原著

Caring Behaviors Perceived by Nurses
in a Japanese Hospital
M asayuki Mizuno
M ieko Ozawa
Ayako Okada
Keiko Takeo

David R. Evans

National College of Nursing, Japan；1‑2‑1Umezono, Kiyose‑shi, Tokyo, 〒 204‑8575, Japanmizunom＠adm.ncn.ac.jp【Abstract】 The purpose of this study is to identify the perception of Japanese nurses regarding the most and least important caring
behaviors and to examine the relationship between nursesʼperceptions, their work experience and their educational background.
The instrument used in this study was a self‑administered Japanese questionnaire version of the CARE‑Q instrument which wasdeveloped by Larson. The questionnaire was disseminated to nurses employed by the government and working at a hospital in
Japan. The CARE‑Q‑Japanese was distributed via the nurse supervisors of this hospital to 602 Japanese staff nurses and nurse
administrators. There were 511 respondents, a response rate of 84.9％. The completed questionnaires(477)were used for the data
analysis.Nurses ranked the three most important behaviors as“listens to the patient”,“helps the patient not to feel dumb by giving
him/her adequate information”, and “gets to know the patient as an individual person”. There were significant differences in the
ranking of human caring behavior when measured according to educational background. Nurses who graduated from nursing
schools or nursing junior colleges ranked the most important behavior as“listens to the patient”. Nurses who graduated fromnursing colleges(bachelorʼs degree)or graduate programs in nursing ranked “gets to know the patient as an individual person”asthe most important. Nurses ranked the least important behavior as“asks the patient what name he/she prefers to be called”.

【Keywords】 caring, nurse, perception, behavior, Japan
using Caring Assessment Instrument(CARE‑Q)ranked
Ⅰ．Introduction

the most important caring behavior as“listens to thepatients”.They ranked the least important as“is profes-

Caring is an important concept in nursing .Caring has

sional in appearance”. Mayer conducted a replication

became the essence and central focus of nursing . Car-studyof Larsonʼ
s work,using 28oncologynurses.Mayering is a complex, elusive concept not only to define but

found that nurses ranked the most important as“listens

also to measure .Caring is provided for clients throughto the patients”and the least important as ”
is profes-

concrete behavior. To identify nursesʼ
perceptions ofsional in appearance”. Keane McDermott et al. foundwhich nursing behaviors are important as caring behav-that 26rehabilitation nurses ranked the most important

ior means to understand how caring is offered.It mightas“knows when to call doctor”and the least important

be meaningful to show the concept of caring in terms ofas“suggests questions for patient to ask doctor”andconcrete behaviors.

“
frequently approaches patient first”.

Leininger described that caring might vary accord-

In Sweden,von Essen & Sjoden ,Widmark‑Petersson

ing to the nursesʼ
cultural background or tradition. If

et al. ,and Larsson et al. ,using a Swedish version ofthere are differences of perception of caring behavior

the CARE‑Q instrument, did research on 73 nursing

between countries, this means culture and values affectstaff in medical and surgical care , 105 nursing staff in

the understanding of the concept of caring and helps us

cancer, general surgical and orthopedic surgical care ,offer more appropriate cross‑cultural nursing.

63nursing staff in cancer care ,and 53nursing staff incancer care ,respectively.Each researcher found nurs-

In the U.S.A, 57cancer nurses in a study by Larson

ing staff ranked the most important caring behavior as⎜ 13 ⎜J Nurs Studies N C N J Vol.4 No.1 2005

and the least important item；four fairly important and“listens to the patients”.
In Finland, 69 nurses in a psychiatric hospital in afour fairly unimportant items；10 somewhat importantusing CARE‑Q ranked theand 10somewhat unimportant items；and 20items thatstudy by Greenhalgh et al.

most important caring behavior as“talks to theare neither important or unimportant.
The psychometric properties of the CARE‑Q related

patients”.
In Japan, only one piece of research has been carried

to validity and reliability were assessed. The CARE‑Q

out to find the nursesʼperceptions as to which nurse

original version was reviewed for content validity by an

human caring behaviors are important. M isao et al.

expert nursing panel of graduate nursing students,and amodified the Caring Behaviors Assessment tool which

panel of patients and nurses from an oncology unit .

was developed by Cronin and Harrison .They made a

Larsonquestionnaire of 35 concrete behaviors and did research

CARE‑Q with a sample of 82 nurses. For the moston 323 nurses in 3 Japanese hospitals. They found thatimportant caring items the test‑retest reliability was

the nurses perceived “making patients comfortable”as79％ and for the five least important caring items it was

the most important caring behavior.

63％.

assessed the test‑retest reliability of thePuangrat et.al. researched in Thailand the extent to

Von Essen & Sjoden tested the internal consistency

which nurses could perform caring behavior bymeans ofof Swedish version of the CARE‑Q by analyzing thea self‑administered questionnaire. They found differ-data from a questionnaire version utilizing a 1‑7 point

ences according to educational background. Ozawa et.

Likert scale without response restrictions with 86medi-

al. repeated the research in Japan,and found the morecal‑surgical patients and 73 nursing staff. The overall

working experience nurses have,the greater their caring

Cronbach alpha was 0.95, and subscale values were：

behaviors are. Therefore, working experience and edu-“
accessible”0.76；“explains and facilitates”0.59；

cational background might affect the perception of“
comforts”0.86；“
trusting relationship”0.86；“
antici-nurses regarding the most and least important caring

pates”0.72, and “monitors and follows through”0.79.

behaviors,which has not been studied to date,and is the

Widmark‑Petersson et al.

focus of this research.

version in 72 cancer patients and 63nurses.The overall

tested the same Swedish

The purpose of this study is to identify the perception

Cronbach alpha was 0.95, and subscale values were：of Japanese nurses regarding the most and least impor-“accessible”0.59；“explains and facilitates”0.60；

tant caring behaviors, to compare these results with“
comforts”0.78；“
trusting relationship”0.86；“
antici-previous ones in other countries, and then to examine

pates”0.60, and “monitors and follows through”0.59.

the relationship between Japanese nursesʼ
perceptions,

To carry out this research in Japan,permission to use
and translate the CARE‑Q instrument was given bywork experience and educational background.

Larson. The original English version of the CARE‑Q
Ⅱ．Instrument

was translated into Japanese by two expert Japanesenurses who are also researchers. Reverse‑translation

In this study,the CARE‑Q was used,as it is the mostwas performed by another person whose first language

frequently used instrument for assessing caring in theis English and who understands Japanese well and is not

world,and therefore the most appropriate instrument

a nurse. The final English version was then compared

for international comparison. The CARE‑Q was devel-against the original questionnaire and the modified

for use with Q‑methodology to iden-

Japanese version.Then the pretest was carried out withtify nurse caring behaviors that are perceived as impor-

an expert nurse,the Japanese version was modified.The

tant.The CARE‑Q consists of 50nurse behavioral items

forced choice format of the CARE‑Q was changed to aordered in six subscales named： “accessible”(67‑point Likert‑type fixed rating measure. Scores as-

items)；“
explains and facilitates”(6 items)；“com-

signed to each item were between 1and 7points,grading(9 items)；“trusting relationship”(16 items)；
forts”

from the least important to the most important. The“anticipates”(5 items)and “monitors and follows

reason for this is that it was very difficult for a nurse to(8 items). The force‑choice distribution of thethrough”

rank the items according to directions and it took a long

CARE‑Q requires selection of the most important item

time to complete the CARE‑Q when the pretest was

oped by Larson

国立看護大学校研究紀要

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⎜ 14 ⎜

Table 1(n＝477)The characteristics of the sample
n

％

M ax.

M in.

M ean

S.D.

Sex
Female
Male

464
13

97.3
2.7

―
―

―
―

―
―

―
―

Position
Staff nurse

395

82.8

―

―

―

―

53
26
3

11.1
5.5
0.6

―
―

―
―

―
―

―
―

397

83.2

―

―

―

―

29
46

6.1
9.6

―
―

―
―

―
―

―
―

4
1

0.8
0.2

―

―

―

―

Age

―

―

59

21

29.7

7.32

Working experience

―

―

37

1

7.87

7.19

Characteristics

Vice head nurse
Head nurse
Other
Education
Nursing school
Nursing junior college
Nursing college(Bachelorʼs degree)
Graduate program in nursing
Other

carried out with an expert nurse. In addition to thethe majority of the respondents being staff nurses

Likert‑type questionnaire, the participants were asked(82.8％). The majority of respondents were from nurs-

to select the 5most important items among the same 50

ing schools(83.2％), 6.1％ were from nursing junioritems.

colleges, 9.6％ were from nursing colleges, and 0.8％
had attended a graduate program in nursing. The averⅢ．Subjects and Method

age age and amount of working experience were 29.7
years and 7.87 years respectively.

Setting and sample. The target population for thisThe Cronbach alpha reliability was 0.93,and subscale

study was staff nurses and head nurses employed by thevalues were：“accessible”0.66；“
explains and facili-

government and working in Japan. Confidentiality wastates”0.67；“
comforts”0.77；“trusting

maintained by the questionnaires being completed

0.85；“anticipates”0.75, and “monitors and follows

anonymously and by not using any form of coding. All

through”0.85.

relationship”

the respondents were informed that if the results of thestudy were published, only group data would be
The means for the 50CARE‑Q‑Japanese items ranged

revealed.
Data collection.The CARE‑Q‑Japanese was distribut-from a high of 6.88 to a low of 3.71. There were 23

ed to 602Japanese nurses through the nurse supervisors

items whose means were more than 6 which showsof the hospital. After filling in the questionnaire, the“most important”or“fairly important”. The 5 items

nurses put it into each envelope personally.Then each ofranked as most important by the respondents are listed

nurses brought her/his envelope to nurse supervisors

in Table 2. The highest ranking item was“helps thevoluntarily.There were 511respondents,a response ratepatient not to feel dumb by giving him/her adequateof 84.9％.The completed questionnaires(477)were used

information”(mean 6.68, SD 0.58). The second highest

for the data analysis.

ranked item was“listens to the patient”(mean 6.57,SD
0.63). The joint third highest ranking items were“getsⅣ．Results(mean 6.47,
to know the patient as an individual person”
SD 0.78)and “
talks to the patients”(mean 6.47, SD

Table 1 shows the background data of subjects. The

0.73). The fifth ranked item was“knows how to give

sample consisted predominantly of females(97.3％)withshots,I.V.s,etc.and how to manage the equipment like⎜ 15 ⎜J Nurs Studies N C N J Vol.4 No.1 2005

Table 2

Nursesʼperceptions of the most important caring
behaviors：5 highest mean score items on the
CARE‑Q(questionnaire)
Item

Score

SD

her adequate information
２．Listens to the patient
３．Gets to know the patient as an individual person

6.68
6.57
6.47

0.58
0.63
0.78

３．Talks to the patients
５．Knows how to give shots, I.V. s, etc. and how to

6.47

0.73

6.39

0.84

１．Helps the patient not to feel dumb by giving him/

manage the equipment like I.V. s, suction
machines, etc.

(mean 6.39, SD 0.84).
I.V. s, suction machines, etc.”

Table 3In regard to working experience,the means for the 50
items were analyzed.The 1‑10year‑working experiencegroup ranked the 5 highest mean scores, as“helps theNursesʼperceptions of the most important
caring behaviors：5 highest ranked items(n＝477)on the CARE‑Q
Itempatient not to feel dumb by giving him/her adequate％

１．Listens to the patient
52.6
２．Helps the patient not to feel dumb by giving
45.7
him/her adequate information
３．Gets to know the patient as an individual
40.9
person４．Check her/his perceptions of the patient with
21.4
the patient before initiating any action
５．Talks to the patients
20.3

information”, “
listens to the patient”, “
talks to thepatients”, “gets to know the patient as an individual
person”,and “encourages the patient to ask her/him any
questions he/she might have”. Those who had between
11 and 37 years of experience had two changes in themost important nursing behaviors. They had “
knows

５．Puts the patient first, no matter what else
20.3
happens

how to give shots, I.V. s, etc. and how to manage theequipment like I.V.s,suction machines,etc.”and “gives
a quick response to the patientʼs call”instead of“talksto the patients”and “
encourages the patient to ask her/
him any questions he/she might have”. The 5 items

know the patient as an individual person”.

ranked with the lowest mean scores by the respondents
were“
asks the patient what name he/she prefers to be(mean 3.71SD 1.31),“is honest with the patient
called”

The respondents were asked to the select five most(mean 4.38SD 0.91),“volabout his medical condition”

important items among the 50 items of the CARE‑Q‑

unteers to do little things for the patient, e.g., bring a

Japanese.These results are shown in Table 3.The most(mean 4.43, SD 1.29), “iscup of coffee, paper, etc.”

commonly selected items were“listens to the patient”(mean 4.60 SD 1.03), and “cheerful”
when with a(52.6％), “
helps the patient not to feel dumb by giving(meanpatient, concentrates only on that one patient”(45.7％), “
him/her adequate information”
gets to know

4.92 SD 1.15). In regard to working experience, the 1‑(40.9％), “
the patient as an individual person”
check

10 year‑working experience group and the 11‑37 year‑

her/his perceptions of the patient with the patient before

working experience group ranked the same 5items with

(21.4％), and joint fifth “talks toinitiating any action”

the lowest scores.When nursesʼfive highest mean scores

the patients”and “puts the patient first,no matter what

were compared according to educational background,else happens”(20.3％). When the nursesʼfive highest

the following three items were ranked among the top

rates were compared according to working experience,

five by both nursing school, nursing junior college,

the following four items were selected among the top

nursing college, and graduate program in nursing：

five by both 1‑10year‑work experience group and 11‑37“
helps the patient not to feel dumb by giving him/heryear‑work experience group；“
listens to the patient”,

adequate information”,“
listens to the patient”,“
gets to“helps the patient not to feel dumb by giving him/her

国立看護大学校研究紀要

第 4巻

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2005年

⎜ 16 ⎜

adequate information”, “gets to know the patient as an

information”also confirm previous research conductedindividual person”, and “check her/his perceptions ofby Misao et al.

the patient with the patient before initiating anyaction”.

nursing behaviors that represent “listening well, whenWith regard to educational background, the following

patients talk to nurse”and “explaining to patients what

three items were most commonly selected(Table 4)；

the nurses will do for them before the nurses do it”as“listens to the patient”, “
helps the patient not to feelthe second and third most important behaviors.

dumb by giving him/her adequate information”, andin which Japanese nurses identified

The findings of the previous studies show that “listen-“gets to know the patient as an individual person”.

ing”is ranked the most important. Therefore,

When considered by rank order, “gets to know thenurses tend to give the highest priority to items belong-patient as an individual person”was ranked third

ing to psychological care.“Helps the patient not to feel

(37.8％)in the nursing school group.However,the item

dumb by giving him/her adequate information”was not

was ranked second(44.8％)in the nursing junior college

ranked as highly in the studies by Larson and vongroup, was ranked first(63.0％)by those who had com-

Essen and Sjoden . Only Japanese nurses might per-pleted a nursing college,and was ranked first(75.0％)by

ceive this item as being the most important.

those who completed a graduate program in nursing.

However, the results of this study in Japan do notMore than half of respondents(55.4％)who were fromagree with patientsʼperceptions of caring.In a previous

nursing schools had more than six year‑working experi-

study by Misao et al.

ence, but only 19.0％ of respondents who were from“knows how to give shots”and “knows how to use

junior nursing colleges, nursing colleges, and graduate

equipment”as the most important. These results mean

programs in nursing had. Therefore, this difference

that Japanese patients probably perceive the giving of

could be due to the length of work experience. So, ancare to them safely, as the most important aspect.

analysis was made of nurses who had different educa-

Japanese nurses might perceive giving psychologicaltional qualifications but similar work experience.

care as most important, and take it for granted that

Nurses with between 1 and 5 years experience fromgiving care safely is done.

Japanese patients identified

these different groups were compared.This showed that“gets to know the patient as an individual person”was‑ ‑ranked as more important by nurses with higher educational qualifications.

With regard to educational background,the following
items are ranked as the top three byall groups；“
listens

Ⅴ．Discussion

to the patient”,“
helps the patient not to feel dumb by
giving him/her adequate information”, and “gets to‑ ‑know the patient as an individual person”.“
Gets to

There were 23 items which had a mean higher than 6know the patient as an individual person”become

which shows those items regarded as“
most important”

increasingly important for those with the highest qualifi-

or“fairly important”. In addition there were 45 items

cations. The rating increased from 37.8％(nursing(90％)that had a mean higher than 5score which shows

school)to 75.0％(a graduate program in nursing).Whenthose items deemed to be“
somewhat important”.

the 1‑5 year‑working experience group is considered toJapanese nurses perceived almost all the caring behav-

reduce the effect of work experience, the rank of theiors identified by CARE‑Q‑Japanese as important.“Lis-item rose according to educational background. Thesetens to the patient”,“
helps the patient not to feel dumb

results mean that the Japanese nursesʼ
perception ofby giving him/her adequate information”, and “gets toimportant caring behavior was affected greatly by edu-

know the patient as an individual person”were the top

cational background. Nurses who hold a bachelorʼs,three items by both mean score and frequency. Thismasterʼs, or doctor degree perceived knowing the indi-

result means that these three items are caring behaviors

vidual as more important than those who graduated only

which Japanese nurses perceive as the most important.

from nursing schools.

The first two items, “listens to the patient”and “helps
the patient not to feel dumb by giving him/her adequate⎜ 17 ⎜J Nurs Studies N C N J Vol.4 No.1 2005

Table 4

With regard to educational background, nursesʼperceptions of the
Nursing school(n＝397)

Nursing junior college(n＝29)
％

Item

Item

１．Listens to the patient
51.9 １．Listens to the patient
２．Helps the patient not to feeldumb by giving him/her
adequate information％
51.7

２．Gets to know the patient as an
46.6

44.8
individual person
３．Helps the patient not to feel
３．Gets to know the patient as andumb by giving him/her
37.8
41.4
individual person
adequate information
４．Check her/his perceptions of
the patient with the patient
21.4 ４．Knows when to call the doctor 27.6
before initiating any action
５．Encourages the patient to call 20.7
if he/she has problems
５．Tell the patient, in under- 20.7
standable language, what is
important to know about his/her disease and treatment
５．Talks to the patents

the number of subjects is not less than those of previous

nursing(pp.5‑68). New York：National League forstudies using the same instrument, the CARE‑Q, (Q‑Nursing Press.
3) M cCance,T.V.,M cKenna,H.P.,Boore,J.R.P. (1997).
Caring：Dealing with a difficult concept. International.

So, these results can be compared with the previous

Journal of Nursing Studies, 34(4), 241‑248.
4) Leininger, M .M. (1993). Cultural care theory：The
comparative global theory to advance human care nursing knowledge and practice. In Delores A.Gaut(Ed. )A
global agenda for caring(pp.3‑18). New York：

international ones.
Furthermore because 45 of the 50 items were perceived as being important by nurses, it may be that theconcept of caring is an integrated concept which is hardto divide into subsets.

National League for Nursing Press.
5) Larson, P.J. (1986). Cancer nursesʼperceptions of caring. Cancer Nursing, 9(2), 86‑91.
6) M ayer, D.K. (1987). Oncology nursesʼ
versus cancer

Ⅵ．Conclusion

patientsʼperceptions of nurse caring behaviors：A replication study. Oncology Nursing Forum, 14(3), 48‑52.
7) Keane, S.M ., Chastain,B.,Rudisill,K. (1987).Caring：nurse‑patient perceptions.Rehabilitation Nursing,12(4),182‑184.

Nurses ranked the three most important behaviors as“listens to the patient”, “
helps the patient not to feeldumb by giving him/her adequate information”, and“gets to know the patient as an individual person”.

8) von Essen, L., Sjoden, PO. (1991). Patient and staff
perceptions of caring：Review and replication. Journalof Advanced Nursing, 16(11), 1363‑1374.
9) von Essen, L., Sjoden, PO. (1991). The importance of

There was a difference in the ranking of caring behavior
when measured according to educational background.
Nurses ranked the least important behavior as“asks thepatient what name he/she prefers to be called”.
■References
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20.72) Leininger, M .M . (1991). The theory of culture carediversity and universality. In M .M . Leininger(Ed),
Culture care diversity and universality：A theory ofThis research was conducted only in one hospital,but

sort：28‑105 subjects, Questionnaire：36 subjects)

20.7 ５．Talks to the patients

第 4巻

第 1号

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nurse caring behaviors as perceived by Swedish hospitalpatients and nursing staff. International Journal of
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Sjoden,PO. (1996).Cancer patient and staff perceptions⎜ 18 ⎜of caring vs clinical care. Scandinavian Journal ofmost important caring behaviors：5 highest ranked items on the CARE‑Q
Nursing college(n＝46)
Item

Graduated program in nursing(n＝4)％

１．Gets to know the patient as anindividual person
２．Listens to the patient％

Item
１．Gets to know the patient as an

63.0

75.0
individual person
２．Encourages the patient to call
58.7
50.0
if he/she has problems

３．Helps the patient not to feeldumb by giving him/her adequate information
41.3 ２．Listens to the patient

50.0

４．Puts the patient first, no matter
what else happens
30.4 ４．13 items
５．Encourages the patient to call if 21.7

25.0

he/she has problems
５．Check her/his perceptions of thepatient with the patient before
initiating any action

21.7

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anxiety and depression. Journal of Advanced Nursing,27(4), 855‑864.
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日本の看護師が認識したケアリング行動
水野正之
小澤三枝子
岡田彩子
David R. Evans
国立看護大学校；〒 204‑8575 東京都清瀬市梅園 1‑2‑1

竹尾惠子

【要旨】 日本の看護師が重要であると認識するケアリング行動を明らかにし，ナースの臨床経験や受けた教育背景によって，重要と認識するケアリング行動に違いがあるかどうか調べることを目的として，調査を行なった。質問紙には，Larson が開発した CARE‑Q(50項目)を日本語に訳した CARE‑Q‑Japanese を使用した。本調査は 1病院で行ない，回収数は511部，回収率は 84.9％であった。そのうち，50項目の質問に完全回答していた 477部を対象に分析を行なった。看護師がかなり重要と認識していたケアリング行動は，「患者の話に耳を傾ける」「わかりやすく適切な表現で情報を伝え，患者に話がよく理解できるようにする」「患者も個別性を持つ人間であることを良く理解している」
であった。教育背景と，重要と認識するケアリング行動の間に違いがみられ，看護専門学校や看護短大を卒業した看護師は，「患者の話に耳を傾ける」
を最も重要と認識していたことに対し，看護系大学を卒業または看護系大学院を修了した看護師は，「患者も個別性を持つ人間であることを良く理解している」
を最も重要と認識していた。看護師が最も重要でないと認識していた項目は，教育背景に関わらず，「患者がどんな名前で呼んで欲しいか聞く」であった。

⎜ 19 ⎜J Nurs Studies N C N J Vol.4 No.1 2005