,
analytical, and communicative skills,” “receptive attitude,”and “readiness for intervention”). The calculation of a
Cronbach’s alpha of each factor showed that there was internalconsistency on these 4 factors.
Extracted factors reflected part of involvement necessary
for forming patient-nurse relationship shown in earlier
studies and supported construct validity. Criterion-related
validity was assured on some items of an emotional empathy
scale and an opener scale.
Acknowledgment

The authors wish to thank nurses including directors of
nursing in national university hospitals for participating inthis research project. This article is based on a Master’s thesis(chief adviser: Prof. Satoru Sugita) submitted and acceptedat Graduate School of Medicine, Oita University in 2009. It
was reported in the 22nd Congress of Japan Academy of
Psychiatric and Mental Health Nursing.
References

Abo, J. (1994). Seishin-ka ryoiki ni okeru kangofu no rinsho handan
nouryoku o dou takameruka, Gekkan Nursing, 14 (10), 62-66.
Combs, A.W., translated by H. Ohashi and Y. Sugawara (1990). Enjyo
kankei: Enjyo senmonshokusha no tame no kihonteki gainen (Helping
Relationships: Basic Concepts for the Helping Professions, 1985),
156, Tokyo: Brain Shuppan.
Forchuk, C. (1995) . Establishing Nurse-Client Relationship. Journalof Psychosocial Nursing 27(2), 30-34.
Forchuk, C. and B. Brown (1989). Development of Nurse-Client
Relationships: What Help?. Journal of the American Psychiatric
Nurses Association, 1(5), 146-152.

9This paper was published at “the Japan Society of Nursing Research” Vol.36 No.1 in 2013.