Original Article

An Investigation into Nurses' Behavior with regard to Human Caring
Puangrat Boonyanurak*1 , Mieko Ozawa*1, David R. Evans*2 , Keiko Takeo*3【Abstract】 The purpose of this study is two-fold. Firstly, the concept of 'human caring' is examined by reviewing the literature andidentifying the elements that constitute its' essence.
The HCMQ is a questionnaire that consists of seven elements of human caring; essence of person, relationships, choices, genuine
dialogue, experiential process, healing, and human/economic resource exchange. Each element consists of 5 items; consequently
thirty-five questions were developed into this questionnaire. Three nurse experts, who earned doctoral degrees from the United States,
validated the content. The pretest was conducted and the reliability coefficient of this instrument is 0.94.
The English version of the HCMQ was translated into Thai, and pre-tested with 30 nurses. A reliability coefficient of 0.95 resulted
for the HCMQ (Thai). The questionnaire was disseminated to the nurses working at six national centers belonging to the Ministry of
Health in Thailand. Data was collected from 1,387 and the response rate was 84.6%. Completed questionnaires only (1,221) wereused for the data analysis. There were no statistically significant differences according to work position, and gender. However, an
ANOVA did show significant differences when the subjects were grouped according to educational background. Nurses who held amaster's degree had the highest scores for practicing the meaning of human caring followed by those with a bachelor's degree, and thetwo-year program group had the lowest scores (p<0.001). Age also has a significant impact on HCMQ scores. For nurses who
graduated from 2-year programs, the HCMQ score fell as the age of the respondents rose, but for nurses who attended 4-year
programs the HCMQ score rose according to age.
Keywords

human caring, questionnaire development, nurse, Thailand

Human caring is an important concept in nursing1). The

ask practicing nurses and administrators to self-evaluate thesense of healing, relief, peace of mind and mutual trust etc., areextent to which they fulfilled these criteria in their working

included in the concept of human caring. In a clinical setting,lives. These findings were then analyzed according to thehuman caring will be achieved through the nurses' daily

subjects' educational background, age, experience, and work

behavior towards patients' care. However, it might vary

position, as human behavior or the way of thinking are2), as inaccording to the nurses' cultural background or tradition

influenced by such characteristics. The subjects of this research

the differences between Asia and the West. This time, nurses'

were nurses and nursing administrators working at six national

behavior with regard to human caring is investigated inhealth centers for the Ministry of Health in Thailand.

Thailand, which has an Asian culture.
Firstly, the concept of human caring was examined by
the behavior of human caring:

reviewing the literature and identifying 7 patterns of behavior(elements) that constitute its' essence. Each element was then

The most important step for the development of thissub-divided into 5 items of behavior. The second stage was toinstrument was the identification and specification of the*1National College of Nursing, Japan（Fundamental Nursing）

1-2-1, Umezono, Kiyose-shi, Tokyo,
204-8575, Japan
TEL:0424-95-2211
FAX:0424-95-2698
e-mail:ozawam@adm.ncn.ac.jp*2National College of Nursing, Japan（Human Science）*3President, National College of Nursing, Japan― 11 ―J Nurs Studies N C N J Vol.1 No.1 2002

concept of human caring. Ford's survey of 192 nurses identified

3. Choices

two major categories for caring: genuine concern for the wellbeing of another and giving of yourself

Understanding the values of others

3). From seventy-five

Providing alternatives to others in their decision-making

behaviors, Wolf4) identified the five highest ranked caring

Respecting the opinions of others

behaviors as attentive listening, comforting, honesty, patience,

Respecting the rights of others

and responsibility.

Understanding the desires of others

5)

Howardpointed out eight theoretical components:

4. Genuine dialogue

inherent worth, irreplaceability, holistic selves, freedom ofUsing warm and kind expressions

action,Listening with understanding

statusequality,shareddecisionmakingand6) developed

responsibility, empathy, and positive affect. Fenton

Expressing oneself

the Scale of Humanistic Nursing Behaviors by observing

Being able to communicate in a humanistic way

nurses' activity in a clinical setting. This scale was based on

Showing willingness to communicate with others

four dimensions: shared decision making, holistic selves,

5. Experiential process

empathy, and status equality. These four dimensions were

Being open to others5) eight components.

based on Howard's

Being gentle and tender

Lakomy7) examined the meaning of human caring by using

Willingly satisfying the needs of others

qualitative methodology, and identified seven themes of human

Satisfying the extra needs of otherscaring: essence of person/being; relationships/encounters;

Being sympathetic to others

decisions/choices/judgments; genuine dialogue; experiential

6. Healing

process; healing modalities; and human/economic resource

Using "touch" in a therapeutic way

exchanges.

Believing in faith

Watson's caring concept and Lakomy's seven themes ofBelieving in hopehuman caring have been adapted for the questionnaire as a

Being willing to help others without hesitation

theoretical base to measure human caring.7,8)

Showing empathy

Consequently, human caring is defined as 7 patterns of

7. Human/economic resources exchange

behavior (elements): essence of person, relationships, choices,

Having a social network

genuine dialogue, experiential process, healing modalities, andHaving supportive exchanges

human/economic resource exchange.

Being satisfied with one's economic status
Being friendly to others

Five items were developed for each of these 7 elements.

Having the ability to utilize supportive relationships with

Consequently, the instrument consists of the following thirty-

othersfive items:
The following Likert scale was used to determine the extent to
1. Essence of person

which the respondents behaved in the manner outlined in the

Understanding and loving humanity

elements described. For each item the respondents awarded

Loving others as well as oneself

self-evaluation grade as follows:

Allowing others the freedom to be human
Promoting and sustaining the human qualities of others

Nearly always = 5 marks (76 -100 % acceptance)

Understanding the reality and the meaning of life and death

Usually = 4 marks (51-75 % acceptance)

2. Relationships

Sometimes = 3 marks (26-50 % acceptance)

Being comfortable in developing friendship with others

Seldom = 2 marks (1-25 % acceptance)

Being willing to develop companionship

Never =1 mark (0 % acceptance)

Being sensitive to the needs of others
Providing support to others
Recognizing the uniqueness of others

国立看護大学校 紀要 第 1 巻 第 1 号 2002 年

In order to keep the respondent's thinking within themeaning of each element of human caring, the headings for the― 12 ―

An Investigation into Nurses' Behavior with regard to Human Caring

lts:

elements were included in the questionnaire. The items, then,were arranged in sequence under each element. Researchers

The sample consisted predominantly of females (92.5%)

indicated how the questionnaire should be completed.

with the majority of the respondents being staff nurses

Completion of all items was requested.

(87.3%). The percentage of respondents holding a bachelor's

This questionnaire, named The Human Caring Meaningdegree was 64.9%, with 4.7% holding a master's degree. The

Questionnaire (HCMQ), was written in English and reviewed

average age and working experience were 36.0 years and 14.0

by three nurse researchers who were interested in the concept

years respectively (See Table 1).

of caring. Additionally, a panel of experts (Thai faculty
members possessing a doctoral degree from the USA) was
asked to review the questionnaire. As a result of theirsuggestions, some changes were made.

Table 1：The characteristics of the sample
Characteristics

N%

Max. Min. Mean

S.D.

Center

The pretest was performed by 15 staff nurses and nurse

General

441

36.1

-

-

-

administrators who could understand English. The internal

Cancer

151

12.4

-

-

-

-

consistency of the test (Cronbach's alpha) was computed andCardiovascular

304

24.9

-

-

-

-

the reliability coefficient was 0.94, which was considered to be

Mental health

325

26.6

-

-

-

-

1,221 100.0

-

-

-

-

Female

1,129

92.5

-

-

-

-

Male

92

7.5

-

-

-

-

Total

quite high.

-Sex

Subjects and Method
To carry out this research in Thailand, the English version of

Position

the HCMQ was translated into the Thai language. The same

Staff nurse

panel of experts tested the content validity. (Reverse-translation

Nurse administrator

was not performed). After making some amendments, the

1,066

87.3

-

-

-

-

155

12.7

-

-

-

-

365

29.9

-

-

-

-

799

65.4

-

-

-

-

-

-

-

-

-

-

-

-

Education
Technical nurse

pretest was carried out with 30 staff nurses and nurse(two-year program)administrators. The reliability coefficient (Cronbach's alpha)Professional nurse

was 0.95 in the Thai version of HCMQ (HCMQ-Thai).

Three-year program

6

0.5

Four-year program

793

64.9

57

4.7

Setting and sample. The target population for this study was
staff nurses and nurse administrators employed by the(Bachelor's degree)

government and working at the National Health Centers such

Master's degree

as General Hospitals, Cancer Centers, Cardiovascular Centers,

Age

-

-

61

20

36.0

9.54

Working experience

-

-

40

1

14.0

9.53

and Mental Health-Neuro-Psychiatric Centers. Confidentiality
was maintained by the questionnaires being completed
anonymously and by not using any form of coding. All the

For all respondents, the mean score for all items was 139.31,

respondents were informed that if the results of the study werewhich corresponds to a mean score of 3.98 for each item. Thispublished, only group data would be unveiled.

indicates that for 75% of their working lives, the subjects

Data collection. The HCMQ-Thai was distributed through theperform the items as outlined in the questionnaire. The meannurse supervisors of each center to 1,640 Thai staff nurses andscore of the respondents holding master's degrees was 145.35,

nurse administrators in 6 national health centers (classified in 4

equal to 4.15 per item, which indicated that for approximately

areas; general, cancer, cardiovascular, and mental health and

80% of the time nurses performed behaviors consistent withpsychiatric) belonging to the Ministry of Health. There were

the questionnaire (see Table 2).
There were no statistically significant differences in the

1,387 respondents, a response rate of 84.6 %. The completedmeans of the total scores when measured according to place ofquestionnaires (1,221) were used for the data analysis.
Data analysis: Each questionnaire was verified and a score

work, age, and experience (see Table 2). However, significant

was calculated. Percentages were used for demographic data

differences (p< 0.001) were found in regard to educational

analysis. Mean, standard deviation, t-test, and ANOVA werebackground (see Table 2). Nurses with master's degrees had theused for the statistical analysis.

highest score on the questionnaire (mean=145.35) followed by― 13 ―J Nurs Studies N C N J Vol.1 No.1 2002

Table 2：Summary of the results of the analysis of variances
Source of variation

Mean

S.D.

Education
Two-year program

136.24(Technical nurse)(3.89)

Bachelor program

140.29and equivalent(4.01)

F

P value

13.302.000

1-10 years

145.3521-40 years

Significance2-year program 138.9 ± 13.9 135.8 ± 15.0 133.2 ± 15.2 p<0.01(ANOVA)(n=160)(n=76)(n=129)15.61
3-year programAge
20-30 years old

138.6014.67

31-40 years old

139.87

15.98

41-61 years old

139.58

16.02

Working experience
1-10 years

138.86

14.86

11-20 years

139.9015.98

21-40 years

139.26

15.95

139.31

15.52

.797

.451

.511

.600

−

−

138.7 ± 22.9
(n=6)

−

4-year program

138.8 ± 15.2 140.3 ± 16.1 143.4 ± 14.8
p<0.01(ANOVA)(n=337)(n=296)(n=160)Master's degree

139.0 ± 25.2 145.7 ± 14.9 146.0 ± 15.4
not significant(n=4)(n=35)(n=18)

15.64(4.15)

Total

11-20 years

mean ± S.D. mean ± S.D. mean ± S.D.

14.76

(Professional nurse)
Master's degree

Table 3：Mean score for HCMQ according to length of work
experience & educational back- ground

The questionnaire was designed to measure the behavior ofhuman caring by nurses who have been working in hospitals in
Thailand. Significant differences were found between groups
only for educational background, and age. Nurses with master's
degrees demonstrated the highest score per item (mean score:4.15), followed by those who hold a bachelor's degree (4.01),(3.98)and the lowest (3.89) was found in technical nurses with 2
years of nursing education. Higher education may be effective
the bachelor degree group (mean=140.29), with the two-year

in influencing the performance of actions consistent with

program group having the lowest score for carrying out thehuman caring. However, it cannot be stated categorically that

items expressed in the questionnaire (mean=136.24). The

this is the case. It might be possible that highly-educated nurses

relationship between age and the HCMQ score for eachwish to be more humanistic and convince themselves that theyeducational group was then analyzed. For technical nurses

are; resulting in higher scores. As more highly motivated(graduates from a 2-year program), the score becomes lower as

nurses gain higher qualifications to improve their ability,

the nurses get older (p< 0.01; ANOVA). However, for nurses

nurses who are more able to perform humanistic care might be

who graduated from a 4-year program, the score becomes

concentrated in these more highly qualified groups. Reviewing

higher according to age (p< 0.01; ANOVA) (see Figure 1). This

the literature of human caring, Schultz et al9) investigated thepattern was also the case for nurses who have a master's degree.

perceptions of caring using the Caring Behavior Assessment

It is possible that the members of masters' group are

instrument. They did not find any difference in scores between

comparatively older than the members of other groups. As theantepartum and postpartum participants. These results are forscore becomes higher according to age, the higher scores ofpatients, not nurses. No articles relating to the direct influencebachelors' and masters' groups might be due to the higher age

of education, culture and age on nurses’ behaviour of humanof the members of this group. Therefore a comparison was

caring could be found. In this study, it has been presumed thatmade for all subjects over 31 years old. An ANOVA showed

the concept of human caring consists of 7 elements or 35 items.

that for these comparable age-groups, the HCMQ score was

A t-test showed no statistically significant differences between

still higher for those who had higher qualifications.

the 7 elements. From the factor analysis for the 35 items, no

When the HCMQ score was analyzed according to length offactors were recognized. This may mean that the concept ofwork experience, the results were similar (see Table 3). For

human caring cannot be divided into elements of behavior as intechnical nurses the score decreases with more experience,

this framework. Each element is closely linked to every otherwhereas for the 4-year group the opposite is the case, and theelement with a high correlation coefficient. However, the

HCMQ score increases(see Figure 2).

elements used in this study might be useful in helping nurses to

No significant differences were according to work position

achieve 'human caring' through actual behavior.

or gender.

国立看護大学校 紀要 第 1 巻 第 1 号 2002 年― 14 ―

An Investigation into Nurses' Behavior with regard to Human Caring

Figure 1：Mean score for HCMQ according to age &educational back groundFigure 2：Mean score for HCMQ according to length of work
experience & educational back ground4）Wolf, Z.R. (1986). The caring concept and nurse
A questionnaire was developed to evaluate nurses' behavior

identified caring behaviors. Topics in Clinical Nursing,of human caring in Thailand. Significant differences were8(2), 84-93.

found between groups only for educational background and5）Howard, J. (1975). Humanization and dehumanization ofage. Higher education might be effective in influencing thehealth care: A conceptual view. In J. Howard & A. Strauss

performance of actions consistent with human caring.

(Eds.) Humanizing health care. New York: John Wiley &Sons.

References

6）Fenton, M.V. (1987). Development of the scale ofhumanistic nursing behaviors. Nursing Research, 36(2),1）Watson, J. (2002). Assessing and measuring caring in
nursing and health science, New York: Springer

82-87.
7）Lakomy, J.M. (1993). The interdisciplinary meaning of

Publishing Company, 11-19.

human caring, In D.A.Gaut, (Ed.) A global agenda for2）Leininger, M. (1993). Cultural care theory : The

caring. New York: National League for Nursing Press,

comparative global theory to advance human care nursing

181-199.

knowledge and practice. In Delores A. Gaut (Ed.) A8）Watson, J. (1999). Nursing : Human science and humanglobal agenda for caring. New York: National League forcare : A theory of nursing, Massachusetts: Jones andNursing Press, 3-18.

Bartlett Publishers.

3）Ford, M.B. (1981). Nurse professionals and the caring

9）Schultz A.A., Bridgham C., Smith M.E., Higgins D.

process. Dissertation Abstracts International.

(1998). Perceptions of caring. Comparison of antepartum
and postpartum patients, Clin Nurs Res, 7(4), 363-78.

― 15 ―J Nurs Studies N C N J Vol.1 No.1 2002

Puangrat Boonyanurak*1，小澤三枝子 *1，David R. Evans*2，竹尾惠子*3【要旨】 タイ国看護職の「ヒューマンケアリング」にかかわる行動を評価することを目的として，ヒューマンケアリ

ングに関する調査票（HCMQ）を開発し，タイ国立ヘルスセンターに勤務する看護職を対象に，質問紙による調査を行った．質問紙では，「ヒューマンケアリング」の核となる 7 要素を文献に基づき採用した．7 要素とは，①人間性に対する理解，②人との関係性，③ものごとの決め方，④会話のしかた，⑤対応のしかた，⑥癒し（ヒーリング），⑦人的・経済的資源の交換，である．要素ごとに５質問項目を作成し，全体で 35 項目からなる質問紙を作成した．質問紙の妥
当性については，タイのエキスパートナース（3 人）の協力を得て，慎重に検討した．また，HCMQ（英語）を用いて，タイの 15 名のナースにプレテストを行い，信頼性係数 0.94 を得た．
HCMQ をタイ語に訳して，タイの 30 名の看護職を対象に行ったプレテストでは，信頼性係数 0.95 を得た．本調査での質問紙回収数は 1,387 で，回収率は 84.6％であった．そのうち，35 の質問項目のすべてに回答していた 1,221 を分析した．各看護職の職位，性別と HCMQ スコアの間に有意な差はみられなかったが，看護教育背景（２年課程，４年課
程，修士）と HCMQ スコアの間には有意な差がみられ，修士号を持った看護職の HCMQ スコアが最も高く，次いで４年課程，２年課程の順となった（ANOVA，p<0.001）．また，年齢と ＨＣＭＱ スコアとの間にも有意な差がみられた．
２年課程の看護職においては年齢が高くなるにつれて HCMQ スコアは減少するが，４年課程のナースにおいては年齢が増すと HCMQ スコアも増加した．
ヒューマンケアリング，質問紙の開発，ナース，タイ国

国立看護大学校 紀要 第 1 巻 第 1 号 2002 年*1

国立看護大学校 基礎看護学〒 204-8575
東京都清瀬市梅園 1-2-1
電話：0424-95-2211
FAX：0424-95-2698
メールアドレス：ozawam@adm.ncn.ac.jp*2

国立看護大学校 人間科学（語学）*3

国立看護大学校― 16 ―

大学校長