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THE DEVELOPMENT OF NURSE-PATIENT RELATIONSHIP SCALES
IN CHRONIC CARE
By
Véronique Boscart
A thesis submitted in conformity with the requirements
for the degree of Doctor of Philosophy
Graduate Department of Nursing Science
University of Toronto
© Copyright by Véronique Boscart 2010
ii
ABSTRACT
The Development of Nurse-Patient Relationship Scales in Chronic Care
Véronique Boscart
Doctor of Philosophy
Graduate Department of Nursing Science
University of Toronto
2010
Quality of life and well-being of patients living in chronic care (CC) are determined to a
considerable extent by the relationships these patients have with nursing personnel caring for
them. Given the importance of these relationships, there is an absence of empirical research and
measurement tools to assess these relationships from a patient’s perspective. The purpose of this
study was to develop and test valid and reliable instruments to determine what qualities of the
humanistic relationships between cognitively competent patients and nursing personnel in CC
settings were most important to patients and what they experience most. A conceptual
framework based on the Humanistic Nursing Theory by Paterson and Zderad (1976) served as a
foundation to develop two scales; the Humanistic Relationship Importance Scale (HRIS)
assessed what attributes of the relationship are most important, and the Humanistic Relationship
Experience Scale (HRES) assessed what attributes of the relationship are experienced. Sixty-nine
content relevant items based on six dimensions of the Paterson and Zderad theory were
developed and tested for content validity resulting in the deletion of 20 items. Forty patients
completed the now 49-item scales to establish their initial internal consistency reliability, test-
retest reliability and construct validity. Another 25 items were deleted in the process. The 24-
item scales were completed by 249 patients in five CC facilities and the results subjected to a
iii
principal axis analysis (PAA). An oblique rotation resulted in a five factor solution labeled:
relational availability, promoting quality of daily life, recognizing and supporting choice,
forming connections, and supporting human uniqueness. This was a simplification of the original
six dimensions of the Paterson and Zderad theory. A PAA of the 24-item HRES resulted in a one
factor solution labeled humanistic connection. Reliability testing of the factors resulted in the
deletion of one more item and an HRIS with a Cronbach′s alpha of .87 indicating strong internal
reliability and an HRES with a Cronbach′s alpha of .98 suggesting some redundancy of items.
Relational availability was rated as the most important factor in the nurse-patient relationship
although all factors were important to patients. The mean score of the HRES indicated that
patients experience a moderate level of humanistic connection in terms of frequency and
intensity with nurses who generally care for them. Findings of this study have contributed to a
better understanding of the nurse-patient relationship, and support the care, research, and
theoretical knowledge of nurses and patients in these environments.
iv
ACKNOWLEDGEMENTS
I have been most fortunate to receive encouragement and assistance from many
individuals as I proceeded through the doctoral program. First, I would like to extend my sincere
thanks to my supervisors, Dr. Dorothy Pringle and Dr. Katherine McGilton for their knowledge,
guidance and untold support. They provided me with more opportunities than I could name. I
also thank my committee members, Dr. Elizabeth Peter and Dr. Francine Wynn. Their thoughtful
comments and encouragement were invaluable and are greatly appreciated. Dr. David Streiner’s
expert advice has been most helpful and is greatly acknowledged.
I offer my regards and blessings to all of the patients who participated in the study. This
study could not have happened without the generous giving of their time. Their thoughtful
comments have given me a deep understanding about nurse-patient relationships and for this I
am very thankful.
Financial support from Toronto Rehabilitation Institute, the Registered Nurses
Association of Ontario, The Canadian Nursing Fund, and a Mildred Claire Pratt Graduate
Nursing Fellowship is great-fully acknowledged.
No effort of this magnitude is ever achieved alone. I am privileged to have a network of
family, friends and colleagues who have helped me accomplish my goals. Above all, I dedicate
my efforts to my parents for their unwavering encouragement. They instilled in me a love of
learning and the joy of following your dreams. My family, Fran en Koen, Belle en Nikie, Linda
and Rob, Robrecht and Maria, Leon and Bernadette, Frans and Cecile, Gabriel, Sister Marie-
Louise, Henri and Nelly, Jef and Maria, Rita and Jean, Marc and Marianne, Kurt and Fabienne
and all others. Your wisdom, interest, and enthusiasm kept my passion alive. I am indebted to
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many of my friends, Kathy and Jim, Rebecca and Rod, Jennifer and Rob, Vannetta and John,
Malini, Anne, and Maryanne, and my colleagues Maureen, Pam, Lynn, Marcia, Holly, and
Rachel. Each of you contributed a listening ear, supported me through the challenging times, and
joined heartily in celebrating my successes. I want to offer a special thanks to Dr. Maria
Grypdonck, my mentor and supervisor at the University of Ghent, Belgium. Her enthusiasm for
nursing knowledge and teaching has greatly influenced my future.
Most importantly, I thank my husband Tom and my boys Emiel and Henri. They were
with me every step along the journey and their love is essential to my endeavors. I share this
accomplishment with them.
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Table of Contents
Chapter One: Introduction .............................................................................................................. 1
Purpose of the Study ................................................................................................................... 6
Chapter Two: Critical Review of the Literature ............................................................................. 7
Conceptual Approaches in Exploring Nurse-Patient Relationships ........................................... 7
Empirical Research on Nurse-Patient Relationships ................................................................ 12
Qualitative Empirical Research on Nurse-Patient Relationships.......................................... 13
Quantitative Empirical Research of Measures of Nurse-Patient Relationships.................... 19
Regulatory Guidelines and Standards for the Nurse-Patient Relationship ............................... 22
Summary of the Literature Review and Current Standards on Nurse-Patient Relationships ... 24
Chapter Three: Theoretical Framework........................................................................................ 26
Justification for the Choice of Theory ...................................................................................... 26
Philosophical Perspectives underlying the Humanistic Nursing Theory.................................. 29
The Humanistic Nursing Theory .............................................................................................. 30
Core Concepts of the Humanistic Nursing Theory................................................................... 33
Supporting Human Uniqueness ............................................................................................ 33
Sustaining Choice ................................................................................................................. 34
Relational Capacity............................................................................................................... 35
Living Dialogue .................................................................................................................... 36
Being Present ........................................................................................................................ 36
Fostering Well-being and More-being.................................................................................. 37
Research Objectives.................................................................................................................. 38
Chapter Four: Scale Development ................................................................................................ 40
vii
Instrument Justification............................................................................................................. 40
Measurement Principles............................................................................................................ 41
Classical Measurement Theory............................................................................................. 41
Phase 1: Item and Scale Development...................................................................................... 45
Item Development................................................................................................................. 46
Scale Construction ................................................................................................................ 49
Content Validation Testing ................................................................................................... 52
Phase 2: Initial Psychometric Testing....................................................................................... 57
Protection of Human Subjects .............................................................................................. 57
Setting and Sample ............................................................................................................... 58
Data Collection Procedure .................................................................................................... 58
Data Analysis ........................................................................................................................ 63
Results................................................................................................................................... 64
Item Deletion Process ........................................................................................................... 72
Implications for Phase 3............................................................................................................ 74
Summary ................................................................................................................................... 76
Chapter Five: Factor Analysis and Results................................................................................... 77
Setting ....................................................................................................................................... 77
Sample....................................................................................................................................... 77
Data Collection Procedure ........................................................................................................ 79
Data Analysis ............................................................................................................................ 80
Procedures to Test Dimensionality ....................................................................................... 80
Procedures for Reliability Testing ........................................................................................ 82
viii
Results....................................................................................................................................... 83
Setting and Sample ............................................................................................................... 83
Testing the Dimensionality of the Humanistic Relationship Scales..................................... 86
Reliability Testing of the Factors of the Humanistic Relationship Scales............................ 98
Item Deletion Process ......................................................................................................... 100
Findings................................................................................................................................... 101
Important Qualities in a Nurse-Patient Relationship .......................................................... 101
Experienced Qualities in a Nurse-Patient Relationship ...................................................... 102
Summary ................................................................................................................................. 102
Chapter Six: Discussion.............................................................................................................. 104
Psychometric Strengths of the Humanistic Relationship Scales............................................. 104
Contributions to the Understanding of the Nurse-Patient Relationship in CC ....................... 109
Paterson and Zderad’s Humanistic Nursing Theory Revisited............................................... 112
Limitations of the Study.......................................................................................................... 115
Chapter Seven: Summary, Conclusions and Implications.......................................................... 118
Summary ................................................................................................................................. 118
Conclusions............................................................................................................................. 120
Implications............................................................................................................................. 121
Implications for Nursing Regulations and Standards ......................................................... 121
Implications for Theory Development................................................................................ 123
Implications for Nursing Practice and Education ............................................................... 125
Implications for Future Research........................................................................................ 126
Final Statement ....................................................................................................................... 128
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Tables
Table 4.1. Operational Definitions and Domains per Concept
Table 4.2. Demographic Characteristics of Phase Two Participants
Table 4.3. Interpretability of Items
Table 4.4. Internal Consistency Reliability for the HRIS-49 and HRES-49
Table 4.5. Suggested Items for Deletion upon Completion of Phase Two
Table 4.6. Number of Items per Concept Before and After Item Deletion Process
Table 4.7. The 24-Item Humanistic Relationship Scale
Table 5.1. Facility Size
Table 5.2. Number of Potentially Eligible Participants per Facility
Table 5.3. Facility Characteristics
Table 5.4. Demographic Characteristics of the Participants per Facility
Table 5.5. Unrotated PAA: Factor Extraction and Total Variance per Factor for the HRIS-24
Table 5.6. Oblique Rotated Factor Loading Matrix for the HRIS-24
Table 5.7. Overview of PAAs for the HRIS-24
Table 5.8. Items Cross Loading for the HRIS-24
Table 5.9. Unrotated Factor Loading Matrix for the HRES-24
Table 5.10. Cronbach′s Alpha per Factor per Scale
Table 5.11. Inter-Item Correlations for Factor 5 of the HRIS-23
Table 5.12. Descriptive Statistics for the Factors of the HRIS-23
Table 6.1. Summary of Concept Clarification and Theory Refinement
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Appendices
Appendix 2.1. Qualitative Empirical Research on Nurse-Patient Relationships
Appendix 2.2. Quantitative Empirical Research on Nurse-Patient Relationships
Appendix 2.3. Concept Utilization of Nurse-Patient Relationships in Regulatory Standards and
Professional Guidelines
Appendix 3.1. Concept Utilization of Nurse-Patient Relationships in Nursing Theories
Appendix 4.1. Content Validation Information Letter for Scholarly Experts
Appendix 4.2. Content Validation Questionnaire for Scholarly Experts
Appendix 4.3. Demographic Sheet for Scholarly Experts
Appendix 4.4. Content Validity Index for the HRIS-69
Appendix 4.5. Content Validation Information Letter for Patient Experts
Appendix 4.6. Consent Form for Patient Experts
Appendix 4.7. Content Validation Questionnaire for Patient Experts
Appendix 4.8. Content Validation Demographic Sheet for Patient Experts
Appendix 4.9. Content Validity Index for the HRIS-52
Appendix 4.10. Information Letter for Phase Two Participants
Appendix 4.11. Consent Form for Phase Two Participants
Appendix 4.12. Relational Care Scale
Appendix 4.13. Presence of Nursing Scale
Appendix 4.14. Nursing Home Resident Satisfaction Scale
Appendix 4.15. Demographic Sheet for Participants
Appendix 4.16. Inter-Item Correlations for the HRIS-49
Appendix 4.17. Inter-Item Correlations for the HRES-49
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Appendix 4.18. Item-to-Total Correlations for the HRIS-49
Appendix 4.19. Item-to-Total Correlations for the HRES-49
Appendix 4.20. ICC Scores for the HRIS-49
Appendix 4.21. Construct Validity for the HRES-49
Appendix 4.22. Variability for the HRES-49
Appendix 4.23. Psychometric properties of the HRIS-49
Appendix 4.24. Psychometric properties of the HRES-49
Appendix 5.1. Information letters for Phase Three Participants
Appendix 5.2. Consent Form for Phase Three Participants
Appendix 5.3. Missing values for the HRIS-24 and HRES-24
Appendix 5.4. Unrotated Factor Loading Matrix for the HRIS-24
Appendix 5.5. Orthogonal Varimax Rotated Factor Loading Matrix for the HRIS-24
Appendix 5.6. Orthogonal Varimax Rotated Four Factor Loading Matrix for the HRIS-24
Appendix 5.7. Inter-Item Correlation for the HRIS-24
Appendix 5.8. Overview of Inter-Item Correlations per Factor for the HRIS-24
Appendix 5.9. Descriptive Statistics per Item for the HRIS-24
Appendix 5.10. Descriptive Statistics per Item for the HRES-24
1
Chapter One: Introduction
A deeply held assumption in nursing is that a close relationship between a nurse and a
patient is at the very heart of nursing (Armstrong-Esther, Brown, & McAfee, 1994). These nurse-
patient relationships are established to address the health needs of the patient and are a vital
means to deliver individualized care in a compassionate and thoughtful manner. Over the course
of the last century, theorists, researchers, and practitioners alike have tried to describe the
development and reconstruction of this complex multi-dimensional construct, the nurse-patient
relationship.
In the early 1900s, the emerging nurse-patient relationship ideal was aimed at providing
safe care in attending to the patients’ physical needs. In the years after the World Wars, the
nurse-patient relationship ideal started to incorporate concepts of holism and humanism,
revealing the influence of existentialist thought (Easley, 1989). The primary goal of the nurse-
patient relationship was recognized as promoting the well-being and safety of the person (Pijl-
Zieber, Hagen, Armstrong-Esther, et al. 2008). Despite this reconceptualization of the nurse-
patient relationship, textbooks and published literature continued to indicate a mechanistic and
unilateral relationship in which the nurse maintained an objective view of the patient. In 1969,
Pugh described the nurse-patient relationship as one in which both parties had a ‘role’. The nurse
needed to gain the trust of the patient and the patient had to abide by instructions and cooperate
in carrying out of the treatment (Pugh). This lack of patient involvement in the relationship is
apparent in many early texts on nursing.
It took some time before the awareness of a shared connection settled in, but the concept
starts appearing in nursing texts from the 70s on. Darwin, Markham, and Whyte (1972)
described how emotional and spiritual needs could be met by the nurse listening with sympathy
2
and compassion. This idea was supported by Kratsz (1979) describing in her book, The Nursing
Process, that the interaction between two people influenced the behaviour of each. These ideas
were consequently supported by nursing theorists who started to describe the notion of a nurse-
patient relationship in more detail. Yet, despite clear theoretical direction, these types of
relationships appear to be the exception rather than the rule. Several qualitative researchers have
reported on patients’ and families’ experiences with nurses and indicated that both felt that
nurses treated them like a set of tasks requiring standardized care (Foner, 1994, 1995; Diamond,
1984, 1986).
The nurse-patient relationship has progressively gained attention over the last 30 years
due to a growing resistance to the traditional paternalistic approach to health and patient care, a
rapidly expanding professionalism in nursing, and an increased consumerism from the patient’s
perspective. Furthermore, the climate of today’s health care delivery system necessitated
reevaluating the existing mechanistic and unilateral nurse-patient relationship. Most patients in
the current health care system are vulnerable due to an increasing age, care complexity and
issues of chronicity. These factors indicate multifaceted and complicated health care needs and
require well-developed nurse-patient relationships to promote optimal nursing care delivery.
The emphasis on a close nurse-patient relationship is even more crucial when considering
patients who live in chronic care (CC) environments. Chronic care facilities are designed to
provide complex and continuing care to patients with chronic illnesses or long-term functional
disabilities who require a range of therapeutic and medical care services (Canadian Institute for
Health Information [CIHI], 2006/2007). The majority of patients admitted to these facilities are
transferred directly from an acute care hospital (82.1%), with a smaller proportion of admissions
originating from home (6.5%), long-term care (LTC) facilities, or rehabilitation hospitals (CIHI).
3
The patients who are admitted to CC present with a variety of physical, cognitive and/or
behavioural conditions, and require skilled rehabilitation and/or restorative care with a focus on
caring for the whole person. These medically complex and specialized services are often
provided over extended periods of time. While some of these patients move on to LTC facilities
(21.3%), home care (15.4%) or active treatment hospitals (12.7%), for many others, the nature of
their condition means that the CC facility will remain their home (CIHI). According to Canadian
Institute for Health Information statistics, the most frequent discharge status was death, with
32.7% of all admissions ending in this manner between 2006 and 2007 in Ontario CC facilities.
Since many patients spend much of their adult lives in CC programs, contributing to their
quality of life is an important focus of nursing personnel working in these environments (Kane,
2001; Thorne & Robinson, 2007). Several researchers have shown that the quality of life for
patients living in CC is determined to a considerable extent by the relationships they have with
the nursing personnel caring for them (Jonas-Simpson, Mitchell, Fisher et al., 2006; McGilton &
Boscart, 2007). Patients describe nurses as having a very important role in their daily lives. In the
last decades, the growing realization of the importance of these nurse-patient relationships,
combined with an expanding professionalism and accountability has spurred a surge in empirical
research and the development of strict standards and guidelines by regulating and professional
organizations for the nurse-patient relationships.
Despite the increase in the volume of research in the area of nurse-patient relationships in
a variety of settings, it is still underdeveloped. A number of authors have described
characteristics underlying the nurse-patient relationship (Ronayne, 2001; de Raeve, 2002a,
2002b; Henderson, 2003; Moyle, 2003), and although these descriptions clearly depict a nurse-
4
patient relationship, several deficiencies in the current understanding of nurse-patient
relationships are apparent in a CC setting.
First, a major shortcoming in these descriptions lies in their failure to acknowledge the
uniqueness of CC settings (Forchuk & Reynolds, 2001; Henderson, Van Eps, Pearson, et al.,
2007). A relationship created between a patient and a nurse in a long-term care environment is
maintained over an extended period of time and should encompass much more than a goal-
directed and purposeful connection established to address illness-related problems. The patients’
extensive stay in CC offers many opportunities for both the nurses and the patients to engage in
stories, life experiences, and personal narratives resulting in a unique knowledge of the other
individual. Most CC patients are also well aware of the permanent nature of their stay, i.e., they
are not likely to leave this setting or return to their previous state of health. Therefore, most
patients in these environments seek relationships with nurses that address not only their illness-
related needs, but extend to a person-to-person reciprocal connection to help them increase the
quality of daily living and promote a mutual sharing of everyday experiences (Bergland &
Kirkevold, 2006). Relationships are formed over interactions in which shared interests in
baseball or reminiscence about grown children, for example, often lead to a strong connection
between a patient and a nurse. This distinctive familiarity within the nurse-patient relationship is
not acknowledged in the current research yet can have a profound impact on the care delivery
process and on the patient’s perceived quality of life (Jonsdottir, Litchfield, & Dexheimer
Pharris, 2004).
A distinctive aspect of the nurse-patient relationship specifically in CC is related to the
goal of the nurse-patient interactions. Focusing on purposeful and goal-directed interactions to
promote health and well-being (CNO, 2006) is absolutely necessary but not sufficient within a
5
nurse-patient relationship in CC. Relationships in these settings are also about achieving comfort,
friendship, and creating meaningful moments over time (Pringle, 2003). Long-term stays,
debilitating diagnoses and a high death rate call for relationships to enhance the best possible
quality of life. Several quality-of-life domains, such as comfort, meaningful activity,
relationships, enjoyment, dignity, autonomy, individuality, and spiritual well-being should be
equivalent to and often prevail over health and safety outcomes (Kane, 2001).
A second limitation of the current state of knowledge is situated in the nurses’
perspective of the nurse-patient relationship. Existing guidelines for the development and
maintenance of this relationship are based on the nurses’ perspective, excluding the patient’s
point of view about the value and qualities of these relationships. When the relationship is
considered a mutual process as proposed by regulating (CNO, 2006) and professional (RNAO,
2006) organizations, patients need to be equal partners. The patient’s voice is an essential
constituent in the understanding of the nature of the nurse-patient relationship.
Third, despite a large body of conceptual and theoretical work regarding the nurse’s role
in the nurse-patient relationship, there is a lack of consensus about the definition of the nurse-
patient relationship. Therefore, the exact qualities of a nurse-patient relationship remain
undefined and therefore difficult to measure. Furthermore, few scales are available that measure
the nurse-patient relationship from the patients’ perspective in a residential setting and most of
these scales lack psychometric testing. More importantly, most existing measurement scales
capture a single aspect of a nurse-patient relationship (Huss, Buckwalter, & Stolley, 1988; Rieck,
2002). Consequently, before understanding the dimensions of nurse-patient relationships that are
most important to patients, valid and reliable scales that measure these relationships in a more
comprehensive way than the scales that currently exist are needed.
6
Purpose of the Study
Given the importance of these relationships, there is a lack of understanding of the nurse-
patient relationship in a CC setting. Little work has been done to examine the relationship
between patients and nursing personnel in CC. Most of this work lacks the patient’s perspective.
Redundancy of qualitative study findings warrants the progression into quantitative research in
order to further explore the extent of the nature of the nurse-patient relationship in these CC
settings and to identify through measurement the specific nurse behaviours that are valued from a
patient’s perspective. Yet, few researchers have tried to conduct quantitative research to fill the
gap in the understanding and measurement of these relationships. Existing scales to quantify
these relationships were developed for different populations and were found to be inappropriate
in assessing the nurse-patient relationship in CC facilities.
The purpose of this study was to develop and test valid and reliable instruments to
determine what qualities of the interpersonal relationships between cognitively competent
patients and nursing personnel in CC settings were most important to patients and what they
experience. Consequently, two scales were developed: one to assess what attributes of the
relationships are most important and one to assess what attributes of the relationships are
experienced.
7
Chapter Two: Critical Review of the Literature
This chapter presents a review of the current empirical research literature and a
discussion of the regulatory guidelines and standards of the nurse-patient relationship. A critical
review of the nursing literature from social sciences and nursing literature (Polit, Beck, &
Hungler, 2001) revealed a large body of conceptual work and qualitative and quantitative
empirical research studies. The material examined focused on the nurse-patient relationships in
general and on chronic care settings specifically. Given the centrality of relationships to this
study, a review of the conceptual work is presented before reviewing empirical research studies
and regulatory guidelines.
Conceptual Approaches in Exploring Nurse-Patient Relationships
In this section, published papers that propose concepts and theories about the relationship
between the nurse and the patient are examined. Medline and CINAHL databases (1980 to 2009)
were searched for the terms: patient/resident/client, nurse/care provider/nursing assistant(s)/staff,
relations/relationships/ relatedness, presence/attendance/ companion, contact/interaction/dialogue
associated with long-term care, chronic care, continuing care, institutional care, home care and
nursing homes. Twenty-tree articles were retrieved. The criteria to select the 23 manuscripts
included: 1) an exploration or discussion of a specific facet of the nurse-patient relationship (i.e.,
development, evolution, qualities), and 2) a contribution to the conceptual understanding of the
nurse-patient relationship. None of the manuscripts retrieved were CC specific.
Theoretical and educational literature on relationships between nurses and patients has
proliferated since the 1960s and has generated a range of divergent accounts of what the nurse-
patient relationship ought to be, how this should be achieved, and how the nurse-patient
relationship is constituted in practice.
8
The first major finding of this review is related to the term "nurse-patient relationship".
There was no consensus and consistency in the use of the construct "nurse-patient relationship"
among theoreticians, researchers, and practitioners across manuscripts and research reports. This
term is liberally used in many manuscripts and research reports, yet seldom described. It is clear
from the review that nurse-patient relationships develop within a clinical setting and are
maintained over time (Ramos, 1992; Hartrick, 1997; McNaughton, 2001). These relationships
are further described as therapeutic and they are based on mutuality, commitment, and
reciprocity (Morse, 1992; Christensen, 1993; Hartrick, 1997; McQueen, 2000; Berg, Skott, &
Danielson, 2006). Unfortunately, none of these concepts are defined causing difficulty in
knowing if authors attribute the same meaning to these concepts.
The review also indicates that nurses are strongly encouraged to develop "therapeutic" or
"professional" relationships with their patients; however, it is not always clear what these terms
encompass. Some authors attempt to describe these therapeutic relationships. Madden (1990)
draws on the term "therapeutic alliance" to describe the nurse-patient relationship and defines
this alliance as "a process in which both the patient and the provider are (1) actively working
toward the goal of developing patient health behaviours chosen for consistency with the patient's
current health status and life style; (2) focusing on mutual negotiation to determine activities to
be carried out toward that goal; and (3) using a supportive and equitable therapeutic relationship
to facilitate that goal" (Madden, p. 85). McQueen (2000) supports this concept of therapeutic
relationship, but adds the concept of trust as an essential component when developing the
relationship, however, this concept, as so many others, is not defined.
A second overall finding in conducting this review is the apparent disagreement about
whether the partners in the nurse-patient relationship should be equal (Fealy, 1995) or should
9
maintain a care provider and care receiver role. Hemingway and Smith (1999), for example,
argue that nurses, if they are to have meaningful relationships with patients, must allow
themselves to care and, with increasing experience, will develop a positive professional bond. In
stepping away from the term "professional" in the depiction of nurse-patient relationships, some
authors choose to describe the role of the nurse as a skilled companion, where the nurse relies on
skills and knowledge to "be with" a patient on their journey (Campbell, 1984). In doing so,
Campbell attempts to bring together the science and moral basis of nursing practice. Bayntum-
Lees (1992) concurs with the concept of skilled companionship, but includes the qualities of
closeness and mutual commitment in the relationship. Bayntum-Lees believes that a professional
nurse should have a non-directive style of interacting to give patients more choice and help them
become more active in their care. In a more recent article, Berg, Skott, & Danielson (2007) add
the component of responsibility of the patient and the nurse to reach out to each other in
establishing a relationship.
Closely related to the issue of professionalism is the degree of the nurse’s involvement in
a nurse-patient relationship. Several manuscripts attempt to distinguish different levels of nurse-
patient relationship, based on the degree of involvement of the nurse. Despite providing a basic
overview of different levels of relationships, these manuscripts fail to take into account that a
relationship can only takes place when two beings are committed, thereby failing to notice and
discuss the patient’s degree of involvement in the nurse-patient relationship. Smith (1980)
presents three different models of the nurse-patient relationship that vary by the degree of the
nurse’s involvement. When too involved in the relationship, the nurse acts as a surrogate mother
and the actions will violate a patient’s right to self-determination. However, when not involved at
10
all in the relationship, the nurse acts as a technician and does not respect the ethical aspects of
practice.
When establishing the right level of involvement in a relationship, the nurse acts as a
contracted clinician and professional expertise is provided in certain situations without
overtaking the patient’s decision process. Similar to Smith’s work, May’s (1991; 1993) and
May's and Purkis' (1995) research documents the degree of nurse’s involvement in nurse-patient
relationships. May’s critique concentrates on the problematic aspects of involvement as well as
on the constraints that limit it. He states that the main qualities of the nurse-patient relationship
are knowledge, reciprocity, and investment from the nurses’ perspective. Lastly, both Kitson
(1996) and Nichols (1993) describe the nurses’ role in the relationship as a "companion", with a
requirement of nursing skills, commitment, and mutuality. Kitson, who is influenced by
Campbell’s (1984) concept of the skilled companion, states that the skills of companionship are
in sensing the need of the other person and accommodating oneself to the other's idiosyncrasies
to help the person move forward by enabling him/her to see how the journey can be
accomplished, and to guard against the imposition of routines that make the patient feel trapped.
This role description for the nurse, as stated by Kitson, involves "being with" as well as "doing
to" (p. 1649).
Finally, a set of researchers compared and contrasted bodies of knowledge organized
around nurse-patient interactions and relationships on the assumption that relationships are
established though the means of verbal communication. Morse (1992) and Morse, de Luca
Havens, and Wilson (1997) describe a model of interaction and relationship and identifies
nursing actions as comforting strategies, styles of care, and patterns of relating. Consequently,
the nurse-patient relationship is negotiated through the nurse’s interactions and the patient’s
11
actions. Morse et al. describe this model as patient-led, dynamic, interactive, and context
dependent. Hartrick (1997) challenges the appropriateness of a mechanistic model of human
relating that focuses on behavioural communication skills and presents an alternative approach
that emphasizes the enhancement of relational capacity to explore the nurse-patient relationship.
Relational capacity consists of responsiveness, mutuality, honouring complexity and ambiguity,
intentionality in relating, and re-imagining, that is, inquiring into concerns of daily life
(Hartrick). Hartrick also states that these qualities are necessary to develop and maintain an
authentic nurse-patient relationship. The transition of a superficial to an authentic or real
relationship is also described by Morse (1992) and Ramos (1992). Ramos refers to close
relationships as being cumulative; they change or deepen according to the perspectives of the
individuals involved and the interactions that take place between them. Ramos uses Marcel’s
(1965, 1967) work to describe how the nurse's relationship with patients grows and develops,
through "closeness, professional bonding, emotional bracketing and existential presence in
thought, word and deed" (Ramos, p. 498).
In summary, this selection of conceptual literature on nurse-patient relationships presents
an array of divergent qualities and concepts, yet few of these individual qualities are explicitly
defined or operationalized. Furthermore, the manuscripts focus on a description of the nurse-
patient relationship from the perspective of the nurse and address only a limited set of concepts.
The main concepts or qualities of a nurse-patient relationship identified in this review describe
the relationship as a therapeutic process that is based on mutuality, reciprocity, closeness, and
trust (Morse, 1992; Christensen, 1993; Hartrick, 1997; McQueen, 2000; Berg, et al., 2006). The
relationship is dependent on both the nurse’s and the patient’s commitment and on the nurse’s
skill, knowledge and responsibility. Furthermore, the process is interactive and context
12
dependent and recognizes the complexity and ambiguity of the concerns of daily life. Despite the
acknowledgement of these concepts as essential components of the nurse-patient relationship,
there is no consistent use of these terms, nor is there an indication of their importance in
developing and sustaining an authentic nurse-patient relationship. Finally, some authors attempt
to describe the different categories or degrees of nurse-patient relationships, yet these theoretical
accounts fail to go beyond an idealized conceptualization of what the relationship should
encompass, and fall into the trap of categorizing and objectifying relationships to meet certain
goals.
Empirical Research on Nurse-Patient Relationships
In this section, empirical qualitative and quantitative research studies were reviewed that
focused on the relationship between nurses and patients in long-term or CC environments. A
search was conducted of Medline and CINAHL databases (1980 to 2009) using the following
terms: patient/resident/client, nurse/care provider/HCA(s)/nursing assistant(s)/staff,
relations/relationships, associated with the terms LTC, CC, complex CC, institutional care, home
care, palliative care, and nursing homes. The qualitative research studies were reviewed according
to the following categories: (1) the source and design; (2) the setting and sample; (3) the focus of
the study; and (4) the findings.
The search strategy for the quantitative studies was similar to that used for the qualitative
research, but the following search terms were added: measurement/tools/scales. The quantitative
research studies were reviewed according to the following categories: (1) the source and the
study design; (2) the study setting and sample; (3) the independent variables; (4) dependent
variables; and (5) the study results. Studies that were conducted with nurses and patients in home
care or palliative care were included in this literature review because of the prolonged time
13
nurses and patients spend together and because of the home or home-like environment. These are
similar characteristics to a CC institutional setting where the nurse and patient see each other on
a regular basis and where the environment of the nursing home or care facility is striving to
present a home-like setting.
Qualitative Empirical Research on Nurse-Patient Relationships
The retrieved sample included 15 articles of a descriptive nature (Appendix 2.1). The first
four studies reflect on overall nurse-patient relationships in residential settings, followed by three
manuscripts portraying the nurses’ perspective. The next four studies focus on the patients’
perspective of the relationship. Lastly, four studies from the home care literature examining the
nurse-patient relationship are discussed.
The first four studies provided an excellent overview of the relationships with
unregulated care providers perceived from the residents’ point of view in LTC settings
(Gubrium, 1975; Vladeck, 1980; Diamond, 1992; Chambliss, 1996). Prior to describing the
findings of these studies, it is important to recognize that both Vladeck and Chambliss describe
their work as ethnographic but provide little information on the design or methods of data
gathering. All four studies were conducted in American nursing homes or CC settings and reveal
the importance of the care provider-patient relationship. Chambliss describes nurses’ work as a
routinization of activities and a parallel flattening of emotions. Nurses, he states, are a special
group of health care providers because of the difficult and often contradictory missions they need
to accomplish: they are expected to be simultaneously caring (i.e., spend time with each resident)
and professional (i.e., meet the administrative and workload requirements). Chambliss then
explores the ethical dilemma this brings within the nursing profession. Vladeck’s work is similar
14
in describing the care providers, residents, and conditions in a nursing home, yet he adds
explanations of how public policy failed to address the shortcomings in the LTC industry.
Diamond (1992) describes nursing home care from a sociological background and uses
institutional ethnography to explore narratives of unregulated care providers. He specifically
pays attention to the many hierarchical routines in the care delivery, routines so insensitive and
remote from actual human needs that they often make good care impossible. Diamond paints a
realistic portrait of the difficulties encountered in LTC work and exposes the physically intensive
and emotionally heart breaking work of the unregulated staff. He carefully describes the web of
relationships residents create with each other and their care providers and the small often subtle
acts of residents’ self-assertion and resistance. Along the same lines, Gubrium’s (1975)
ethnographic study reports on the social organization of a nursing home. Although there is some
dehumanization, boredom and anger, there are also intimate social ties, trust, love and hope
within its walls. Gubrium describes the social ties between staff and residents, the bed and body
work, the endless dilemma of passing time for residents, and the process of dying and death in a
nursing home.
The strengths of the above studies lie in the rich descriptions of the culture of the unit and
there is no question that they reveal the importance of the nurse-patient relationship in a
residential setting. They indicate that knowing the patient is central to providing quality care and
that a caring relationship constitutes the fabric of the patient’s life in these environments. These
studies also expose conflicts concerning expectations for care giving and care seeking behaviour,
different interpretations of the meaning of care and constraints placed upon staff by the
organization of work and workload demands.
15
Several other qualitative studies have provided information on the nurse-patient
relationship in residential settings. Three portray the care providers’ perspective of the nurse-
patient relationship in CC settings. This group of manuscripts presents very similar concepts as
the articles reviewed for the conceptual approaches to exploring nurse-patient relationships. In a
study by Welch (2005), six nurses identified empathy, uniqueness, meaning and purpose, and
appropriate self-disclosure as essential in a therapeutic relationship with their patients in a home
care setting. She states that although it is conventional wisdom that the therapeutic relationship is
a cornerstone of nursing, even those who profess to practice or utilize it, or those who advocate it
most strongly, have difficulty in saying exactly what it is (Welch), thereby confirming the
findings of the theoretical review.
Li (2004) takes this concept of uniqueness one step further and introduced the idea of
symbiotic niceness in constructing a therapeutic relationship in palliative care. She observed 28
nurses and found that a nurse-patient relationship is based on a therapeutic existence of this
symbiotic niceness; patient and nurse have to engage in the process of mutually feeling,
absorbing, and niceness work, i.e., being caring and kind. Li also found that nurses categorized
their patients into four groups and consequently gave different psychosocial care. Trouble-free
patients deserved care and niceness, whereas undeserving patients deserved obligatory care,
minus niceness. In a similar fashion, Campbell’s (2005) conceptual model describes
attractiveness as a factor influencing quality of care for older adults in LTC. Staff’s conscious
and unconscious perceptions of resident attractiveness led them away or toward certain residents.
Four qualitative studies were found that specifically focused on the patients’ perspective
of the relationship in LTC settings. In Nussbaum’s (1991) study, patients indicated that a close
relationship offers companionship and personal relating; however, they do not have a
16
relationship with every nurse caring for them as staff were not always interested in this kind of
relationship. Patients did not see it as their responsibility to develop a personal relationship with
staff. If nurses initiated a relationship, the patient reciprocated with friendly behaviour. These
findings are confirmed by Henderson et al. (2007), who found in their observational study of
four patients over 48 hours, that opportunities to develop closeness in a relationship were limited.
The work of Bowers, Fibich and Jacobson (2001) indicates that residents are able to
report different categories of care related to their level of dependency and reputation among
nurses. Independent residents and residents perceived as complainers by the nurses described
care as a "service," with a focus on instrumental aspects of care, i.e., efficiency, competence and
value. Dependent residents and residents perceived as "sweeties" by the staff described care as
"relating," with a focus on the affective aspects of care, i.e., friendship, reciprocity, and degree of
closeness. Totally dependent residents and the residents perceived as complainers and/or
manipulators described care as "comfort," with a focus on quality of care, i.e., maintaining
physical comfort. The importance of care delivery in assessing the relationship from a patient’s
perspective was confirmed in a study by McGilton and Boscart (2007), where nurses, residents,
and family members were asked to describe the meaning of a close relationship. Residents
defined close relationships as care providers presenting a caring attitude and behaviour. An
interesting finding of Bower’s study points to the residents’ perception that their functional status
and their reputation determine the relationship nurses have with them.
Lastly, four home care studies examining the nurse-patient relationship are discussed.
McNaughton (2001) analyzed the development of nurse-patient relationships by focusing on the
nursing action needed to address patient problems. Peplau's (1952, 1991) Theory of Interpersonal
Relations provided the theoretical framework for this naturalistic, multiple case study design.
17
Nurses describe nurse-patient relationships as developing in three overlapping phases:
Orientation, Working, and Resolution. All relationships began with a majority of interaction
occurring in the Orientation phase. As relationships progressed, more time was spent in the
Working phase for each dyad until resolutions were met. Interaction and communication is an
important aspect of the relationship, and this is also confirmed by Heineken and McCoy (2000).
They describe the requirements to establish a successful home care nurse-patient relationship and
present case-studies to describe the nurse's ability to promote a bond of trust. Findings indicate
that gaining a thorough understanding of the patient through a dialogue of listening and trust is
critical to achieve positive outcomes.
A study by Caron (2003) explored the care-giving activities of 10 nurse-patient dyads in a
home care setting. Caron found that care-giving activities occurred in a complex environment of
nurse-patient relationships and considerations. Negotiations of shared space and the situation
aimed at creating consensus in perceptions of a patient's well being and progress. Establishing an
amicable working relationship involving the development of a friendly collaboration, whereby
both nurses and patients recognized the individuality of the other beyond immediate care giving
activities. This occurred by volunteering information, sharing stories, and keeping track of events
in each other's lives.
Ladd, Pasquerella, and Smith (2000) discuss the nurse-patient relationship through a
case-based analysis. This analysis demonstrates that traditional frameworks for the nurse-patient
relationship are inadequate to capture the richness of the relationship the home health care nurse
has with both patient and family. By developing a new framework for the nurse/patient/family
relationship that (a) recognizes the patient's decision-making authority and autonomy, (b) allows
18
the exercise of the nurse's moral rights, and (c) recognizes the patient's relationships to
significant others, the authors attempt to resolve some challenging legal and ethical questions.
In light of the above results, important weaknesses of the qualitative studies need to be
discussed. Only a few of the studies used a theoretical framework on which to base their research
or interpret their findings. Although qualitative studies often commence without a theoretical
framework, they often develop a framework once the data analysis is completed. Without a
theoretical framework, research findings have limited potential to add to the scientific body of
nursing knowledge. If research is to expand the understanding of what constitutes evidence for
theory-guided, evidence-based nursing practice, a narrow focus from empirical evidence needs to
broaden into a more comprehensive focus of knowing (Fawcett, Watson, Neuman, et al, 2001).
Other shortcomings are related to the design reported by the researchers. Five studies
report observations as the main tool to collect data; however, none of the studies describes
exactly what was observed or report how the collected data informed them about the relationship
process. Several manuscripts lack information on the qualitative rigour of the study, including
aspects of keeping an audit trail, verification, and transferability. Of the six studies presenting an
ethnographic method, only five used a distinct ethnographic approach to collect and interpret the
data. Welch (2005) reports a ‘reflective’ design but does not define this type of design. Lastly,
only one of the 15 qualitative studies recorded limitations in their manuscripts. Bowers et al.
(2001) reported a small sample size.
In summary, findings of the qualitative studies that were reviewed explore the nurse-
patient relationship from both the nurse’s and the patient’s perspective in a chronic care
environment. Based on this review, several new qualities of the nurse-patient relationship were
identified. Concepts that are essential to the relationship include the recognition of the patient’s
19
uniqueness leading to a personal listening, interaction, relating and collaboration. Patients and
nurses share stories and nurses acknowledge and value the patient’s significant others. In taking
these qualities into consideration, nurses demonstrate kind, caring, and competent behaviour
striving to enhance the patient’s physical comfort and wellbeing while respecting the patient’s
decision-making authority and autonomy. Consequently, the patient perceives a feeling of being
cared for, a degree of closeness, and even friendship.
Quantitative Empirical Research of Measures of Nurse-Patient Relationships
This last section of the synthesis of literature presents a critical review of empirical
research related to measures of relationships (Appendix 2.2). Five studies were found that used
self-report measures to assess the quality of the relationship between nursing staff and patients
from the patient’s perspective. Both Rieck (2002) and Huss, Buckwalter, and Stolley (1988)
examined the nurse-patient relationship in acute care, while the three remaining studies took
place in a LTC environment (Goldwater & Auerbach, 1996; Nunley, Hall, & Rowles, 2000;
McGilton, O’Brien-Pallas, Darlington, et al., 2003).
Rieck (2002) developed a Spiritual Dimension Inventory (SDI) to measure the patient’s
perception of the spiritual dimension of a nurse-patient relationship. The SDI is a synthesis of
theories of spirituality (Reed, 1992) and the nurse-patient relationship as defined by Peplau
(1991). The SDI consists of five concepts: connection, understanding, acceptance, commitment,
and trust, represented in a 25-item scale. A Cronbach′s alpha reliability coefficient of .96
indicated theoretical redundancy. This scale captures important aspects of the nurse-patient
relationship; however, only patients from acute care were in the sample. Furthermore, a
relationship has many components, and the spiritual dimension of a relationship is only one of
20
those. By using the SDI to evaluate the relationship in CC, an incomplete view of the nurse-
patient relationship would be presented.
Huss et al. (1988) utilized one subscale, the Trusting Relationship Dimension (TRD), of a
measure developed by Risser (1975) to evaluate the nurse-patient relationship and its impact on
patients’ life satisfaction. The internal consistency of the TRD subscale, as evaluated by Risser
for two trials, was acceptable at .76 and .81 but was not re-evaluated by Huss et al. The 11 items
in the TRD subscale capture empathic communication and trusting relational behaviour of the
nurse, and includes items such as taking an interest in the patient and being sensitive to the
patient and his/her feelings. The population for which the scale was intended is different (i.e.,
acute care hospital patients) from that in CC, and the focus on the aspect of ‘trust’ within the
relationship is too limited a perspective to assess nurse-patient relationships in CC settings.
McGilton et al. (2003) employed a quasi-experimental design to examine the influence of
a Relationship Enhancing Program of Care (REPC) on resident-care provider relationships from
the perspective of the resident and his or her family members, and on the behaviour of the care
provider. To evaluate the REPC, the Relationship Care Scale (RCS) was developed based on
Winnicott’s (1960) conceptualization of a holding relationship. The RCS measures the reliable
and empathic behaviour of the care provider, using a three-point Likert scale. Empathy was
conceptually defined as identifying with the wishes and particularities of the individual,
recognizing the needs of another, and being sensitive to the individual’s responses. Reliability
was conceptually defined as being dependable, protecting the person from the unpredictable, and
tolerating rejection without retaliating. The RCS had adequate internal consistency (Cronbach′s
alpha coefficient of .88) and item-to-total correlations were acceptable at between .30 and .75.
The test-retest scale correlation was .69, which is moderate. Over time, residents on the
21
intervention unit perceived positive changes in their relationships with their care providers (t[20]
= 2.88, p = .009); however, residents did not perceive that close relationships had been
developed.
Goldwater and Auerbach (1996) developed a 15 item Attitudes toward Nursing Staff
Scale (ATNS) to measure the impact of an audience-based reminiscence therapy intervention for
36 alert elderly nursing home patients. The ATNS self-report scale was developed by the
investigators for the study and included the following domains: patients’ perception of staff’s
responsiveness, understanding of patients’ needs, extent to which staff respects patients, and the
quality of relationships between patients and staff. No psychometric testing of the scale was
reported.
Lastly, Nunley et al. (2000) used the Autonomy and Relatedness Inventory (ARI)
developed by Schaefer and Edgerton (1982) to assess the quality of the relationship between 37
community dwelling elderly and their primary home caregivers. The ARI is a 32 item scale that
measures the positive and negative dimensions of primary intimate relationships between two
people and originally was created to assess the relationship between mothers and their children.
Subscales include autonomy, relatedness, acceptance, support, listening, control, detachment or
rejection, and hostile control. The subscales had good internal consistency (between .80 and .86)
and initial construct validity was achieved by testing the ARI with a dyadic adjustment scale for
mothers and children (Schaefer & Edgerton, 1982). A major limitation of using the ARI scale to
assess the patients’ perception of the nurse-patient relationship lies in the fact that the ARI was
developed to measure an intimate relationship between mothers and children and no
psychometric testing has been done to assess its validity when applied to older people and their
non-related care providers.
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Overall, the review of the quantitative research literature identified the lack of valid and
reliable measurements to examine the nature of a nurse-patient relationship in CC from the
patient’s perspective. Existing measurement tools capture only a single aspect of a nurse-patient
relationship, are developed for a different population and setting, or lack sound psychometric
testing.
Regulatory Guidelines and Standards for the Nurse-Patient Relationship
To have a better understanding of how the nursing profession perceives the construct of
the nurse-patient relationship from a regulatory perspective, a review of the Standards of Nursing
Practice from every province in Canada was conducted. These standards are published by
colleges of nurses or professional associations to regulate the nursing profession and all
registered nurses are legally obliged to adhere to these practice standards. The guidelines and
standards are developed based on the literature presented earlier. Some colleges of nurses or
professional associations produced additional documents that explain practice standards and
expectations called guidelines or discussion papers. The specific findings of this review are
presented in Appendix 2.3.
Based on a synthesis of the review, all colleges of nurses or professional associations
published Standards of Nursing Practice for the registered nurses of their province. In addition,
the provinces of Ontario (RNAO, 2006), Nova Scotia (2002) and Alberta (2005) published Best
Practice Guidelines on the Nurse-Client Relationship, indicating a need for more information in
regards to this aspect of nursing practice. The provinces of Ontario (2006), Manitoba (2007),
British Columbia (2003), Nova Scotia (2002), New Brunswick (2000) and Alberta (2005)
published an additional Standard for the Nurse-Client Relationship. These documents cover the
same content and are mostly based on the Practice Standard for Therapeutic Nurse-client
23
Relationships (CNO, 2006). Ontario is the only province that has both a professional association
(Registered Nurses Association of Ontario [RNAO]) and a regulatory college and both separately
published guidelines on the nurse-client relationship in 2006. Other provinces often referred to
these two documents.
In defining a nurse-patient relationship, colleges of nurses and professional associations
state that this relationship is purposeful and goal-directed between nurses and clients and is
established and maintained by the nurse. Furthermore, this relationship is based on trust, respect,
professional intimacy, and empathy with the client and requires the appropriate use of power
inherent in the care provider’s role (CNO, 2006). The province of Manitoba adds the component
of choice to the definition and the province of British Columbia mentions the vulnerability of the
patient as an additional concern within the principles of the nurse-patient relationship. The
provinces of Ontario, Alberta, British Columbia, Nova Scotia and New Brunswick explicitly
state that the nurse-client relationship is a therapeutic relationship. However, there is no
difference in their definition of the nurse-patient relationship compared to the definition used in
other provinces. The Northwest Territories simply state that a nurse-patient relationship is based
on mutual respect, shared objectives and the right to self-determination (2002). In regard to the
application of the policy, most colleges of nurses and professional associations provide practice
examples of developing and maintaining a nurse-patient relationship, all situated in the acute
care setting. Only the province of British Columbia presents examples of relationships in a CC
setting.
Based on this review, it can be concluded that these standards and guidelines describe the
nurse-patient relationship from a limited perspective. Not only is the patients’ perspective
neglected, the use of terms such as goal-directed and purposeful cause the guidelines and
24
standards to disregard the uniqueness of CC settings where relationships are maintained over an
extended period of time and involve a person-to-person connection to help increase the quality of
daily living and share everyday experiences.
Summary of the Literature Review and Current Standards on Nurse-Patient Relationships
A synthesis of research and regulatory guidelines examining the nurse-patient
relationship was conducted. Based on the synthesis of the literature on nurse patient relationship
in CC, the following important characteristics of the nurse-patient relationships are proposed:
1. The nurse-patient relationship is a relational process where the nurse is aware of and
supports the human uniqueness of the patient.
2. The nurse-patient relationship is a partnership where:
a. The patient is provided a choice to be involved in care or care-related decisions
and identifications of his/her needs; and
b. There is respect for the patient’s choice and self-determination.
3. In a nurse-patient relationship the nurse is committed to:
a. Be responsive and available to the patient’s needs; and
b. Provide skilled care in promoting, maintaining and nurturing well-being and
comfort.
4. The nurse-patient relationship is an ongoing, interactive relationship within a CC facility
in which the nurse is responsive to the patient’s needs.
5. Within a nurse-patient relationship the nurse demonstrates professional accountability
and a willingness to be present.
25
6. The nurse aims at nurturing the patient’s well-being and comfort and supports the
patients’ choice in searching for and accepting a level of comfort in accordance with
his/her potential in a particular situation.
Despite this list of important characteristics of the nurse-patient relationship, several
concerns are noted. First, the current state of knowledge of nurse-patient relationships presents a
wide array of qualities and concepts which lack clear definitions. Existing research is sporadic
and there is a lack of systematic and substantive empirical support. The quantity of empirical
research is limited and important weaknesses of the studies, such as unclear designs, small
sample size and the absence of theoretical underpinnings were noted. There is a clear need for
methodological improvement based on the quality of the published studies. Second, only a few
manuscripts were directed at the patient’s perspective on the nurse-patient relationship, thereby
ignoring the perceptions and experiences of the important target group. The review of the
quantitative research literature identified the lack of valid and reliable measures to examine the
nature of a nurse-patient relationship in CC from the patient’s perspective. Lastly, the review of
the regulatory guidelines and standards reveal a one-sided and limited perspective of the nurse-
patient relationship. Therefore, there is a need for theoretically driven sound psychometric tools
to conceptualize and operationalize nurse-patient relationships in CC.
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Chapter Three: Theoretical Framework
This chapter presents the theoretical framework for this study, which is based on the
Humanistic Nursing Theory by Paterson and Zderad (1976, 1988). It starts with a justification of
the Humanistic Nursing Theory as the choice for the framework, followed by a brief review of
philosophies underlying the theory. Next the Humanistic Nursing Theory is explicated.
Justification for the Choice of Theory
Several nursing theorists have described the phenomena of a nurse-patient relationship
(Appendix 3.1), and for the purpose of this study; three of the more relevant nursing theories are
discussed.
Peplau (1952) proposed the first theory of the nurse-patient relationship, called the
Interpersonal Nursing Theory, as a means to provide optimal care. Peplau, an interactionist,
describes the nurse patient relationship as a helping relationship, a process by which the nurse
facilitates the patient’s personal growth by helping him/her to identify difficulties, experience
emotions, and understand his or her own behaviour. Although this nursing theory presents a
strong framework to examine the nurse-patient relationship, the theory was initially developed to
guide the nurses’ practice in mental health settings, and thus, several of the theory’s components
and definitions are not relevant to the CC setting.
The second nursing theory relevant to this study is the Human to Human Relationship
Model by Travelbee (1966). Travelbee's experience in psychiatric nursing led her to believe that
the care given in these types of institutions lacked compassion. She felt nursing needed a
humanistic revolution and a renewed focus on caring as central to nursing. Consequently,
Travelbee defined a nurse-patient relationship as a process which enables a nurse to establish a
human-human relationship with a patient, thereby fulfilling the purpose of nursing in assisting
27
individuals and families to prevent and cope with experiences of illness and suffering, and assist
in finding meaning in these experiences. In addition, Travelbee presents the concept of
boundaries to protect the nurse from over-involvement with a patient and opens up the discussion
of finding a balance between an all-giving, unconditional relationship as a response to the call of
the vulnerable patient, and a professional or instrumental friendship where a nurse sets
boundaries to avoid getting too involved in the relationship (Rawnsley, 1990; May, 1991; Morse,
1992). Although this theory involves several essential components of the nurse-patient
relationships, it is less comprehensive than the theory of Paterson and Zderdad which is the third
theory considered.
The third theory that was reviewed in order to address the research objectives was the
Humanistic Nursing Theory by Paterson & Zderdad (1976, 1988). This theory was considered a
sound theoretical framework to examine the nurse-patient relationship in CC. Although Paterson
and Zderad do not directly address nursing care in a CC environment in their theoretical
descriptions, the strong phenomenological foundation and the focus on the human experience
creates the potential to inform this type of nursing. This framework offers several advantages for
studying the humanistic nurse-patient relationship in CC from a patient’s perspective.
First, this framework identifies the essential qualities of a humanistic relationship
between patients and nurses in a CC setting. The framework focuses on the nurse’s and patient’s
existential relationship conceptualized through an awareness of uniqueness and sameness along
with human relating (Kleinman, 2009). The patient in CC is a unique individual and seeks to
give meaning to his/her existence through the subjective experience of relating with the people
that give care. Therefore, this framework offers the right structure to explore the relationships
from a patient’s point of view.
28
A second advantage in using this framework to study nurse-patient relationships in CC is
related to its compatibility with the patient centred approach in caring for patients in these
environments. Several concepts discussed in the framework are important aspects of the patient’s
experiences within a nurse-patient relationship; uniqueness is one of them. Paterson and Zderad
(1988) underscore the distinctiveness of the person, as every person holds his or her own
‘angular view’ (p. 37). Specifically in CC environments, long-term stays offer the possibility to
know one another well. The acknowledgement of uniqueness as a central aspect of a nurse -
patient relationship, makes this framework very suitable to explore these relationships in the CC
setting.
Lastly, this framework acknowledges nursing’s involvement in health and illness, but
notes that some of the most exquisite nursing acts occur in situations whereby health, taken in its
narrow sense as the absence of disease, is not feasible as an aim (O’Conner, 1993). CC nursing
care does not focus on cure, but on living with as much freedom and autonomy as possible at
every stage and in whichever direction the patient progresses. Paterson and Zderad (1988) chose
to define the aim of nursing as ‘comfort’, because health is more than the absence of disease (p.
99). This notion of comfort in the framework conveys the sense that persons can be comfortable
without being healthy and it is the promotion of this comfortable way of being that reflects
nursing’s most immediate concern. For patients in CC, restoration of health is not always
possible, and the focus on comfort illuminates the important tasks of CC nurses in assuring their
patients’ well-being within the nurse-patient relationship.
The Humanistic Nursing Theory’s (Paterson & Zderad, 1976, 1988) focus on the
essential nature of the nurses’ experiences that arise in face-to-face encounters with patients
(Kleinman, 2009) make this theory highly valuable in exploring the nurse-patient relationship in
29
CC from a patient’s perspective. The theory serves as a vehicle to describe the meaning of
everyday experiences between nurses and patients. Because of the importance of these everyday
experiences in CC settings, this theory is suitable to explore the nurse-patient relationship in
these environments.
Philosophical Perspectives underlying the Humanistic Nursing Theory
In reviewing the Humanistic Nursing Theory (Paterson & Zderad), it is important to
understand the perspectives of some important philosophers who have published on human
relating. The Humanistic Nursing Theory is grounded in the works of Buber (1958) and Marcel
(1965, 1967) and a brief overview is provided for each of these philosophers.
The first philosopher discussed is Buber (1958), an Austrian-born Jewish philosopher.
Buber is best known for his philosophy of dialogue; a religious existentialism proposing that
human beings may address existence in two ways: that of the I towards the It, an object that is
separate in itself which we either use or experience; and that of the I towards the Thou, in which
we move into existence in a relationship without bounds. According to Buber, human beings
may adopt these two attitudes toward the world; some humans relate to their world by viewing
both objects and people by their functions (I-It relationships), and others relate to the world by
placing themselves completely in the relationship (I-Thou relationships).
A second philosopher whose work is relevant to this study is Marcel (1965, 1967).
Marcel concurs with Buber’s (1958) work, by asserting that having tends to be the normal mode
of relating to the world. This mode of having represents a certain way of dealing with the world
with the objective of organizing, mastering, and controlling it.
30
Buber’s (1958) and Marcel’s (1965, 1967) perspectives on relating have established some
important aspects of the nurse-patient relationship. Not only are these encounters taking place
between two unique individuals, there is the strong assumption that one chooses to relate to
another with a willingness to place oneself completely in the relationship to see the subjective
other. When one truly meets the other person, a feeling of responsibility is created to alleviate the
other’s suffering. In reviewing these concepts, some essential aspects of the CC setting need to
be taken into account. First, aside from new staff, patients and nurses usually know each other
well in these settings, and therefore, the encounter cannot be a relationship between ‘strangers at
the bedside’ but an encounter that brings the particular unique otherness of both partners into
focus. Second, the complex care needs of these patients require the nurses to take on the role of
main caregiver. This review highlights the nurse’s responsibility and commitment to explore the
patient’s needs while respecting his/her uniqueness and individuality. Overall, this review
reveals the actuality that the nurse-patient relationship in CC is not an arrangement as in a simple
contract between two equal partners where each party negotiates from a position of self-interest.
The Humanistic Nursing Theory
The Humanistic Nursing Theory (1976, 1988) developed over the period 1950 through
1970 as Paterson and Zderad both recognized that the scientific principles nurses were taught
were essential, yet, they were only a part of what being a nurse was all about. There was much
more to nursing not explainable in scientific terms. They decided that this aspect of nursing was
valuable and of great worth in assisting patients (Kleinman, 2009). Drawing on Buber (1958),
Paterson and Zderad applied a framework of existentialism to examine nurses’ experiences of the
nurse-patient relationship. They argue that existentialism does not treat the individual as a
concept, yet emphasizes individual subjectivity, so both the nurse and the patient are seen as
31
unique human individuals who undergo distinctive experiences. Paterson and Zderad define
nursing as a nurturing response of one person to another in a time of need that aims towards the
development of well-being and more-being. The act of nursing occurs within the context of a
relationship, a nurse-patient encounter.
Paterson and Zderad describe nursing as ‘an experience lived between human beings’
(1988, p. 3) and urge the nurse to move beyond the technical doing of nursing and open
his/herself up to the feeling and being of nursing. This proposition relies solidly on Buber’s
(1958) description of the I-Thou relation, in which humans engage in a dialogue involving each
other's whole being. Paterson and Zderad apply this to nursing, and portray nursing as a lived
dialogue with the nurse-patient relationship as a human-to-human, intersubjective transaction at
the centre of the nurse’s world. "The meaning of nursing as a living human act is in the act
itself....Nursing is a response to the human situation....one human being needs a kind of help and
another gives it" (1988, p. 11).
O’Connor (1993), a humanistic nursing activist, suggests that perhaps the major
contribution that Paterson’s and Zderad’s Humanistic Nursing Theory (1976, 1988) offers, is the
view of nursing as a particular kind of human relating. At the centre of their theory is an
understanding of nursing as ‘a happening between people’. The theory emphasizes a particular
way of being that involves presence and awareness to support a ‘withness’ between nurse and
patient. Paterson and Zderad emphasize the importance of this way of being within the doing of
nursing. They distinguish the objective reality (what can be observed, pointed at, and examined),
the subjective reality (what is known from the inside, and awareness of one’s own experience),
and intersubjective reality (what is experienced in the in between space when two or more people
come together). Paterson and Zderad emphasize that humanistic nursing dwells primarily in the
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intersubjective realm, while simultaneously recognizing the trifold (“objective, subjective, inter-
subjective”) reality of the nursing world (O’Connor, p. 9).
The overall goal of humanistic nursing is to provide a nurturing response to the person
with perceived needs related to the health-illness quality of living. In doing so, humanistic
nursing is concerned with the individual’s unique being and strives toward becoming. Paterson
and Zderad (1976, 1988) claim that it is through relations with others that a person becomes, that
his/her unique individuality is actualized. This awareness that relations with others is a means to
becoming is very clearly articulated in the writings of Paterson and Zderad, ‘To me, a nurse is a
being, becoming through intersubjectively calling and responding ... And, through their [sic]
presence it is possible for other persons to be all they can be in crisis situations of their
worlds...In humanistically recalling and reflecting a nurse will understand and respond
empathetically and sympathetically to both one's [sic] own humanness and the other's’ (Paterson
& Zderad, 1988, p. 56).
Paterson and Zderad (1976, 1988) describe in detail this process of call and response.
The patient’s act conveys a call and a nurse responds with a nursing act. The call and response of
an authentic dialogue between a nurse and patient has great potential power, the power to change
the lived experiences of both patient and nurse, to change the situation. The patient’s call is a
demand for a nurse who is willing to listen and understand the lived experiences of the patient.
When found, it brings the comforting feeling of well-being. Nursing, then, as a human response,
is a concern not merely with a person’s well being but also with his/her more being, with helping
him/her become as humanly possible in his/her particular life situation (Paterson & Zderad).
Paterson and Zderad (1976, 1988) portray the moments when nurses are aware of an
intersubjective transaction as illuminating, and richly rewarding. They note that the perception of
33
the nurse and the patient may be different or alike, with some perception based in the obvious
and others in the imprecise unconscious. Yet, there is a kind of ‘being with’ or ‘being there’, that
is really a kind of ‘doing for’ that involves the nurse’s active presence. Paterson and Zderad
explain that this is not the same as being attentive; a listener may be attentive and still refuse to
give him/herself. Availability implies therefore, not only being at the other's disposal but also
being with the other. Presence also involves reciprocity where the other is also seen as a
presence, as a person rather than an object. ‘I realize that my openness is an openness to a
person-with-needs and my availability is an availability-in-a-helping-way’ (Paterson & Zderad,
1988, p. 31).
Core Concepts of the Humanistic Nursing Theory
Several central concepts of the theory will drive the scale development in this study.
These "core" concepts capture the nurse-patient relationship experience in a CC setting from the
perspective of the patient. The concepts are presented in six core groupings: (1) supporting
human uniqueness, (2) sustaining choice, (3) relational capacity, (4) living dialogue, (5) being
present, and (6) fostering well-being and more-being. Each of the six core concepts will be
discussed in detail.
Supporting Human Uniqueness
This concept captures three domains: awareness of uniqueness and view of the world,
recognition of particularity, and response to view of the world. The first domain, awareness of
the uniqueness and view of the worlds, describes the nurses’ awareness of self and how one
differs from others. Both the nurse and the patient are understood as unique persons who present
their view of the world. Paterson and Zderad (1976, 1988) highlight the distinctiveness of the
person. Every person holds his or her ‘angular view’. This angular view refers to the fact that
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every person sees, hears, feels, tastes and experiences the world in a particular way and the
individual's perspective of reality is therefore necessarily restricted by the angle of the particular
here and now. These different experiences, which include the influence of family and life
history, give rise to a singular viewpoint of seeing the world. Paterson and Zderad believe that,
while every person is unique, it is this shared fact of uniqueness that persons have in common
with each other. This uniqueness results in choices that, ‘only each person can describe or choose
the evolvement of the project which is himself-in-his-situation’ (Paterson & Zderad, 1988, p. 4).
The second domain, recognition of particularity, describes the nurse recognizing this
angular view and choosing to engage in a relationship. Human uniqueness is supported through
the process of searching for one’s capacity for uniqueness and becoming aware of one’s view of
the world. Through the shared willingness of nurse and patient to connect, relatedness is created.
The third domain, response to view of the world, describes the nurse entering in the
nurse-patient encounter as a caring-compassionate individual, willing to give of her/himself and
potentially risking vulnerability to respond to the angular view of the patient. The nurse and the
patient engage in an existential dialogue, a dialogue where a unique individual person is present,
open to, and relates to the other, seen in his/her uniqueness. ‘Through relating with other persons
as human beings, individuals become more and realize their own uniqueness’ (Paterson &
Zderad, 1988, p. 16).
Sustaining Choice
Within this concept three domains were identified: freedom to choose to respond,
freedom to choose how to respond, and respecting choices. The first two domains, freedom to
choose to respond and freedom to choose how to respond, describe the individual’s choice to
respond to different situations. According to Paterson and Zderad (1976, 1988), a major aspect of
35
human nature is that humans are responsible for their condition of being and making choices.
Therefore, each individual has an inherent capacity to choose to respond and to choose how to
respond to situations presented by life. A person is not seen as choosing a situation but is held
accountable for his/her personal response to the situation. To choose also implies that
alternatives or other possibilities exist. This freedom of choice or ‘free agency’ exists to varying
degrees in any situation.
The last domain, respecting choices, portrays the nurse who is self-aware of this free
agency and who makes responsible choices at the same time recognizing that the patient also has
this free agency. The nurse respects the patient’s choice to respond and how to respond to
different life circumstances.
Relational Capacity
Relational capacity encompasses three domains: connecting, being available, and
nurturing. The first domain, connecting, refers to person-to-person relating. Paterson and Zderad
(1976, 1988) state that one’s capacity for relationship’s with others is a key attribute of human
beings. This capacity for relating brings us to the second domain, that is, being available. The
ability for person-to-person relating imparts a capacity for presence, or being with another
human being. When the nurse is present, she/he is in a mode of being available or open and
present the gift of the self. Paterson and Zderad state that at that moment, the nurse’s existence is
confirmed because of the difference made in the situation. Therefore, the nurse needs to nurse,
just as the patient needs to be nursed. This nurturing describes the third domain. The nurse is
committed to express the fullest meaning of humanistic nursing, which is an existential
engagement directed toward nurturing human potential. Relational capacity, therefore, is defined
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as forming a connection between a nurse and a patient through openness and communication of
the nurse’s availability to be involved as a person, with the goal of nurturing the patient.
Living Dialogue
Two domains were identified within the concept: responding and calling. These two
domains are intertwined in the process of a living dialogue. Paterson and Zderad (1976, 1988)
assert that when a patient suffers, he/she sends out a call for help. The nurse responds to this call
of a human being with needs within the health-illness quality of life. When the nurse responds to
the call, a connection is formed. The act of the call and response results in a lived dialogue, a
form of existential relating.
Being Present
Paterson and Zderad’s (1976, 1988) discussion of presence focuses on the quality of the
nurse’s being as involving one’s whole being and as being given freely and chosen freely. Four
domains can be distinguished in this concept: professional accountability, availability,
reciprocity, and mutuality. The first domain, professional accountability, refers to the
accountability of the nurse. The second domain, availability, portrays the nurse’s presence in
which the nurse can demonstrate respect, closeness and caring. Availability is described as
‘availability-in-a-helping-way’ (Paterson and Zderad, 1988, p. 31). Being with a patient in its
fullest sense requires, “turning one’s attention toward the patient, being aware of and open to the
here and now shared situation and communicating one’s availability” (Paterson and Zderad,
1988, p. 14). The personal dimension attests to the unique quality of presence that each nurse
brings to the nursing situation given his/her angular perspective.
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The third domain, reciprocity, is a relational process as a result of the nurse’s presence
where he/she is seeing the other as persons rather than as objects or functions. When a nurse is
truly present with a patient, the patient will act in response to reveal his/her individuality.
The fourth domain, mutuality, describes the reciprocal flow of the concept presence. In
this view, the nurse and the patient actively co-constitute the relationship. The engagement is
mutual, an interactive process that flows between two persons with different modes of being in
the shared situation.
Fostering Well-being and More-being
Four domains encompass the concept: nurturing well-being and comfort, searching,
accepting, and helping to recognize. The first domain, nurturing well-being or comfort,
represents the main goal of nursing. Paterson and Zderad (1976, 1988) define the aim of nursing
as comfort, which is “an umbrella term under which all other health-related terms should be
sheltered” (Paterson and Zderad, 1988, p. 26). This notion of comfort conveys a sense that
persons can be comfortable without being healthy; it is the promotion of this comfortable way of
being that reflects nursing’s most immediate concern.
The second domain, searching, describes the essential tension between being and
becoming, between what is and what might be. The concept of well-being or comfort
underscores the basic belief that persons are capable of becoming ever more, that is, more-being.
Therefore, well-being and more-being are related terms, referring to human actuality and
potentiality. Both the nurse and the patient could strive to reach the highest level of comfort,
searching for and contributing to the overall level of comfort of a patient. More-being conveys
the notion that a human being is all he/she could be in accordance with his/her potential at any
particular time in any particular situation.
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The third domain, accepting, describes the notion that humans are free to choose to
become more. ‘Moreness’ is a chosen way of being; it cannot be superimposed from the outside.
The patient can choose to accept a certain way of well-being or more-being as acceptable,
without striving towards a higher level of more-being.
The last domain, helping to recognize well-being and comfort, portrays the nurses’ role in
supporting and nurturing the patient’s potential and helping him/her to recognize and accept
limitations. Paterson and Zderad (1976, 1988) state that the term health is an essential component
of the equation from the broadest definition of well-health to the narrowest such as dying.
Nursing is integral to this continuum. “Nursing, then, as a human response, implies the valuing
of some human potential beyond the narrow concept of health taken as absence of disease”
(Paterson & Zderad, 1988, p. 12). Well-being also involves helping the patient search for
meaning of life and recognizes reality of death.
Research Objectives
Based on the need to develop and test instruments based on a theoretical underpinning
applicable to nurse-patient relationships in CC, the research objectives for the study were
identified:
1. To develop two instruments to assess nurse-patient relationships in CC settings, one
focused on importance and the other on experience and both guided by the theoretical
underpinning of Paterson and Zderad (1976, 1988).
2. To assess the content validity of the Humanistic Relationship Scales.
3. To determine the test-retest reliability of the Humanistic Relationship Scales.
4. To determine the construct validity and internal consistency of the Humanistic
Relationship Scales.
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5. To reassess the Humanistic Relationship Theory in light of the constructs identified in the
scales.
6. To describe the qualities of the humanistic relationships between cognitively competent
patients and nursing personnel in CC settings that were most important and experienced
by patients.
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Chapter Four: Scale Development
This chapter begins with the justification for developing the nurse-patient relationship
measures, followed by an overview of the principles of measurement. Next, a description of how
the items and scales were developed is detailed, followed by the results of the initial
psychometric testing of the scales.
Instrument Justification
As noted in the literature review, the actual measurement of the nurse-patient relationship
is underdeveloped. The scales developed either had a limited view of the nurse-patient
relationship (Huss, et al. 1988; Goldwater & Auerbach, 1996; Barber & Foltz, 1998; Kostovich,
2002; Rieck, 2002; McGilton et al., 2003; Van der Feltz-Cornelis et al., 2004). If the nurse-
patient relationship in CC is to be better understood in its connection to the daily encounters
between nurses and patients, there is a need for a sound psychometric tool developed based on a
theory that captures all dimensions of a humanistic nurse-patient relationship from a patient's
perspective. Only in this way can the potential effect of variables such as nurse-patient ratios,
work assignments, enhanced quality of care, or relationship and communication training be
tested for their influence on nurse-patient relationships.
When deciding to develop a new measure to examine the nurse-patient relationship in a
CC setting from the perspective of the patient, it became clear that two separate measures were
necessary in order to capture both the preferences and the experiences of the patient. The
literature review indicated a clear dichotomy between the relationship qualities that patients
preferred and the actual experience of those qualities in the relationship (May & Purkis, 1995).
To measure only the preferred or only the experienced qualities would not address the purpose of
this study, that is, to understand, examine and measure the humanistic relationships between
41
cognitively competent patients and nursing personnel in CC settings, whereby nursing personnel
is defined as the nurses who generally give care to the patient. To have a better understanding of
these relationships from the patient's perspective, it was deemed important to look at both facets
of the relationships—the preferred and the experienced humanistic qualities of the nurse-patient
relationship—hence the decision to develop two Humanistic Relationship Scales.
Measurement Principles
The act of measurement is an essential component of scientific research (Streiner &
Norman, 2004). Developing instruments to measure a subjective state, in this case the qualities
of the nurse-patient relationship in CC, requires a precise and careful process. Therefore, the
principles of health measurement scale development as described by Streiner and Norman were
followed and are described in the next section.
Classical Measurement Theory
In this present study, classical measurement theory (CMT) was employed to guide the
development of the instrument and to evaluate its psychometric properties. The application of
CMT in studies focusing on measurement is strongly supported by experts (Nunnally and
Bernstein, 1994). CMT presents a model for assessing random error by examining the extent to
which the observed data actually fit the conceptual model as measured by the variables included
in the measurement model (Streiner & Norman, 2004). The basic formulation of classical
measurement is presented as:
O = T + E
Where O = the observed score; T = true score, and E = errors of measurement.
The observed score (O) is the observed quantity or score computed from an assessment.
The observed score is composed of two important and independent quantities, according to
42
CMT: the true score and the error components (Novick, 1966). The true score, which can never
be known with certainty, can only be estimated. The error consists of all the conditions that
interfere with the precise and accurate measurement of the participants’ true score. Errors in
measurement are of two types: random error and systematic error (Waltz, Strickland, & Lenz,
2005).
Random error is caused by chance factors that confound the measurement of any
phenomenon. The error is random in that it emerges in an unsystematic manner in all
measurement (Zeller & Carmines, 1980). Such random error can be attributed to poorly created
test items or inadequate test conditions. A measuring device affected by random error will yield
results that are sometimes higher or lower than the actual magnitude of the attribute measured
(Nunnally & Bernstein, 1994). The higher the reliability of the measure, the less error is in the
measuring procedure (Waltz et al., 2005).
Systematic error refers to systematic influences that distort the instrument scores. This
source of error has a biasing influence on measurement procedures and influences an
instrument’s validity (Zeller & Carmines, 1980). Systematic error is due to some characteristic
that is regularly tapped by the measure other than that for which the instrument was constructed.
Other sources of systematic error are not associated with the instrument but with enduring
aspects of the respondent, such as characteristics of the participant (i.e., fatigue), that are likely to
influence responses to the measure in a consistent manner (Brink & Wood, 1998). Validity
denotes the scientific utility of a measuring instrument. Knapp (1985) interprets validity as an
indicator of the fit between the construct and the true score.
The quality of an instrument then can be evaluated by its psychometric properties,
reliability and validity. To develop sound measures, it is necessary to understand the nature of
43
the accuracy of measurement, so that error can be avoided as much as possible. The development
of the Humanistic Relationship Scales for this study and their testing followed the principle of
CMT.
Reliability
Reliability cannot be estimated directly since that would require one to know the true
scores, which according to CMT is impossible. However, estimates of reliability can be obtained
by various means. One way of estimating reliability is by using a measure of internal consistency
known as Cronbach′s α. Overall, it is accepted that a reliability α-value of .80 is needed for
research; α-values over .90 indicates redundancy of items (Streiner & Norman, 2004). Another
type of reliability is concerned with the stability over time of an instrument. The assessment of
the test-retest reliability is done by correlating the scores obtained on repeated administrations
(Streiner & Norman). If a scale truly reflects a meaningful and stable construct, it should reach
equivalent scores on separate occasions (DeVillis, 1991).
Validity
Validity is concerned with the extent to which a tool actually measures the construct it is
intended to measure. Two aspects of the validity can be tested: content validity and construct
validity.
Content validity is the degree to which the items in an instrument adequately represent
the universe of the content and is often viewed as the minimum psychometric requirement for
measurement adequacy (Streiner & Norman, 2004). To ensure content validation, the construct
has to be well defined and a panel of experts evaluates the individual items on the new tool, as
well as the entire instrument. An instrument is considered content valid if all items are relevant
to measure the construct, and if the items adequately measure all dimensions of the construct.
44
Often a Content Validity Index is used to quantify the degree of agreement between the different
experts rating the instrument (Lynn, 1986).
Construct validity has traditionally been defined as a demonstration that a scale or test is
measuring the construct it claims to be measuring (Moss, 1998), a construct being defined as an
attribute, proficiency, ability, or skill that is derived from established theories (Streiner &
Norman, 2004). However, not all qualities, abilities, or skills are readily observable and able to
be operationalized and measured. When trying to measure a more abstract construct or variable,
such as a humanistic nurse-patient relationship, an instrument is needed to measure the
behaviours that, according to the underlying theory, are the result of that variable (Streiner &
Norman). These proposed underlying factors are referred to as hypothetical constructs (Streiner
& Norman). Construct validity then can be defined as the theoretical context of implied
relationships to other constructs (Messick, 1989). The theoretical context represents underlying
factors: hypothetical constructs to explain the relationships among various behaviours or
attitudes (Streiner & Norman).
Several researchers suggest that there is no single best way to study construct validity
(Streiner & Norman, 2004). Construct validity for new instruments is most often determined by
using extreme groups, or by evaluating convergent or discriminant validity (Streiner & Norman).
For this study, testing the construct validity of the scales by comparing results between extreme
groups was not possible. It is unrealistic to expect that one of the patient groups will only have
intensely positive relationships with nurses while another group will not have any such
relationships.
To establish construct validation for the scales developed in this study, the researcher
relied on convergent validity testing. Convergent validity refers to how closely the new measures
45
are related to other measures of the same construct (Streiner & Norman, 2004). This places the
researcher in a position to make a prediction about how the construct will behave in relation to
another concept. The principle underlying convergent validity is that different measures of the
same construct should correlate highly with each other. Although this construct validation
appears quite straightforward, it is burdened with the challenge of finding a reliable and valid
tool that measures the same construct. The literature review revealed a lack of existing
instruments to measure the nurse-patient relationship. In this case, Streiner and Norman
recommend selecting a tool that only measures specific constructs to which the new measure
should be related.
The next step in determining construct validity of the instrument included a factor
analysis approach (Waltz et al., 2005). There are two types of factor analysis approaches:
exploratory factor analysis and confirmatory factor analysis (Nunnally & Bernstein, 1994;
Streiner & Norman, 2004). Exploratory factor analysis is used to determine empirically how
many constructs, or latent variables, or factors underlie a set of items. This approach was used in
the present study. A confirmatory factor analysis is used as a measurement model to confirm
existing relations of indicators (items) and factors (latent variables). This technique can only be
used when the relations among the measures are reasonably well-defined. Because this study was
exploring what relationships existed among the variables and the study focused on theory
development, an exploratory analysis was considered appropriate. Future studies will involve
confirmatory factor analysis testing.
Phase 1: Item and Scale Development
This first phase of the scale development encompassed four stages: item development,
scale construction, content validation of the new items, and the process of eliminating items.
46
Because the two scales are composed of the same set of substantive items, the steps described are
applicable to both scales.
Item Development
The first component of scale development is the creation of items for the scales. Items
were developed based on the Humanistic Nursing Theory by Paterson and Zderad (1976, 1988).
Selecting a nursing theory as the basis for scale construction presents many advantages to a study
(Streiner & Norman, 2004). Not only does the theory provide a basis from which to derive the
concepts and variables, it also provides a framework for selection and interpretation of the
concepts in relation to other concepts. The construct of a nurse-patient relationship is well
defined within the Humanistic Nursing Theory. Furthermore, when using a theory as the
framework for instrument development, psychometric testing of the instrument can lead to a
reduction of the abstract concepts to more refined indicators with a broader application. Lastly,
testing a theory-based instrument can lead to reaffirmation of the theory, or to alternative
relationships among the concepts. By doing so, a contribution is made to the nursing theory by
adding specific definitions, conceptual frameworks, and the utility of the theory for
operationalizing nursing to the body of nursing knowledge.
A thorough review of the Humanistic Nursing Theory by Paterson and Zderad (1976,
1988) made it possible to identify the theoretical construct of the nurse-patient relationship in
chronic care. To render these theoretical nursing concepts measurable, it was necessary to
translate and operationalize them into events that are observable and into measurable facts,
phenomena, or events (Waltz et al., 2005). Significant concepts were isolated from other inter-
related concepts, and ambiguous and abstract notions were reduced to a set of concrete
behavioural indicators. The concepts were operationalized and these operational definitions
47
formed the foundation of item development (DeVellis, 1991; Streiner & Norman, 2004). Six core
concepts were identified: (1) supporting human uniqueness, (2) sustaining choice, (3) relational
capacity, (4) living dialogue, (5) being present and (6) fostering well-being and more-being.
Each of the concepts was carefully described, operationalized, and where necessary, represented
in specific subconcepts. The operational definitions for each concept are provided in table 4.1.
Table 4.1. Operational Definitions and Domains per Concept
Concept 1: Supporting human uniqueness is the awareness of self and how one differs from others. Human uniqueness is supported through the process of searching for one’s capacity for uniqueness and becoming aware of one’s view of the world and response to it. Domain 1: Awareness of uniqueness and view of the world. Domain 2: Recognition of particularity. Domain 3: Awareness of view of the world and response to it. Concept 2: Sustaining choice: Patients have the freedom to choose to respond and to choose how to respond to situations. The nurses respect those choices. Domain 1: Freedom to choose to respond. Domain 2: Freedom to choose how to respond. Domain 3: Respecting choices. Concept 3: Relational capacity: is forming a connection between a nurse and a patient through openness and communication of the nurse’s availability to be involved as a person, with the goal of nurturing the patient. Domain 1: Connecting. Domain 2: Being available. Domain 3: Nurturing. Concept 4: Living dialogue: A lived dialogue is a particular form of relating where the dialogue between the nurse and the patient is viewed as communication in terms of a call and a response. The dialogue occurs in response to a perceived need related to the health-illness quality of the patient’s condition. Domain 1: Responding. Domain 2: Calling. Concept 5: Being present: Presence is a personal and professional nursing quality that is brought to the relationship. Professional quality refers to the accountability of the nurse. Personal quality refers to availability (being within its fullest sense by turning one’s attention toward the other), reciprocity (seeing the other as a person, rather than as objects or functions), and mutuality (the flow between two persons with different modes of being in the shared situation). Domain 1: Professional Accountability. Domain 2: Availability. Domain 3: Reciprocity. Domain 4: Mutuality.
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Concept 6: Fostering well-being and more-being: Humanistic nursing seeks to promote the well-being and comfort of the patient by nurturing the patient’s potential and helping him/her to recognize and accept limitations. Well-being also involves helping the patient search for meaning of life and recognizes reality of death. Domain 1: Nurturing well-being and comfort. Domain 2: Accepting. Domain 3: Searching. Domain 4: Helping to recognize.
These theoretical definitions were used as a guide for the item development (Fornaciari,
Sherlock, Ritchie, et al., 2005). Item construction employed a deductive approach based on the
Humanistic Nursing Theory (Paterson & Zderad, 1976, 1988). The deductive approach, also
called "logical partitioning" or "classification from above," requires a good understanding of the
phenomenon to be measured (Hersen, 2004, p. 255).
Based on the definition of each concept, items were generated that reflected the meaning
of the concept (Streiner & Norman, 2004; Fornaciari et al., 2005). The principles of domain
sampling were followed, in that the measure needed to be constructed by randomly selecting a
specified number of measures from a homogeneous, infinitely large item pool (Nunnally &
Bernstein, 1994). The fundamental goal at this stage was to systematically sample all content that
is potentially relevant to the key concepts of the nurse-patient relationship in CC. The underlying
rationale for and advantage of creating what could be perceived as an over-inclusive item set, is
that the initial item pool was broader and more comprehensive than the researcher's own
theoretical view of the construct. Furthermore, the item pool should also include content that
ultimately will be shown to be tangential to the core constructs. Subsequent psychometric
analysis will identify weak, unrelated items that are dropped from the emerging scale, but this
analysis is unable to detect missing content that should have been included at the initial stage of
item development (Streiner & Norman).
49
Therefore, a minimum of three items were developed for each domain to ensure that the
meaning of each concept was operationalized in a language that CC patients would understand.
The candidate led a team of experts, including one of the supervisors (DP), and a PhD candidate
with experience with the setting and patient population, to create the items. A total of 69 items
was developed to represent the construct of a humanistic nurse-patient relationship in CC.
Scale Construction
As noted in the instrument justification, it was important to have two separate Humanistic
Relationship Scales to measure the intensity of the preferred and the experienced qualities of the
nurse-patient relationship in CC settings, from the patient's perspective. The scales were
composed of the same set of substantive items but the response format was designed to elicit the
extent of the patient’s preferences (Humanistic Relationship Importance Scale) and the quality of
the patient's experiences (Humanistic Relationship Experience Scale) of a humanistic
relationship.
Important in the construction of the scales is the consideration of social desirability bias.
Social desirability bias refers to the tendency of some individuals to misrepresent their attitudes
by giving answers that are consistent with prevailing mores (Polit et al., 2001). Some strategies
proposed by Waltz et al. (2005) and Nunnally and Bernstein (1994) were followed to reduce the
influence of social desirability. They include: designing measures that assess multidimensions of
a phenomenon rather than only one dimension; clear and concise wording of the directions to
avoid ambiguity; avoiding item formats that use fixed-response alternatives such as true/false
and yes/no; all responses are of equal effort; paying attention to details of item wording; and
providing participant anonymity.
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A second important consideration in the design of the Humanistic Relationship Scales is
related to the population for which the scales are intended. Burnside, Preski, and Hertz (1998)
stated that it is essential that instrument development for older adults take into consideration their
specific needs. Therefore, researchers must carefully identify potential problems, both in
instrumentation and data collection, to maximize the effectiveness of the study and to strengthen
generalizability of the results (Burnside et al.). For this study, items were carefully worded and
complex content was avoided. Based on the work by Fox, Sidani and Streiner (2007) it was
decided to not include any items with negative stems as these items are associated with
difficulties for older persons during the comprehension stage of responding to items.
The Humanistic Relationship Importance Scale
The Humanistic Relationship Importance Scale (HRIS) aims at capturing the patients'
preferences for qualities of the relationship with nursing personnel by asking the patient about
the importance of these qualities. The HRIS starts with an overall directive asking the patient to
reflect on all relationships she/he has with nursing personnel. With these overall encounters in
mind, the patient is asked to rate the importance of each proposed item in their relationship with
the nurses. Patients rate the importance on a 5-point response adjective scale (Streiner &
Norman, 2004). The responses are scaled along a continuum of "not important, somewhat
important, important, fairly important, or very important." When a patient's individual HRIS item
scores are added, they indicate how important the qualities of humanistic relationships with
nurses are. The higher the score, the more important humanistic relationships are to the patient.
An adjective scale answer format was chosen to enhance the responding process, as it
presented the patient with five adjectives or categories from which to answer the question. The 5-
point scale also allowed the researcher to make fine discriminations among patients with
51
different points of view (Streiner & Norman, 2004). While a 7-point scale would offer an even
finer gradation of answer scores, Bernal, Wooley, and Schensul (1997) found that elderly
participants were often unsure how to respond to these 7-point scales.
The Humanistic Relationship Experience Scale
The Humanistic Relationship Experience Scale (HRES) was the second scale to examine
the nature of the relationships between patients and nursing personnel in CC settings. The HRES
aims at capturing the patient's actual experiences in relating to nursing personnel who generally
cared for them. The HRES asks the patient about the intensity or frequency with which nursing
personnel demonstrate the same set of qualities as those presented in the HRIS. The relationship
with nursing personnel forms the basis for answering the questions.
The patient is asked to rate the frequency or the intensity of each quality in the
relationship with nursing personnel. For example, patients rate the frequency of the item "Most
nurses take the time to listen to your concerns," on a 5-point response adjective scale with responses
scaled along a continuum of "never, occasionally, sometimes, frequently, and always." For some
items, an intensity score rather than a frequency score is required. For example, patients rate the
intensity of the item "Most nurses recognize the importance of your family and friends in your
life," on a 5-point response adjective scale with responses scaled along a continuum of "not at
all, a little, some, a fair amount, a great deal." When the scores of the HRES items are added,
they present a total score indicating the quality of the patient's actual experiences in relationships
with nurses. Higher scores indicate higher quality relationships, with quality defined as frequent
and intense levels of the humanistic elements of the relationship.
52
Content Validation Testing
The first step in testing the psychometric properties of any scale is to examine the item
pool for content validity (Streiner & Norman, 2004). Because the two scales are composed of the
same set of substantive items, the content validation testing on one set of items was applicable to
both scales. The content validity testing encompassed two components: the assessment for
content relevance and content coverage, and the content validation by experts.
Content Relevance and Content Coverage
The first step in content validation consisted of testing the items for content relevance and
content coverage. The researcher ensured that each item was content relevant, i.e., related to one
of the six concepts that were identified within the Humanistic Nursing Theory (Paterson &
Zderad, 1976, 1988); and that each domain of the six concepts was represented by at least three
items (DeVellis, 1991). Next, the number of items had to be equally divided over the number of
domains, indicating that each domain was equally important, a step called the representativeness
of the domains. These criteria were all met.
Content Validation
The next step in assessing content validity of a new measure requires the expertise of
content experts to select the best items to represent a particular concept. The content validity of
the items was evaluated by using the approach outlined by Lynn (1986). All items were
evaluated by two groups of reviewers: a panel of four scholarly experts and a group of five
patients residing in CC. Scholarly experts were asked to review the content and relevance of the
items based on the underlying theory. Patients were asked to rate the relevance of each item and
ease of understanding based on their experience with nursing personnel in a CC setting. These
53
two review groups required different procedures to evaluate content validation and are discussed
separately (Slocumb & Cole, 1991).
Scholarly Experts
Four scholarly experts were invited to review all items for their content and relevance.
Criteria used to select the four experts included clinical expertise, research experience on the
phenomenon of interest, and expertise related to the theoretical framework. All experts were
known to the researcher and the supervisors and deemed experts in this area of study. Two
experts were employed at a CC facility in Ontario as Nursing Practice Leaders. One of the
experts was employed at a university affiliated CC facility as a Nurse Practitioner. The last
expert held a faculty position at a university. All experts had 20 or more years of experience
working with a CC population and two out of the four experts had previously participated in the
development of scales.
The experts received a Content Validation Information Letter (Appendix 4.1) and a
Content Validation Questionnaire based on Lynn (1986) (Appendix 4.2). The letter of
introduction included information on the purpose and target population of the new instrument, a
brief overview of the Humanistic Nursing Theory, and an explicit description of each of the
concepts selected for the development of the Humanistic Relationship Scales. The Content
Validation Questionnaire described in detail the procedures to evaluate the items. All experts
were asked to rate the relevance or representativeness of the 69 items to the operational
definition of the concept on a 4-point scale (1 = not relevant; 2 =unable to assess relevance
without item revision; 3 = relevant, but needs minor revision; and 4 = very relevant and
succinct). The scale was presented as a 4-point adjective scale to enhance the clarity of the
response format. The provision of an even number of categories did not allow the experts the
54
choice of expressing a neutral position (Streiner & Norman, 2004). To facilitate this evaluation
process, the items were already categorized under their nominated concepts prior to the
evaluation process, and the definition of each of the identified concepts was provided. The
questionnaire also asked for overall comprehensiveness of the items, suggestions for
improvement, and qualitative information concerning any aspect of the scales. The experts were
asked if any domains or items were missing from the scale. Lastly, demographic data were
collected from the scholarly experts (Appendix 4.3).
Once the experts had rated all items, content validity was determined from the proportion
of experts who scored items as relevant with either a rating of 3 or 4. Next, the content validity
index (CVI) was calculated (Lynn, 1986). The CVI is defined as the percentage of total items
judged to be content valid by receiving a score of 3 or 4. A new content valid instrument should
have a minimum content validity index of .80 (Streiner & Norman, 2004).
Using this procedure, 38 items were given ratings of 3 or 4 by all experts. Thirty-one
items had a low relevance, that is, with a value of less than 3. Of those 31 items, 14 items were
revised (when the value was 2) and 17 items were deleted (when the value was 1) (Appendix
4.4). The items were revised based on the majority opinions of the reviewers. The revised scales
consisted of 52 items. The four experts reviewed the items a second time and completed a CVI.
The CVI was 1.00. Inter-rater agreement, the degree of agreement among raters, was calculated
at 1.00, indicating a high level of homogeneity or consensus in the ratings given by the four
experts (Streiner & Norman, 2004).
Patient Experts
Once the scholarly experts considered the items to be content valid, a second group of
content validation experts, i.e., five CC patients, were invited to evaluate the 52 items. The
55
decision to use a patient-as-expert approach has been used before (Wei, Dunn, & Litwin, 2000)
and is highly relevant in this study as the scales are developed to capture the patients'
perspective. The rationale to present the patients with content valid items from the scholarly
experts' point of view was twofold. First, it was expected that the scholarly experts had a better
conceptual understanding of the underlying theory to evaluate and rate the relevance and content
of the items than the patients. Second, based on a review of practical challenges related to
research in nursing homes, Ouslander and Schnelle (1993) describe the vulnerability of a chronic
patient population, such as their fatigue, as limiting their participation in research studies.
Therefore, patients were presented with items that already incorporated changes suggested by the
scholarly experts, thereby limiting the time and effort investment from a patient's perceptive.
The researcher guided the patients through the content validation procedure on a step-by-
step basis. First, the researcher invited the patients to participate. Selection criteria for patients
included: (a) residing in the facility for at least 3 months; (b) being cognitively competent and
oriented to person, place, and time; and (c) having the ability to understand and speak English. It
was reasoned that a minimum of 3 months residence in the facility was an adequate time period
for patients to develop relationships with the nurses (Hagerty & Patusky, 2003). Patients were
considered competent to participate in the research if they were able to understand and describe
back to the researcher all of the following four points: (a) their name, and length and place of
stay; (b) the purpose of the research; (c) the procedures involved; and (d) that they understood
they were free to refuse to participate at any time (Resnick, Gruber-Baldini, Pretzer-Aboff, et al.,
2007).
The researcher approached the patient individually, introduced herself, and verified that it
was a convenient time to speak to her/him. The researcher then fully explained the purpose of the
56
research, the content validation process and the role of the patient (Appendix 4.5). If the patient
agreed to participate in the content validation process, the researcher booked a mutually
convenient time. On the day of the appointment, the researcher repeated the content validation
process and the role of the patient information, and answered any questions the patient had. The
researcher then asked the patient to sign an Informed Consent Form (Appendix 4.6). Next, the
researcher elicited the patient’s comments on each items' relevance and ease of understanding to
ensure the meaning of the item was clear. The patient experts were asked to rate the relevance or
representativeness of the items on a 4-point scale (1 = not relevant; 2 =unable to assess relevance
without item revision; 3 = relevant, but needs minor revision; and 4 = very relevant and
succinct). An interview format allowed the researcher to explain the questions to the patients and
elaborate when necessary (Appendix 4.7). At the end of the interview, the researcher asked for
information to complete the Demographic Data Sheet (Appendix 4.8).
Five patients agreed to take part in this content validation test. Participants, on average,
were 66.8 years old and four were female. Overall, participants had an average CC length of stay
of 3.9 years. The patients rated all 52 items and the CVI was derived (Appendix 4.9). The patient
experts' opinion differed from the scholarly experts' opinion on some items. Nine items received
a low relevance from the patient experts, that is, had a value of less than 3. The patients'
expertise was perceived as very important for the validity of the scales as the scales were
designed to be used by patients, therefore, all the patients' suggestions were taken into account.
Of the nine items with low relevance, six items were revised and three items were deleted (when
the value was 1). The scales now had 49 items. The 5 patient experts reviewed the items again.
No further changes were suggested. The CVI, after the revisions were made, was 1.00.
57
Phase 2: Initial Psychometric Testing
This phase reports on the initial psychometric properties and the feasibility of the
Humanistic Relationship Scales. Upon completion of the content validation, the scales each
contained 49 content valid items. Still, every new scale needs to be further tested to ensure it is a
reliable and conceptually valid measure (Streiner & Norman, 2004). During Phase 2 of the scale
development, data were collected from a sample of 40 CC patients to examine the following
psychometric properties: interpretability, internal consistency, test-retest reliability, construct
validity, and variability of the scales. The setting, sample, and data collection procedures are
reported, followed by the procedures for initial reliability and validity testing. Based on the
findings of the initial psychometric testing, some items were deleted. This section concludes with
recommendations for the next phase of the study.
Protection of Human Subjects
Ethics review boards at the university and each participating facility approved the study
before data collection started. Permission to access the patients was requested from the vice-
presidents and nursing directors of the facilities and the unit managers of the units involved in
data collection. Potential participants were informed that data obtained were confidential and no
data would be shared with any of the nursing staff. Participants were also informed that the
researcher had no affiliation with the facility staff, therefore, completion of the scales would not
impact the quality of the care received by the patient. There were no known risks for a patient to
participate in this study. If a patient felt uncomfortable responding to any of the questions, she/he
could terminate the interview. Anonymity of all participants and confidentiality of the data both
during the research and in the release of the findings were protected.
58
Setting and Sample
Data collection took place in one CC facility in an urban setting. The facility has 276
beds and the patient population consists of adult patients with chronic illnesses. To maximize
participation, a convenience sample of 40 patients was selected, as 40 provided sufficient data to
test initial construct validity and reliability of the scale (Nunnally & Bernstein, 1994; D. Streiner,
personal communication, September 18, 2008).
The same sample selection criteria as in Phase 1 of the study were applied to identify
potential patient participants. The number of eligible patients in the selected facility was
estimated to be approximately 35% of the patients, i.e., 90 patients. The advanced practice nurse
(APN) employed in the facility distributed letters of information to all eligible participants
(Appendix 4.10). Interested participants notified the APN who then informed the researcher. The
researcher fully explained the study to the patient, including the purpose and procedures for data
collection. Patients were told that participation was voluntarily and that their care would not be
affected by their decision to participate or not to participate in the study. If the patient agreed to
participate, informed consent was obtained by the researcher (Appendix 4.11).
Data Collection Procedure
The researcher administered the Humanistic Relationship Scales in an interview format.
The decision to collect the data during a personal interview with the patient was made upon
careful consideration of the patient population in CC.
Bowsher, Bramlett, Burnside, et al. (1993) provided a comprehensive list of advantages
and disadvantages of different types of instruments when working with an elderly population.
Based on their review, a self-completed questionnaire was considered inappropriate for this
population; therefore, both scales were administered in an interview format. By doing so, any
59
physical limitations prohibiting the patient from participating in the study were removed. Other
barriers such as limited reading or writing skills were eliminated by reading the questions out
loud to the patient. The researcher was able to help patients who required special attention
because of problems with hearing, seeing, writing, or remembering (Preski & Burnside, 1992).
Although both the HRIS and the HRES are composed of the same items, it was decided
to administer the scales separately as opposed to alternately asking a question from the HRIS
followed by the same item from the HRES. Several reasons contributed to this decision. First, to
answer the questions in each scale, the patient needed to take into account different
circumstances. For the HRIS, the patient was asked to reflect on all relationships she/he had with
nursing personnel. For the HRES, for this phase of the instrument testing, the patient was asked
to reflect on the relationship with the nurse she/he felt most close to or with whom she/he had a
close relationship. It was decided to ask the patient to reflect on this type of relationship with a
nurse because two of the three construct measures (PONS and RCS, described below) measured
close or important relationships with nurses, and the purpose of phase two of the study was to
test initial construct validity of the HRES. If the HRIS and the HRES items were to be asked
alternately, the patient would be asked to shift from one perspective to the other for each item
posed. This process could potentially lead to confusion on the part of the patient about what
perspective applies at any point in time. When administering the scales separately, the patient
was first asked to reflect on all relationships she/he had with nursing personnel and to complete
the HRIS. Then the researcher asked the patient to identify the nurse with whom she/he had the
closest relationship. With this person in mind, the patient was asked to complete the HRES.
A second reason for administering the scales separately related to the response format.
The HRIS asks patients to rate the importance of a relationship quality on a 5-point response
60
adjective scale along a continuum from "not important" to "very important." Alternately, the
HRES aimed to capture the intensity or frequency of experiencing a quality in the relationship.
Patients were asked to indicate the frequency of the qualities on a 5-point response adjective
scale along a continuum from "never" to "always" and the intensity of some other qualities along
a continuum from "none" to "a great deal." All items with a frequency scoring were presented
first. Once these items were completed, the researcher explained the change in response format
to the patient, and then presented items with an intensity score.
To facilitate the scale completion, all items with a frequency scoring were presented first.
Once these items were completed, the researcher explained the change in response format to the
patient, and then presented items with an intensity score. The patient was also given cardboard
copies with the two 5-point scales presented in a visual analogue scale in large print.
By administrating the two scales separately, the principles of patient instrument
development for gerontological nursing research are taken into account (Burnside et al., 1998).
Factors such as fatigue (Burnside, Guy, Koch, et al., 1991) and confusion were kept to a
minimum by letting the patient first complete the HRIS and then the HRES. Finally, it was
believed that by answering the HRIS first, the patient had an increased awareness of the qualities
of the relationship. This responsiveness would enhance the completion of the HRES.
Next, three related construct measures were administered. Three instruments were
selected to test the construct validity of the newly developed scales: the Relational Care Scale
(RCS) (McGilton et al., 2003), the Presence of Nursing Scale (PONS) (Kostovich, 2002), and the
Nursing Services subscale of the Nursing Home Resident Satisfaction Scale (NHRSS) (Zinn,
Lavizzo-Mourey, & Taylor, 1993). These scales were selected because their constructs are
61
similar to some of the constructs of the HRES. The content and psychometric properties of each
scale are discussed.
The RCS was developed by McGilton et al. (2003) to evaluate relational care that nursing
staff provide to residents living in nursing homes. The RCS is a self-report measure for patients
and consists of six items (Appendix 4.12). Psychometric properties of the scale have been
reported (McGilton et al., 2003). Content validity with five content experts was calculated at
100%. Internal consistency of the RCS scale was .88 (n = 46) and the item-total correlations
were acceptable between .35 and .75. Construct validity of the RCS was assessed by using factor
analysis resulting in a one-factor solution explaining 75% of the variance. Construct validation
was demonstrated by a moderate correlation between a newly established Relationship Visual
Analogue Scale (VAS) (McGilton et al., 2003) (r = .63, p <.0001, n = 36) and a positive
correlation between RCS scores and an observational Relational Behaviour Scale (r = .42, p
<.001), which was developed to assess relational care. It was decided to use the RCS for
construct validation in this study because of the RCS's thorough evaluation and many similarities
between a LTC and CC setting.
The PONS was developed by Kostovich (2002) to measure nursing presence from a
holistic point of view (Appendix 4.13). A conceptual definition of nursing presence was
developed based on the Humanistic Nursing Theory by Paterson and Zderad (1976, 1988) and
spiritual theories by Gardner (1993) and McKivergin (2000). Nursing Presence was
operationalized in a 27-item, self-report scale. Content validity was established by five experts.
Psychometric properties were ascertained with 330 acutely ill medical-surgical patients in a
community hospital. Construct validity was supported by comparing total scores on the PONS to
a single-item indicator of patient satisfaction, yielding a high positive correlation (r = .801, p
62
<.001). Support for reliability was provided by a Cronbach′s alpha of .95 and a test-retest
correlation of .73.
The PONS is limited in its construct validity as it was not evaluated against any
established scales measuring the construct of presence. Despite initial construct validity with an
indicator of patient satisfaction being presented as high, it is important to take into consideration
that this indicator consisted of only one item presenting a very general question: "Overall, how
satisfied were you with the care provided by all of your RNs?" Furthermore, at the time of the
PONS completion, the average stay of the patient on the unit was only 4.32 days. Given the
limited time each patient spent on the unit, and the use of a very general question, it is
questionable if the high values on the satisfaction indicator and correlation coefficient indicate
sound construct validity. No studies were found that used the PONS beyond its initial
development and psychometric testing.
Despite the above argumentation, it was decided to use the PONS to test the construct
validity of the newly developed scales for this study for several reasons. First, content validity of
the PONS was established by scholarly experts, including Paterson and Zderad (1976, 1988), the
originators of the Humanistic Nursing Theory. It can be assumed that the PONS is a valid
instrument in assessing the single construct of presence from the Humanistic Nursing Theory.
Also, the internal consistency reliability of the PONS measured .95, an acceptable, yet high value
for a new instrument.
The third measure selected to test the construct validity of the HRES was the NHRSS by
Zinn et al. (1993). The NHRSS was developed to measure clients' satisfaction with nursing care
(Appendix 4.14). The instruments consist of three domains, i.e., physician, nursing, and other
services, with three items in each domain, plus a global satisfaction item. For this study, only the
63
nursing services subscale was used. In previous use, test-retest and inter-rater reliability were
evaluated at both the item and group levels, and indicated that the tool measures satisfaction
reliably over time and with different interviewers. Test-retest reliability was .79 for the nursing
services subscales (Zinn et al.).
After all scales were completed, the interview was concluded with the collection of
demographic information about the patient (age, gender, diagnosis, date of admission, country of
origin, and first language spoken) (Appendix 4.15). Two weeks following the original
administration of the questionnaires, the patient was contacted again to complete all the scales.
The researcher administered the scales on both occasions.
Data Analysis
All data from phase two were entered electronically into a data entry template created in
the Statistical Package for the Social Sciences (SPSS®), version 17.0. The template consisted of
patient variables, including age, gender, diagnosis, date of admission, country of origin, first
language spoken, as well as the item variables of the HRIS, the HRES, and the construct
measures.
For the reliability analysis, the data from the 40 participants were used to calculate a
Cronbach’s alpha to test the internal consistency of the instrument. An item-to-item and item-to-
total analysis was performed using the same data to calculate correlations among items within
each subscale and between each item with the total subscale score. Items with low correlations
(< .30) or high correlations (>.70) with the relevant subscale score were rechecked and
considered for revision or deletion.
The same data were used for examining the test-retest reliability. Total scores for the
HRIS and HRES were obtained for time 1 and time 2 in order that a test-retest reliability
64
coefficient could be calculated by correlating the time 1 scores with the time 2 scores. The
correlation coefficient of the two administrations of an instrument is a numerical index of the
magnitude of the test’s reliability (Polit et al., 2001). A high correlation coefficient indicates high
stability or test-retest reliability of the instrument. A reliability coefficient above .70 is
considered satisfactory. Items with low test-retest correlations (< .40) were rechecked and
considered for revision or deletion.
A last consideration in the data analysis was related to missing data. Missing data often
occur due to factors beyond the control of researchers such as the failure of subjects to respond
to a question or their attrition from a study. Its seriousness depends on how much of the data are
missing and whether the pattern of missing data is random or systematic (Streiner & Norman,
2004). Randomly missing data scattered throughout a data matrix rarely pose serious problems.
Systematically missing values, on the other hand, are always serious.
The approach of dealing with missing data in this study included checking the data for a
missing data pattern. If a Humanistic Relationship Scale was missing less than 20% of the total
items of each subscale, the scales were included in the analysis with the missing data imputed
with the item mean. Scales with missing data more than 20% of one or more subscales were
excluded from the analysis.
Results
Participants
Forty patients agreed to take part in the pilot test (participation rate of 95.2%). The
demographics of the patient sample are presented in Table 4.2. Participants, on average, were
59.6 years, but the sample represented a very broad age range from 21 to 96 years. Most patients
65
participating in the study were female (57.5%). Overall, participants had an average CC length of
stay of 4.2 years.
Table 4.2. Demographic Characteristics of Phase Two Participants
Variables Participants (n=40) Age (years) M (SD) Median Range (min.–max.)
59.6 (18.1) 62.3 65 (21–96)
Gender Female Male
Frequency (%) 23 (57.5) 17 (42.5)
Diagnosis Neurologic Disorders Hip fracture Other
Frequency (%) 22 (55.0) 2 (5.0) 16 (40.0)
Length of Stay (years) M (SD) Median Range (min.–max.)
4.2 (4.5) 2.9 37.6 (.4–38)
Country of birth Canada Other
Frequency (%) 22 (55.0) 18 (45.0)
First Language English Other
Frequency (%) 29 (74.4) 11 (25.6)
Testing the Initial Psychometric Properties
Several components of the psychometric testing for the Humanistic Relationship Scales
were assessed: interpretability, internal consistency reliability, test-retest reliability, construct
validity, and variability. Detailed findings are discussed.
66
Interpretability
The first criterion for selecting the items for a scale is to eliminate any items that are
incomprehensible or where the intent is not clear or not valid (Streiner & Norman, 2004).
Despite the extensive content validation process, some items on the scales were not clear to
patients. Items were considered unclear if a patient had to ask for additional explanation when
the item was presented during the interview or if an item response was missing. There was no
indication of systematically missing values above 20% within one subscale. Three items (2, 20,
and 39) were not performing well on both scales (Table 4.3). These items were deleted from the
scales.
Table 4.3. Interpretability of Items
Item HRIS HRES
Item 2: "Most nurses understand where your beliefs come from."
Six missing answers (15%). 30 patients (75%) needed additional information to answer.
Eight missing answers (20%).
Item 20: "Most nurses are willing to be involved in the relationship."
Five missing answers (13%). 20 patients (50%) needed additional information to answer.
Six missing answers (15%). 30 patients (75 %) required additional information to answer.
Item 39: "Most nurses like to be with you."
Four missing answers (18%). Eight patients (20 %) required additional information to answer.
Eight missing answers (20%). Eight patients (20 %) required additional information to answer.
Internal Consistency Reliability
The second component in the psychometric testing consisted of internal consistency
reliability testing by calculating a Cronbach′s α reliability coefficient for the subscales and total
score of both the HRIS and HRES. It is important to note that in Phase 2, the Cronbach′s α was
67
used as an evaluative measure to assess the internal consistency reliability of the scales. None of
the items was considered for deletion based on these findings. The initial Cronbach′s α reliability
coefficient indicated a high level of redundancy for the HRIS (.97) and for the HRES (.98),
which was expected at this stage of the scale development (Table 4.4).
Table 4.4. Internal Consistency Reliability for the HRIS-49 and HRES-49
HRIS HRES Subscales Number of items Cronbach′s
Alpha Cronbach′s
Alpha Supporting human uniqueness
11 items .868 .868
Sustaining choice 4 items .921 .875 Relational capacity 7 items .851 .877 Living dialogue 7 items .862 .890 Being present 11 items .907 .930 Fostering well-being and more-being
9 items .902 .923
Overall 49 items .969 .978
The next step in the internal consistency reliability testing was to examine the values of
the inter-item and item-to-total correlations to assess relationships of each item to the overall
scale and test for multicollinearity. The inter-item correlations for the HRIS are presented in
Appendix 4.16, and for the HRES in Appendix 4.17. Items 2, 20, and 39, were not taken into
account for the item-to-total analysis because of poor performance on the first component of
initial psychometric testing, interpretability. For both scales, several inter-item correlations were
higher than .70, indicating items measuring very similar aspects of the concepts (Streiner &
Norman, 2004). As expected, inter-item correlations of items of the same subscale had higher
values than inter-item correlations of items of different subscales.
68
Next, an analysis of the item-to-total correlations revealed several items with a high
correlation (>.70) on both scales, indicating that these items were not discriminating or not
measuring a different aspect of the construct (Streiner & Norman, 2004). None of the items had
low correlations (< .30). The findings are presented in Appendix 4.18 for the HRIS and
Appendix 4.19 for the HRES. The above results suggested deleting up to 25 items with item-to-
total correlations >.70. At this point of the analysis, however, none of the suggested items was
deleted, as a careful consideration of all required components for psychometric testing was
required for the deletion process.
Test-Retest Reliability
The third component that was used to examine the initial psychometrics was test-retest
reliability. For this study, it was hypothesized that the importance of the qualities of a nurse-
patient relationship in CC from the perspective of the patient is a stable concept. The researcher
opted for a 2-week interval, as the nurse-patient relationship is considered a stable concept and
scores should be similar on the separate occasions. Furthermore, this patient population was able
to recall answering the scale, yet the 2-week interval limited the chances that the patient would
remember the actual ratings of each item. The second rating, therefore, was a true measure of
stability over time.
Scores on the two administrations of the HRIS were prepared to be correlated using an
Intra-Class Correlation (ICC). Using the analysis of variance to calculate the ICC coefficient,
two assumptions were considered. The normality and equal variance of the sample needed to be
evaluated through descriptive statistics and Levene's tests. The normality test was performed
using Fisher's skewness coefficient (Pett, Lackey, & Sullivan, 2003). The Fisher skewness
coefficient for the HRIS test score (first measure) equalled -.536 and the retest score (second
69
measure) equalled -1.065. These two coefficients were both between +1.96 and -1.96 indicating
that the distribution of scores is not significantly different from a normal distribution. Next, the
assumption of equal variances was tested using SPSS®, version 17.0. One-way analysis of
variance with Levene's test gave the value of Levene's statistic for the test and retest scores (.73,
p = .828) indicating that the two measures had equal variances. Once the normality and equal
variance of the sample were confirmed, the total test-retest ICC score for the HRIS was
calculated and was .73, indicating a high and positive relationship between the two sets of scores.
Nine items had a low ICC (<.40) and were considered for elimination as they were not
sufficiently stable over a 14-day time interval (Streiner & Norman, 2004) (Appendix 4.20).
The same procedure was repeated for the HRES. The Fisher skewness coefficient for the
HRES test scores, however, was -1.24 and the HRES retest scores was -2.69. Therefore, the
retest coefficient is not between +1.96 and -1.96, indicating that the distribution of scores was
significantly different from a normal distribution. The assumption of normality could not be
accepted and the process of calculating an ICC for the test-retest reliability of the HRES could
not be completed.
Construct Validity
The evaluation of construct validity was based on testing the convergent validity of the
new tool. Most scales available in the literature rate experiences rather than preferences.
Therefore, only the HRES was tested for convergent validity by relying on comparing the
constructs of the HRES to related concepts. As stated earlier, three instruments were selected to
test the construct validity: (a) the Relational Care Scale (RCS) (McGilton et al., 2003); (b) the
Presence of Nursing Scale (PONS) (Kostovich, 2002); and (c) the Nursing Services subscale of
the Nursing Home Resident Satisfaction Scale (NHRSS) (Zinn et al., 1993). It was hypothesized
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that for patients who experience humanistic relationships, composite scores of the HRES would
moderately correlate with those of the RCS, the PONS, and the Nursing Services subscale of the
NHRSS.
A Pearson correlation was used to evaluate the relationships between the different scales.
The result of this analysis is presented in Appendix 4.21. The HRES demonstrated high
correlations with the RCS (.79), the PONS (.86), and the Nursing Services subscale of the
NHRSS (.77). All correlations were significant at the 0.01 level, indicating that there was a
statistically significant positive relationship between the HRES and its construct measures
(Streiner & Norman, 2004).
The correlation coefficient of the RCS was moderately high (.79) with the HRES. The
correlation between the RCS self-report scale and the HRES demonstrates convergent validity
and provides evidence that the qualities of the humanistic relationship are demonstrated in
reliable and empathic behaviour of the nurse. Yet, the substantially different conceptual basis for
the development of the RCS, that is, the parent-infant relationship theory (Winnicott, 1960)
distinguishes the scale from the HRES.
The results of the correlation with the PONS demonstrated a high correlation (.86)
indicating that the HRES and the PONS are measuring a similar set of constructs. The scores of
HRES items that measure the presence domain were correlated with the total scores of the PONS
and revealed a high correlation of .93, indicating that the "presence items" of the HRES
demonstrate convergent validity and measure nursing presence as defined in the Humanistic
Nursing Theory (Paterson & Zderad, 1976, 1988). However, the HRES was designed to measure
several other constructs besides the concept of presence and is therefore a more inclusive tool to
explore the nature of the nurse-patient relationship in CC.
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The correlation coefficient of the Nursing Services subscale of the NHRSS was
moderately high (.77) with the HRES, providing initial support that patients who experience a
humanistic relationship with the nurse are more satisfied with the nursing care received.
Variability
The last component in the psychometric properties testing is an analysis of the variability
of the scores on the Humanistic Relationship Scales. Both the HRIS and the HRES were
examined for their variability, that is, for a measure to be sound, the scores should be spread over
the whole range of the adjective scale (Streiner & Norman, 2004). Analysis for the HRIS
indicated a normal distribution or acceptable variability. However, for the HRES, analysis
revealed a low variance and a "positive skew," indicating that responses were not evenly
distributed over the range of alternatives but showed a positive skew toward the favourable end
(Streiner & Norman) (Appendix 4.22). Most items (45 of the 49 items), had a mean score that
was above the middle point on the 5-point scale; resulting in the lower half of the scale never
being used. The decision to ask the patients to reflect on their relationship with a nurse they were
close to when answering the questions, while it supported the construct validity of the scale
(Moss, 1998) by demonstrating that most patients perceived their close relationship as "very
humanistic," also created issues of skew and problems of a ceiling effect.
Although it is interesting to know that patients experience a humanistic relationship with
the nurse that they are close to, it also means that it is impossible to detect any improvement in
these relationships, or to distinguish among various grades of humanistic relationships within
close relationships. The HRES was originally designed to distinguish a range of closeness in
nurse-patient relationships, however, the decision to ask patients to respond to the items in terms
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of a relationship with a nurse with whom they had a close relationship limited the scale’s ability
to do that. A different approach was needed to allow the comparison of different nurse-patient
relationships. This approach will be discussed later in this chapter.
Item Deletion Process
Based on the initial psychometric testing of the Humanistic Relationship Scales
(Appendix 4.23 and 4.24), findings for the five components of the psychometric testing for both
scales indicated that several items needed to be considered for elimination (Table 4.5).
Table 4.5. Suggested Items for Deletion upon Completion of Phase Two
Subscale Interpretability Internal consistency reliability
Test-retest reliability
Supporting human uniqueness
Item 2 Items 1, 3, 4, 8, 9, 10, 11
Items 2, 8, 9
Sustaining Choice Items 12-14 Items 14
Relational capacity
Item 20 Items 16-17, 19, 21
Items 17, 20-22
Living dialogue
Items 24-26, 29
Items 24
Being present Item 39 Items 35, 36, 38 Fostering well-being and more-being
Items 42, 46-48
The suggested items for deletion failed to meet one or more components of the
psychometric testing; however, the list of these items presented several problems. Firstly, several
of the suggested items for deletion belonged to the same concept. If the suggested items were
deleted, some concepts would have no items left, and some concepts would be left with just one
item. Streiner and Norman (2004) suggest that each concept should be represented by at least
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two to three items, otherwise it is not being adequately measured by the scale. Lastly, the number
of items should be equally divided over the number of concepts, assuming that each domain is
equally important for the scale. If the items were to be deleted as suggested, the
representativeness of the concepts would be unequal. The suggested items for deletion were
carefully considered in relation to the total scale and the five criteria.
Several items were deleted per theoretical concept: Supporting human uniqueness (items
1, 2, 4, 6, 8, 9, and 10), sustaining choice (no items), relational capacity (items 17, 20, and 21),
living dialogue (items 24, 25, and 29), being present (items 31, 32, 33, 34, 36, 37, and 39),
fostering well-being and more-being (items 41, 48, 44, 46, and 48) (Appendix 4.23 and 4.24).
This process resulted in a 24-item scale (Table 4.6).
Table 4.6. Number of Items per Concept Before and After Item Deletion Process
Number of items Subscales Before psychometric
testing After psychometric
testing Supporting human uniqueness 11 4 Sustaining choice 4 4 Relational capacity 7 4 Living dialogue 7 4 Being present 11 4 Fostering well-being and more-being
9 4
Total 49 24
The revised 24-item sale contained 6 concepts, all represented by 4 items. An overview
of the remaining items is presented in Table 4.7.
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Table 4.7. The 24-Item Humanistic Relationship Scale
Supporting human uniqueness 1. The nurses recognize the importance of your family and friends in your life. 2. The nurses make an effort to ask questions to find out who you are. 3. The nurses take the time to listen to your concerns. 4. The nurses show concern for you as a person. Sustaining choice 5. The nurses recognize your right to make choices about your life. 6. The nurses recognize your right to make choices about your care. 7. The nurses support you in your choices. 8. The nurses respect your choices. Relational Capacity 9. You and the nurses enjoy each other's company. 10. You and the nurses feel close to each other. 11. You have a warm and personal relationship with at least one nurse. 12. The nurses are there for you when you need them. Living Dialogue 13. The nurses respect your need to be alone. 14. The nurses know how much care you need. 15. The nurses can figure out what you need without you asking them. 16. The t nurses let you know that they are there for you. Being present 17. The nurses feel responsible for your care. 18. The nurses give you their full attention when they are with you. 19. The nurses use your name when talking with you. 20. The nurses help your day go well. Fostering well-being and more-being 21. The nurses make you feel better when they're with you. 22. The nurses help you to have a good quality of life. 23. The nurses help to boost your confidence in what you can do. 24. The nurses help you to make the best of the situation you are in
Implications for Phase 3
Data collected with the HRES revealed low variance in patients' responses, as most
patients perceived their close relationship with a nurse as very humanistic. This positive skew
limited the interpretability of the results. Furthermore, it is important to determine how the
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patients experience day-to-day relationships with nurses in general in order to assess the
sensitivity of the scale to a range of relationships and achieve variance in responses. Therefore,
patients were asked to reflect on how they experienced humanistic relationships with nursing
personnel on their unit for Phase 3.
To test the feasibility of using the HRIS and the HRES (24 items each) with the new
context, a pilot test with five patients was conducted. The researcher guided the patients through
the data collection procedure on a step-by-step basis. Selection and recruitment criteria were
similar to Phase 2. The researcher used an interview format to complete the HRIS and the HRES.
The patients were asked to reflect on nurses who generally care for them and because some had
difficulty with this context, they were guided to think about the nurse who provided morning
care as long as she/he was not a nurse with whom they had a close relationship as the context for
answering the HRES scale.
The demographics of the patient sample were similar to the demographics of the
participants in Phase 2 of the study. The five participants, on average, were 62.8 years old, and
60% of the patients participating were female. Overall, participants had an average CC tenure of
4.6 years. The majority of the participants were born in Canada (80%) and all spoke English as
their first language. Patients were able to distinguish between the HRIS and the HRES and could
reflect on the relationship with nurses who generally cared for them. No fatigue or problems with
attention span were noticed when the scales were completed (Preski & Burnside, 1992; Bowsher
et al., 1993). This finding confirmed that the scales could be used together to collect data on the
qualities of the nurse-patient relationships in CC.
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Summary
In Phase 2 of this study, data were collected from 40 patients to test the newly developed
Humanistic Relationship Scales. The original scales each consisted of 49 items. Testing of the
psychometric properties revealed several items that were unstable or unreliable. Each item was
assessed relative to the five criteria for initial psychometric testing and each item was considered
in relation to the other items within the concept. Suggested items for deletion were carefully
considered in relation to the total scale, ensuring that each concept was represented by at least
three items, and that the number of items was equally divided over the number of concepts,
assuming that each concept was equally important for the scale. Psychometric testing of the 49
items led to the deletion of 25 items. The revised scales now had 24 items. The data collected
with the HRES revealed a positive skew. It was, therefore, decided to ask the patient to focus on
a different population when completing the HRES, that is, the nurses who generally cared for
them. Pilot testing with 5 patients indicated that patients were able to complete the scales without
difficulty. The 24-item scales served as the data collection measure for the third phase of the
study.
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Chapter Five: Factor Analysis and Results
This chapter discusses the third and last phase of the scale development commencing
with the setting and sample, followed by the data collection procedures, the data analysis plan,
the factor analysis and the reliability testing of the factors. Lastly, the findings of the data
collected for the HRIS and HRES are presented.
Setting
Data were collected from patients residing in five different CC facilities in an urban
setting in Ontario, Canada. The facilities were chosen because the patients living in these
environments had similar circumstances, i.e., they were dependent and had lived in the facility
for a prolonged length of time. Two CC facilities were university-affiliated institutions. All
facilities provided care to adult patients with chronic illnesses, and varied in size from 119 beds
to 535 beds (Table 5.1).
Table 5.1. Facility Size.
Facility 1 Facility 2 Facility 3 Facility 4 Facility 5 Total Number of CC beds
276 145 119 435 535 1510
Sample
To maximize participation, a convenience sample was selected. The sample size was
determined by the number of items in the Humanistic Relationship Scales. As both the HRIS and
HRES had the same items, the sample size was determined by the number of these items, i.e., 24,
at the completion of Phase 2 of the study (Sulmasy, McIlvane, Pasley, et al., 2002). In order to
have sufficient data to conduct a factor analysis of a newly developed scale, a minimum of 10
subjects is required for each item (Streiner & Norman, 2004). Phase 3 of the study included a
sample of 249 patients, surpassing the minimum criterion of 240.
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The selection criteria for the sample were similar to those in Phase 2 and included: (a)
residing in the facility for at least 3 months; (b) being cognitively competent and oriented to
person, place, and time; and (c) having the ability to understand and speak English. It was
reasoned that a minimum of 3 months residence in the facility was an adequate time period for
patients to develop relationships with the nurses (Hagerty & Patusky, 2003). Based on research
conducted by Resnick, Gruber-Baldini, Pretzer-Aboff, et al. (2007), patients were considered
competent to participate in the research if they were able to understand and describe back to the
researcher all of the following four points: their name, and length and place of stay; the purpose
of the research; the procedures involved; and that they understood they were free to refuse to
participate at any time.
To calculate the percentage of eligible patients in the selected facilities, the Cognitive
Performance Score (CPS) for each of the participating facilities was retrieved from the Ontario
CCC hospital report (Teare, G.F., et al., 2005). The CPS Scale combines information on memory
impairment, level of consciousness, and executive function, with scores ranging from 0 (intact)
to 6 (very severe impairment) (Morris et al., 1994) and has been shown to be highly correlated
with the MMSE in a number of validation studies. According to Simmons and Schnelle (2001), a
CPS score of 3 or less indicate that the patient has the cognitive capacity to complete a self-
report questionnaire. Given that 35% of the CC population across the 5 facilities had a CPS of 3
or less, 35% of the sample met the eligibility criteria for this study (Table 5.2) which translated
into approximately 525 patients across the five facilities. Since only 240 patients were required
for the principal axis analysis (PAA) the number of potentially eligible patients across the
facilities was sufficient.
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Table 5.2. Number of Potentially Eligible Participants per Facility
Facility 1 Facility 2 Facility 3 Facility 4 Facility 5 Total
Estimated number of eligible patients
56 51 42 152 187 488
The information about eligibility was collected from the advanced practice nurse (APN)
employed in the facility. The researcher screened those patients who were considered eligible
and then the APN distributed letters of information to eligible participants (Appendix 5.1).
Interested participants notified the APN who then informed the researcher. The researcher fully
explained the study to the patient, including the purpose and procedures for data collection.
Patients were told that participation was voluntarily and that their care would not be affected by
their decision to participate or not to participate in the study. If the patient agreed to participate,
informed consent was elicited and obtained (Appendix 5.2).
Data Collection Procedure
The researcher developed a standard procedure for data collection and trained the
research assistant. Both the researcher and the assistant followed the procedure to collect data.
Inter-rater reliability testing on a sample of 15 patients yielded 100%. The researcher collected
100% of the data for the first two phases of the study and 76.7% (191 interviews) of the data for
the subsequent phase 3.
The researcher and the research assistant administered the Humanistic Relationship
Scales (HRIS and HRES) in a facilitating interview format. At the time of data collection, the
researcher explained the different scales, and the procedures for completion. The patient was
given an opportunity to ask any questions related to the study. Subsequently, the researcher
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presented the questions of the HRIS, followed by the HRES questions. After the scales were
completed, the interview was concluded with the collection of demographic information about
the patient, i.e., age, gender, diagnosis, date of admission, country of origin, first language
spoken (Appendix 4.15).
Data Analysis
All data were entered into the computer using a data entry template created in SPSS®,
version 17.0. The template consisted of patient variables, including age, gender, diagnosis, date
of admission, country of origin, first language spoken, as well as the item variables of the
Humanistic Relationship Scales. Data were analyzed using SPSS®, version 17.0 to test the
psychometric properties of the Humanistic Relationship Scales. The approach to deal with
missing data was the same as described in phase two of the study.
The analysis for psychometric testing focused on testing the dimensionality of the
Humanistic Relationship Scales and the reliability of the newly emerging factors.
Procedures to Test Dimensionality
The dimensions of the Humanistic Relationship Scales were assessed by means of a
factor analysis (FA) (Norman & Streiner, 2000; Waltz et al., 2005). An FA is a statistical
procedure that reduces a large set of variables, i.e., items, into a smaller set of variables, i.e.,
factors, with common characteristics or underlying dimensions (Norman & Streiner). The item
variance of each item on the HRIS consists of three components: (a) loading on a factor, (b)
uniqueness of the item, and (c) error. The aim of the FA is to reduce the number of variables and
explain the same amount of uniqueness with fewer variables (Norman & Streiner).
Among the many ways to conduct an FA, one of the most conventional is a principal axis
analysis (PAA) (Norman & Streiner, 2000). An eigenvalue decomposition of a correlation matrix
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is completed and then the communalities for each variable are estimated by the first few factors.
A PAA aims at explaining the uniqueness between items in terms of uncorrelated underlying
factors or latent variables. To conduct a PAA, the following procedure was followed (Nunnally
& Bernstein, 1994; Norman & Streiner, 2000). An exploratory PAA was conducted, starting with
factor extractions by identifying which items comprised each factor. The purpose of this factor
extraction was to come up with a series of linear combinations of the items to define each factor.
A scree plot (Cattell, 1966) presenting eigenvalues greater than 1 was used to identify the
number of factors. Factors were rotated when needed.
The factor loading matrix demonstrates the factor pattern. To simplify interpretation of
the factors, the factor loading matrix should satisfy four conditions (Norman & Streiner, 2000):
1. Distribution of variance: The sum of the eigenvalues of the first few factors should explain a
high percentage of the total variance (70%). Furthermore, the variance should be evenly
distributed across the factors.
2. Factorial complexity: The items should load on one factor only, to avoid factors that are
complex and difficult to interpret.
3. Magnitude of the loadings: Factor loadings should be close to 1.0 or 0.0 to facilitate
interpretation.
4. Unipolar factors: To interpret the factor, factors should be unipolar, that is, all loadings
should be positive or negative.
The PAA was aimed at finding the factor solution with the greatest structural simplicity,
and took place in several steps based on the above described criteria.
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Procedures for Reliability Testing
The testing of the dimensionality of the Humanistic Relationship Scales could result in
several factors that might be different from the original six theoretical concepts. Therefore, the
second component in the psychometric testing consisted of internal consistency reliability testing
by calculating a Cronbach′s α reliability coefficient for each factor of the scales. A minimum
Cronbach′s α coefficient of .70 is considered acceptable for a newly developed instrument,
however, a coefficient of .80 is required to support wide use of the instrument (Carmines &
Zeller, 1979). Cronbach′s α coefficients between .80 and .90 indicate that the scale can detect the
discriminations between the factors designed to assess the construct (Burns & Grove, 2005). If
the alpha coefficient is greater than .90, there is an indication of redundancy among the factors
on the scale.
The next step in the internal consistency reliability testing was to examine the values of
the inter-item and item-to-total correlations to assess relationships of each item to the overall
factor and test for multicollinearity. The inter-item correlations per factor should be within .30
and .70 as recommended by Kerlinger (1992), to exclude the possibility of redundancy of the
items. Ideally, none of the inter-item correlations should be higher than .70; higher correlations
indicate that those items are measuring very similar aspects of a concept within the same factor
(Norman & Streiner, 2000). Items with low correlations (< .30) should be eliminated and a new
Cronbach′s α calculated. If items are truly irrelevant or redundant, eliminating low correlation
items will significantly increase the alpha level; however, if the alpha level only decreases
minutely after the elimination of the items thought to be redundant or irrelevant, it indicates that
all of the items are measuring some aspect of the same construct and therefore, those items will
be retained. The internal consistency reliability of the new scale was determined by calculating
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inter-item and item-to-total correlations for each factor of the scales. Based on factor loadings, it
was decided which items were retained or deleted.
Results
Setting and Sample
Data were collected from patients residing in five different CC facilities in the Greater
Toronto Area. Facilities varied in size from 119 beds to 535 beds (Table 5.3).
Table 5.3. Facility Characteristics
Variables Facility 1 Facility 2 Facility 3 Facility 4 Facility 5 Total Number of CC beds 276 145 119 435 535 1510
Estimated number of eligible patients
56 51 42 152 187 488
Number of patients who met the criteria
60 50 42 148 168 468
Number of invited patients
60 50 42 61 55 268
Number of participating patients who completed the scales
60 49 42 54 44 249
Number of participating patients
60 49 42 54 44 249
Nurse/patient ratio 1/6 1/6 1/6 1/6 1/7 N/A
A total of 249 patents participated in the study for a participation rate of 93%. The
demographics of the overall sample are presented in table 5.4. Most patients participating in the
study were male (53.4%), yet in three of the five facilities women outnumbered the male patients
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in the sample. Facility five, a veteran’s facility, had a high proportion of male patients and
considerably increased the overall percentage of male participants. Participants, on average, were
70 years old, yet the sample represented a very broad age range varying from 21 to 98 years. The
patients in this sample were approximately 10 years older than the phase two participants and
this difference is largely due to the much older population in facility five. Overall, there was
considerable variation of admitting diagnoses, with the most common diagnoses being stroke,
multiple sclerosis, hip fracture, and head injury. Participants had an average CC tenure of 2.9
years. It is also important to note that all facilities presented a wide range of length of stay for
their patients, with two facilities providing up to 34 years of care to some participants. Most
participants were born in Canada (66%) and spoke English as their first language (79%). Overall,
the selected CC facilities provided care to a very diverse population in regards to age, length of
stay, and admitting diagnosis, demonstrating the complexity of the patient population in CC
settings.
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Table 5.4. Demographic Characteristics of the Participants per Facility
Variables
Total n=249
Facility 1 n=60
Facility 2 n=49
Facility 3 n=42
Facility 4 n=54
Facility 5 n=44
Gender Frequency (%) Male Female
133 (53.4) 116 (46.6)
28 (46.7) 32 (53.3)
17 (34.7) 32 (65.3)
19 (45.2) 23 (54.8)
29 (53.7) 25 (46.6)
40 (90.9) 4 (9.1)
Age (years) M (SD) Median Range (min.-max.)
69.6 (16.6) 73.0 77 (21-98)
64.6 (14.3) 64.5 65 (24-98)
64.1 (15.7) 67.0 62 (29-91)
69.1 (15.2) 69.5 59 (36-95)
67.1 (16.9) 72.5 65 (26-91)
86.0 (10.8) 87.0 77 (21-98)
Diagnosis Frequency (%) Stroke MS Hip fracture Head injury Other
43 (17.3) 26 (10.4) 18 (7.2) 26 (10.4) 136 (54.6)
12 (20.1) 8 (13.4) 5 (8.4) 8 (13.4) 27 (45.0)
10 (20.3) 8 (16.3) 2 (4.1) 10 (20.3) 19 (38.8)
8 (19.0) 3 (7.1) 6 (14.3) 1 (2.4) 24 (57.1)
7 (13.0) 7 (13.0) 1 (1.9) 5 (9.5) 34 (63.0)
6 (13.7) 0 4 (9.1) 2 (4.6) 32 (72.7)
Length of Stay (years) M (SD) Median Range (min.-max.)
2.9 (4.2) 1.5 33.9(.3-34)
5.1 (6.4) 2.2 33.6(.4-34)
3.4 (3.7) 1.5 33.9(.3-34)
1.2 (1.3) .9 7.9 (.3-8)
1.7 (2.1) .8 10.7(.3-11)
2.7 (3.5) 1.5 15.5(.5-16)
Country of birth Frequency (%) Canada Jamaica England Other
164 (65.9) 11 (4.4) 10 (4.0) 64 (25.7)
27 (45.0) 4 (6.7) 2 (3.3) 27 (45.0)
28 (57.1) 3 (6.1) 5 (10.2) 13 (26.5)
35 (83.3) 0 0 7 (16.7)
39 (72.2) 3 (5.6) 0 12 (22.3)
35 (79.5) 1 (2.3) 3 (6.8) 5 (11.4)
First Language Frequency (%) English Other
196 (78.7) 53 (21.3)
37 (61.7) 23 (38.3)
38 (77.6) 11 (22.4)
37 (88.1) 5 (11.9)
45 (83.3) 9 (16.7)
39 (88.6) 5 (11.4)
When examining the resident demographics for differences across facilities; it was noted
that the sample from facility five included more male participants. Furthermore, the sample in
facility five was older, yet no statistical significant differences were found between the facilities
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(F2,43 = 8.88, p-value = .000). The sample from facility one appeared to have a longer length of
stay, but, again, no statically significant difference was found for this variable when compared to
the other facilities (F2,59 = 0.598, p-value = .867).
Testing the Dimensionality of the Humanistic Relationship Scales
The data collected from the 249 participants did not indicate any systematically missing
values. The total number of missing values was 1.8% (215/11952). Missing values included
random missing values on items scores throughout the HRES and HRIS as patients choose not to
answer a certain question (Appendix 5.3).
To examine the psychometric properties of the Humanistic Relationship Scales, a PAA
was conducted. For each scale, the PAA took place in several steps, based on the above criteria
aimed at finding the factor solution with the greatest structural simplicity. Both Pett et al. (2003)
and Norman and Streiner (2000) caution the researcher against using rigid guidelines for
determining the ultimate number of factors to be extracted. The ultimate criteria for determining
the number of factors are factor interpretability and usefulness both during the initial extraction
procedures and after the factors have been rotated to achieve more clarity.
Humanistic Relationship Importance Scale
The HRIS was analyzed by using an unrotated PAA, followed by PAA with a Varimax
rotation, then a four-factor forced solution with a Varimax rotation and finally an oblique
rotation was performed. The details of each PAA are described in detail.
HRIS-Unrotated PAA
Five factors emerged from the PAA (Table 5.5) and met the criteria for an eigenvalue of
≥ 1.00. The first factor selected had an eigenvalue of 10.06, which accounted for 41.94% of the
variance. The remaining factors accounted for 7.20 %, 5.80%, 5.14%, and 4.21% of the variance,
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respectively. The combined five factors explained 64.28% of the total variance. A scree plot
showed a first strong factor with the remaining factors contributing smaller amounts of the
variance.
Table 5.5. Unrotated PAA: Factor Extraction and Total Variance per Factor for the HRIS-24
Eigenvalues Factor Total % of Variance Cumulative %
1 10.065 41.939 41.939 2 1.728 7.201 49.140 3 1.391 5.795 54.935 4 1.232 5.135 60.070 5 1.011 4.211 64.281
After the factors were extracted, the next step was to calculate the factor loadings for
each item. These factor loadings represent the standardized regression coefficients. The
unrotated factor loading matrix is presented in Appendix 5.4. This matrix presents the correlation
between the items and the various factors. Only those factor loadings that were significant were
retained. The level of significance was calculated based on the critical value (CV) of the
correlation table at the 1% level for a sample size of 249 (Norman & Streiner, 2000). The CV of
2.576 was doubled because the standard errors of factor loadings were up to twice those of
ordinary correlations; therefore, the CV was calculated to be [5.152/√(249-2)] = 0.3278. Factor
loadings of ≥ .33 for an item are shown in grey, as these loading values indicated a close
relationship between the factor and the item.
The unrotated matrix demonstrated some basic independence between factors, yet several
characteristics of this initial factor pattern limited its utility. Based on the four criteria, the
following conclusions were drawn:
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1. The sum of the eigenvalues of the first five factors totaled 15.43 and explained 64.28% of the
total variance. Of this amount, the first factor accounted for 41.94%, a disproportionate share of
the total variance explained by the five factors. Furthermore, 23 of the 24 items presented high
loadings on the first factor. Because the variance is not evenly distributed across the factors, the
non-rotated solution is difficult to interpret.
2. Eleven items loaded strongly on two or more factors, making them factorially complex.
3. Most items in this unrotated factor matrix had factor loadings in the middle range.
4. Four of the five factors in the unrotated factor matrix had some loadings that were positive
and others that were negative.
The unrotated factor loading matrix presented five factors with most of the variance in
the first factor, factorial complexity, factor loadings in the middle range, and bipolar factors,
making this solution not easily interpretable (Pett et al., 2003). Furthermore, this factor solution
was not meaningful and did not lead to structural simplicity. Therefore, the next step in the
analysis involved rotation, a process in which the factors were repositioned in such a way as to
give them more interpretability.
HRIS-Varimax Rotation PAA
There are many ways to rotate the factors, but for the purpose of this study, that is, to
develop and test a psychometrically sound instrument, the researcher started with an orthogonal
Varimax rotation. The assumption underlying the orthogonal rotation is that the subscales that
form the factors are independent of each other (i.e., they are uncorrelated) (Pett et al., 2003). The
Varimax rotation is the most commonly used orthogonal rotation (Norman & Streiner, 2000).
The goal of a Varimax rotation is to simplify the factor solution by rotating the factors in such
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way that items load substantially only on one factor. Factors, once rotated in a Varimax rotation,
remain independent of one another.
The principal axis analysis with Varimax rotation presented very different factor loadings
then the unrotated factors (Appendix 5.5). Factor loadings of ≥ .33 for an item are indicated in
grey. To interpret this Varimax rotation, the factor loading matrix was examined for the four
conditions:
1. The first five factors explained 64.28% of the total variance. In this rotated solution, 12 of the
24 items presented high loadings on the first factor, compared to 23 items in the unrotated
solution. Yet, because half of the items still loaded on the first factor, the variance was not
equally distributed across the factors, causing this solution to be difficult to interpret.
2. Eleven items loaded strongly on two or more factors, making them factorially complex. This
complexity is similar to the unrotated solution.
3. Most factor loadings had loadings in the middle range, similar to the unrotated factor matrix.
4. All factors in the rotated factor matrix were unipolar (positive). This criterion was positive
compared to the unrotated solution, where four of the five factors were bipolar.
This Varimax rotated factor loading matrix presented five unipolar factors with 12 items
loading on the first factor. The factorial complexity and the factor loadings in the middle range
cause difficulty in interpreting the factor structure and did not lead to the expected structural
simplicity. To further simplify the interpretation of the factors, the researcher decided to use the
same rotation, but force a four-factor solution (Pett et al., 2003; Norman & Streiner, 2000).
HRIS-Varimax Rotation Four-Factor PAA
The overall goal of a PAA is to reduce the number of items to smaller subsets that
contain as much valuable information from the initial items as possible (Pett et al, 2003). The
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previous PAA solution revealed a five-factor solution. In an attempt to reduce this solution even
more, the researcher conducted a PAA with a forced four-factor solution (Streiner & Norman,
2004) (Appendix 5.6). A forced factor solution requires the PAA to associate variables by
limiting the number of factors. The four factors met the criteria for an eigenvalue of ≥ 1.00.
Factor loadings of ≥ .33 for an item are indicated in grey. To interpret this forced four-factor
solution Varimax rotation, the factor-loading matrix was examined for the four conditions:
1. The four factors explained 60.07% of the variance, less then the previous two PAAs that had
five factors each. The forced solution caused 13 of the 24 items to load on the first factor,
compared to 12 items in the five-factor solution.
2. Twelve items loaded strongly on two or more factors, making them factorially complex. This
complexity is similar to the unrotated solution (11 items) and the rotated five-factor solution (11
items).
3. Factor ladings, similar to the unrotated and rotated five-factor solution factor matrix, had
loadings in the middle range.
4. All factors in the rotated factor matrix were unipolar (positive).
This forced Varimax rotated factor loading matrix presents four unipolar factors with 13
items loading on the first factor. This uneven distribution of the variance, combined with
factorial complexity and factor loadings in the middle range are similar to the five-factor solution
and cause difficulty in interpreting the factor structure. To simplify interpretation of the factors,
the researcher decided not to pursue this solution. Furthermore, the results of this PAA
supported the decision to not conduct a confirmatory analysis with six factors. The forced four-
factor solution did not present a desirable factor structure, and therefore a forced six-factor
solution would cause even more difficulty in interpreting the factor structure.
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HRIS-Oblique Rotation PAA
Although the first Varimax PAA presented an orthogonal rotation with a somewhat
attractive solution, this rotation rests on the critical assumption that the factors are uncorrelated
with one another. However, this assumption is rarely met in health care research (Pett et al.,
2003). It is a reasonable hypothesis that factors might be correlated because this study is dealing
with conceptually different but nevertheless correlated dimensions of the construct, nurse-patient
relationships. The dimension of nurse-patient relationship, for example, might be broken down in
supporting human uniqueness and choosing. These are two constructs that, although separate, are
also correlated to some extent. Therefore, the researcher tried an oblique rotation on the data
collected. The PAA with an oblique rotation is presented in Table 5.6. Factor loadings of ≥ .33
for an item are identified.
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Table 5.6. Oblique Rotated Factor Loading Matrix for the HRIS-24
Scale item/factor 1 2 3 4 5
1. The nurses recognize the importance of your family and friends in your life. .083 .090 .217 -.038 .666
2. The nurses make an effort to ask questions to find out who you are. .201 -.174 .080 .256 .629
3. The nurses take the time to listen to your concerns. .693 -.119 .082 -.003 .2994. The nurses show concern for you as a person. .624 -.082 .192 .120 .1305. The nurses recognize your right to make choices about
your life. -.140 .151 .635 -.034 .295
6. The nurses recognize your right to make choices about your care. .311 .022 .583 -.081 .232
7. The nurses support you in your choices. .044 .121 .686 .251 -.0098. The nurses respect your choices. .176 .144 .674 .066 -.0279. You and the nurses enjoy each other's company. -.083 .087 .363 .657 .00910. You and the nurses feel close to each other. -.118 .006 -.020 .891 .11111. You have a warm and personal relationship with at
least one nurse. .208 -.107 -.005 .752 -.023
12. The nurses are there for you when you need them. .586 -.003 .237 .185 -.25413. The nurses respect your need to be alone. -.039 .078 .015 .053 .42314. The nurses know how much care you need. .636 -.052 .131 .061 .07915. The nurses can figure out what you need without you
asking them. .208 .234 -.154 .442 .143
16. The nurses let you know that they are there for you. .632 .186 .190 .065 -.20617. The nurses feel responsible for your care. .734 .108 -.071 .076 .03218. The nurses give you their full attention when they are
with you. .663 .268 -.100 -.086 .084
19. The nurses use your name when talking with you. .058 .424 -.039 .050 .40020. The nurses help your day go well. .375 .399 -.155 .259 .12721. The nurses make you feel better when they're with
you. .330 .519 -.083 .188 -.044
22. The nurses help you to have a good quality of life. -.116 .864 .132 .045 .03623. The nurses help to boost your confidence in what you
can do. .068 .866 .121 -.098 .003
24. The nurses help you to make the best of the situation you are in. .049 .729 .111 .102 .057
The factor loading matrix was examined for the four conditions of this oblique rotation:
1. The sum of the eigenvalues of the first five factors explained 15.43 (64.28%) of the total
variance. Nine of the 24 items presented high loadings on the first factor (two double loaded).
The second factor consist of six items (two double loaded), the third factor had five items (one
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double loaded). The fourth factor and fifth factor each contain four items. This variance is better
distributed across the factors then any of the previous solutions.
2. Only four items loaded strongly on two factors, indicating a reduced factorial complexity
compared to the other solutions.
3. The majority of the loadings were nearer to 1.0 or 0.0, facilitating the interpretation of the
factors.
4. All of the variables were positive or had very small negative loadings.
With the five-factor solution, there were no items that did not load ≥ .33 (CV) on any of
the factors. The variance was reasonably distributed over the different factors and the factorial
complexity was kept to a minimum. All factors were unipolar and the magnitude of the loadings
facilitated the interpretation of the factors. This solution seemed to obtain as distinct and as
maximally interpretable a solution as possible for the HRIS.
Summary of PAAs for the HRIS
Four different PAAs were conducted to identify the uniqueness between items and come
up with linear combinations of the items to define each factor. Each of the PAAs offered a
different solution (Table 5.7).
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Table 5.7. Overview of PAAs for the HRIS-24
PAA 1 PAA 2 PAA 3 PAA 4
Type of Rotation
None Orthogonal varimax
Orthogonal varimax
Oblique
Number of factors
5 5 Forced 4 5
64.28 % 64.28 % 60.07 % 64.28 % 1. Distribution of variance
2. # of items per factor*
Fact 1: 23 Fact 2: 3 Fact 3: 4 Fact 4: 3 Fact 5: 2
Fact 1: 12 Fact 2: 8 Fact 3: 6 Fact 4: 5 Fact 5: 7
Fact 1: 13 Fact 2: 8 Fact 3: 9 Fact 4: 6
Fact 1: 9 Fact 2: 6 Fact 3: 5 Fact 4: 4 Fact 5: 4
Factorial complexity
12 15 13 4
Magnitude of loadings
Middle range
Middle range
Middle range
Near 1.00 and 0.00
Polarity of factors
Bipolar Unipolar Unipolar Unipolar
* The number of items per factor includes those items that loaded on more than one factor.
The four different PAAs solutions were analyzed based on four conditions: distribution of
variance, factorial complexity, magnitude of loadings, and unipolarity of factors. A factor
solution should explain a significant share of the variance and the variance should be distributed
evenly across the different factors. PAA 1, 2, and 4 explained 64.58% of the variance and PAA 4
had a reasonable distribution of the variance across the factors. Items should not load on more
than one factor to obtain a simple factorial structure. PAA 4 had the lowest number of items with
double loading. Factor loadings should be close to 1.0 or 0.0 to facilitate interpretations. Only
PAA 4 fulfilled this requirement. Lastly, factors should be unipolar, and PAA 4 met this
criterion. It was therefore decided that the factor solution based on the oblique solution made it
possible to obtain as distinct and as maximally interpretable a solution as possible for the HRIS.
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This solution explained the highest amount of variance, had the best distribution of factors over
the five factors, factor loadings near 1.00 or 0.00, and unipolar factors.
This PAA with an oblique rotation, however, had four items that cross-loaded on two
different factors (Table 5.8).
Table 5.8. Items Cross Loading for the HRIS-24
Scale item/factor 1 2 3 4 5
9. You and the nurses enjoy each other's company. .363 .65719. The nurses use your name when talking with you. .424 .40020. The nurses help your day go well. .375 .399 21. The nurses make you feel better when they're with
you. .330 .519
Item 9 loaded on Factor 3 and Factor 4. Item 19 cross loaded on Factor 2 and Factor 5.
Item 20 cross loaded on Factors 1 and 2. Item 21 loaded on Factor 1 and Factor 2. These four
items were reviewed by an expert panel of two doctoral-prepared nurse researchers and the
candidate. Based on the criteria described above, the decision was made to allocate each item to
the factor with which it conceptually fitted best. The criteria used were the magnitude of the
factor loading, interpretability, conceptual clarity, and consistency within each factor. Item 9 was
left in Factor 4, item 19 was left in Factor 5, and items 20 and 21 were left in Factor 2.
Interpretation of the Factors
Factor 1, now comprised of seven items (3, 4, 12, 14, 16, 17, and 18), and contained a
mixture of items from three of the six original theoretical concepts. Items 3 and 4 came from the
concept supporting human uniqueness, Items 12, 14, and 16 from the concept living dialogue,
and Items 17 and 18 from the concept being present. This factor describes qualities of a
connection formed between a nurse and a patient. Connecting attributes of this quality involve
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support, understanding, availability, and responsiveness. Following careful examination of the
item grouping, Factor 1 was named relational availability.
Factor 2 contained five items. Four of the items (21, 22, 23, and 24) came from the
original concept: fostering well-being and more-being. One item (20) came from the concept
being present. All five items indicate a particular form of connecting where the dialogue between
the nurse and the patient aims at promoting the well-being and comfort of the patient. The
dialogue occurs in response to a perceived need related to the health-illness quality of the
patient′s condition and seeks to promote the well-being and comfort of the patient. Factor 2 was
named promoting quality of daily life.
Factor 3 was consistent with the attributes of the original concept of supporting choice.
All four items (5, 6, 7, and 8) describe the nurses′ awareness of the patient′s freedom to choose,
freedom to respond, and their respect of those choices. Factor 3 was labeled recognizing and
supporting choice.
Factor 4 was comprised of four items (9, 10, 11, and 15), and contained a mixture from
the original theoretical dimensions relational capacity (9, 10, and 11) and living dialogue (15).
Most of the items had an underlying attribute of personal involvement and described qualities
such as forming a special connection and a willingness to let the other know you as a person.
This factor was named forming connections.
Factor 5 consists of four items (1, 2, 13, and 19) from the original theoretical dimensions
supporting human uniqueness (1 and 2), living dialogue (13), and being present (19). Factor 5
describes the awareness of self and how one differs from others. Supportive attributes are
listening, searching for human uniqueness, and recognition of particularity. This factor was
labelled supporting human uniqueness.
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Humanistic Relationship Experience Scale
The HRES underwent an unrotated PAA and one dominant factor emerged. This central
factor met the criteria for an eigenvalue of ≥ 1.00. The factor had an eigenvalue of 16.226, which
accounted for 67.61% of the variance. A scree plot showed one dominant factor.
After the factor was extracted, the factor loadings for each item were calculated. These
factor loadings represent the standardized regression coefficients. The unrotated factor loading
matrix is presented in Table 5.9. Factor loadings varied between .512 and .886. The unrotated
matrix demonstrated one general factor.
Table 5.9. Unrotated Factor Loading Matrix for the HRES-24
Scale item/factor 1 1. This nurse recognizes the importance of your family and friends in your life. .804 2. This nurse makes an effort to ask questions to find out who you are. .767 3. This nurse takes the time to listen to your concerns. .835 4. This nurse shows concern for you as a person. .861 5. This nurse recognizes your right to make choices about your life. .833 6. This nurse recognizes your right to make choices about your care. .858 7. This nurse supports you in your choices. .813 8. This nurse respects your choices. .812 9. You and this nurse enjoy each other's company. .858 10. You and this nurse feel close to each other. .850 11. You have a warm and personal relationship with this nurse. .796 12. This nurse is there for you when you need him/her. .858 13. This nurse respects your need to be alone. .731 14. This nurse knows how much care you need. .864 15. This nurse can figure out what you need without you asking him/her. .800 16. This nurse lets you know that he/she is there for you. .882 17. This nurse feels responsible for your care. .880 18. This nurse gives you his/her full attention when he/she is with you. .512 19. This nurse uses your name when talking with you. .683 20. This nurse helps your day go well. .886 21. This nurse makes you feel better when he/she is with you. .866 22. This nurse helps you to have a good quality of life. .870 23. This nurse helps to boost your confidence in what you can do. .864 24. This nurse helps you to make the best of the situation you are in. .856
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Based on the four criteria, the following conclusions were made:
1. The eigenvalue of the first factor explained 16.226 (67.61%) of the total variance. This first
factor explains a disproportionate share of the total variance. Furthermore, all 24 items had high
loadings on the first factor.
2. There were no items that cross loaded.
3. All items in this unrotated factor matrix had moderatly high factor loadings.
4. The single factor was unipolar.
The unrotated factor loading matrix presented one general factor with a high amount of
total variance accounted for by the single-factor solution (67.61%). This result strongly
suggested that a single factor underlies the experience of a nurse-patient relationship. This factor
was labelled humanistic connection, and was comprised of 24 items. This factor describes
qualities of a nurse-patient relationship that consist of purposeful and goal-directed interactions
to promote health and well-being. Attributes of this quality are focused on the establishment of
interactions that are characterized by respect, empathy, and validation in addressing illness-
related problems.
Reliability Testing of the Factors of the Humanistic Relationship Scales
The last component of the psychometric testing of the Humanistic Relationship Scales
focused on examining the reliability of the newly emerged factors of the scales. The internal
consistency reliability is examined for both the HRIS and the HRES. The results of the reliability
testing are displayed in Table 5.10. Values indicate the Cronbach′s α reliability coefficients of
factors for the HRIS and the HRES. A Cronbach′s α for the total scale is presented in the bottom
row of the table.
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Table 5.10. Cronbach′s Alpha per Factor per Scale
Factors # of items Cronbach′s alpha HRIS
Cronbach′s alpha HRES
Relational availability 7 .88 NA Promoting quality of daily life 5 .88 NA
Recognizing and supporting choice 4 .85 NA
Forming connections 4 .80 NA Supporting human uniqueness 4 .49 NA
Humanistic connection 24 NA .98 Total 24 .92 .98
Four of the five factors of the HRIS had Cronbach′s α coefficients between .80 and .90
indicating that these factors can detect the discriminations between the items designed to assess
the construct (Burns & Grove, 2005). The fifth factor has a low Cronbach′s α coefficient (.49)
suggesting that this factor is measuring several attributes or dimensions rather than one, causing
the Cronbach’s’s α to deflate.
The overall alpha for the total HRES is .98 which is higher than the accepted 0.90 for
scales, indicating that there is a redundancy among the items within the factor measuring the
quality of the experience of a relationship between the patients and the nurses who generally care
for them. The high α could also be influenced by the high number of items, i.e., 24.
The next step of the reliability testing examined the values of the inter-item correlations
of the factors. The internal consistency reliability was determined by calculating inter-item and
item-to-total correlations for each factor of the HRIS. There was no need to repeat this procedure
for the HRES, as there was only one factor. The results of this component of the reliability
testing are displayed in Appendix 5.7 and 5.8. The inter-item correlations should be within .30
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and .70 as recommended by Kerlinger (1992), to exclude the possibility of redundancy of the
items. Ideally, none of the inter-item correlations would be higher than .70, indicating that those
items were measuring very similar aspects of a concept within the same factor.
HRIS inter-item correlations for factor 1, 3, and 4, were all within .30 and .70 indicating
that there was no redundancy of the items within the factor. Inter-item correlations for factor 2
were mostly within .30 and .70. Yet, Items 22, 23, and 24 had slightly higher inter-item
correlation, pointing to some redundancy among these three items. Inter-item correlations for
factor 5 were mostly within .30 and .70 with Item 13 presenting low inter-item correlations with
all other items in this factor, indicating that this item measures a different aspect of the concept
supporting human uniqueness.
Item Deletion Process
Based on the psychometric testing of the Humanistic Relationship Scales, findings
indicated that one item needed to be considered for elimination from the HRIS.
Item 13, "Most nurses respect your need to be alone," was deleted and new inter-item
correlations for Factor 5 were calculated (Table 5.11). All inter-item correlations were within .30
and .70 as recommended by Kerlinger (1992).
Table 5.11. Inter-Item Correlations for Factor 5 of the HRIS-23
Factor 5 Item 1 Item 2 Item 19
Item 1 1.000 .700 .692 Item 2 .700 1.000 .720 Item 19 .692 .720 1.000
Upon deletion of Item 13, it was necessary to recalculate the reliability. For the HRIS, the
Cronbach′s alpha coefficient for Factor 5 increased from .49 (including Item 13) to .67. This
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change also affected the overall alpha for the HRIS which went from .92 to .87; acceptable for a
new scale. For the HRES, the overall Cronbach′s alpha coefficient remained .98.
Findings
Descriptive results are presented for the important and experienced qualities in the nurse-
patient relationship in CC from the perspective of the patient.
Important Qualities in a Nurse-Patient Relationship
Descriptive statistics (Range, Mean, and SD) for each item of the HRIS were computed and
displayed to see the differences on an item-by-item basis (Appendix 5.9). These statistics
presented high means for each item, indicating that patients perceived all of the qualities listed as
important in the relationship with nurses in CC. Standard deviations are within acceptable
boundaries. Descriptive statistics (i.e., Mean and SD) for each factor were computed. The factors
that had the highest mean scores indicated the most important qualities in the relationship to
patients (Table 5.12). All of the SDs are within acceptable boundaries.
Table 5.12. Descriptive Statistics for Factors of the HRIS-23
Factor # of items Mean SD Relational availability 7 4.34 1.08 Recognizing and supporting choice 4 4.19 1.12 Forming connections 4 3.99 1.23 Promoting quality of daily life 5 3.97 1.19 Supporting human uniqueness 3 3.79 1.33
All of the factors had high mean scores. Relational availability has the highest mean
score (4.34), indicating that this factor is the most important in the humanistic relationship, and
supporting human uniqueness the lowest (3.79).
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Experienced Qualities in a Nurse-Patient Relationship
Descriptive statistics (Range, Mean, and SD) for each item of the HRES were computed
and displayed to see the differences on an item-by-item basis (Appendix 5.10). The data
demonstrated means in the mid-range for each item and standard deviations that were within
acceptable boundaries, except for Item 12, which had an SD of 2.31.
Next, descriptive statistics (i.e., Range, Mean, and SD) for the one factor of the HRES
were computed. The factor humanistic connection had a mean score of 2.93 (SD 1.52) out of a
possible 5, indicating that the patients experienced a moderately humanistic relationship with
nursing personnel in terms of the frequency and intensity of the qualities that compose these
relationships.
Summary
This chapter presented the dimensionality testing and results of the Humanistic
Relationship Scales. Data were collected from 249 patients. The original 24-item HRIS was
analyzed using a PAA with an oblique rotation. The five-factor solution reconfigured the original
theoretical concepts extracted from the theory of Paterson and Zderad (1976, 1988). The
reliability testing resulted in four of the five factors with Cronbach′s α coefficients between .80
and .90. The fifth factor had a low Cronbach′s α coefficient (.49). Upon deletion of Item 13, the
Cronbach′s α for the factor increased (.67) and the Cronbach′s α for the total HRIS scale was .87.
The 24-item HRES underwent an unrotated PAA. A one-factor solution was established,
explaining 67.61% of the total variance. The HRES presented a high Cronbach′s α for its factor
(.98), indicating some redundancy among the items.
The last part of this chapter focused on examining the data collected with the Humanistic
Relationship Scales. The HRIS results presented high mean scores for all its factors, indicating
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that they were all important to patients. The factor relational availability was rated as most
important in a nurse-patient relationship in CC. The HRES focused on the experience of these
humanistic relationship qualities. The one factor had a mean score in the mid-range, indicating
that these relationships with nursing personnel were moderately humanistic.
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Chapter Six: Discussion
This chapter is divided into four major sections. The first section describes the
psychometric strengths of the Humanistic Relationship Scales. Second, contributions to our
understanding of the nurse-patient relationship in CC settings are highlighted followed by a
discussion on the refinement of the Humanistic Nursing Theory (Paterson & Zderad, 1976, 1988)
based on these findings. The final section describes the limitations of the study.
Psychometric Strengths of the Humanistic Relationship Scales
Two Humanistic Relationship Scales were developed to elicit the patients’ preferences
(HRIS) and their experience (HRES) of a humanistic relationship with nurses in a CC setting.
Two separate scales were deemed necessary because research in this field (Baltes, 1996;
McGilton & Boscart, 2007) revealed a discrepancy between descriptions on how the nurse-
patient relationship ought to be and how the nurse-patient relationship was actually experienced
in the clinical setting by the patients. Additionally, the literature review (Henderson, et al. 2007)
supported the decision to develop these Humanistic Relationship Scales from a patient
perspective rather than from that of nurses. Existing qualitative research is based mainly on
nurses' perspective of what mattered to patients, and although this approach produced interesting
findings about the relationships, it is important to acknowledge the bias inherent in having nurses
describe the perceived importance or experience of a phenomenon from the perspective of the
patient. To have a better understanding of relationships from the patient's perspective, it was
deemed important to look at both facets of the relationships, the preferred and the experienced
humanistic qualities of the nurse-patient relationship, hence the decision to develop two
Humanistic Relationship Scales.
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A well established process (Streiner & Norman, 2004) was followed to develop and
psychometrically test the two new scales. As part of this process, Lynn’s (1986) approach for
content validation of the scales was used with one modification. The change was related to the
the decision to recruit five patients in addition to scholarly experts to serve as experts in the
content validity process. Although some researchers have involved patient experts in the
validation of a new measure (Wei et al., 2000), there are no guidelines available as to how to do
this including in what order to involve the different sets of experts and how to handle different
ratings of patients and scholarly experts should they emerge. In this study, the patients' revisions
were at times different then the scholarly expert's recommendations. Because the goal of this
study was to develop a measure from the patients' perspective, the patients' expertise was
perceived as highly important for the validity of the scales. Therefore, all the patients'
suggestions were taken into account to adjust or delete items even if they were at odds with the
scholarly experts. The final scale(s) resulted in well established content validity indexes from
both groups of experts.
The psychometric testing suggests that the Humanistic Relationship Scales are valid and
reliable, that is, they measure the nurse-patient relationship from the patient's perspective with a
good degree of accuracy. The scales demonstrated a high level of internal consistency and
stability, and the construct validity was supported through factor identification (Streiner &
Normal, 2004). The five factors were named (1) relational availability, (2) promoting quality of
daily life, (3) recognizing and supporting choice, (4) forming connections, and (5) supporting
human uniqueness. Four of the five factors were named differently than the original six
theoretical dimensions because of the mixture of items in the factor analysis which were different
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than the original theoretical dimensions and led to a revised conceptualization for the Humanistic
Relationship Scales.
The largest factor, relational availability, describes qualities of the nurse-patient
relationship where both the nurse and the patient are involved as individuals. The clinical
significance of this factor is supported by the frequent indications in the literature that nurses
must relate well to the patient and according to their preferences in order to provide tailored care
(Bowers et al., 2001; McGilton et al., 2003). This idea is further embraced by Liaschenko (1998)
who states that the focus on the person involves recognition that patients are more than their
disease or illness, and as such involved the nurse's commitment to form a connection with the
patient as a unique person.
Factor 2, named promoting quality of daily life, describes the dialogue between the nurse
and the patient aimed at promoting the well-being, comfort, and quality of life of the patient. The
nurse nurtures the patient's potential and helps him/her to make the most of his/her capabilities
regardless of how compromised he/she might be. This role of the nurse in encouraging well-
being and enhancing the patient's quality of life is a recurrent theme in literature focused on
caring for chronically ill patients (Schulz, Hebert, Dew, et al., 2007) and is especially central in
CC settings (Kane, 2001).
Factor 3, recognizing and supporting choice, emphasizes the patient’s freedom to make
decisions. Providing choices is essential to patients in chronic care environments and an
important quality of a nurse-patient relationship, as recognized by Forchuk and Reynolds (2001)
and Duncan-Myers and Huebner (2000). The latter investigators found a significant positive
correlation (r = .54; p = .01) between the amount of choice residents perceive they have and their
quality of life. An older, yet very relevant study by Kane, Caplan, Urv-Wong, et al. (1997)
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demonstrates that both nursing home residents and nursing assistants attach importance to choice
and control over daily matters such as bedtime, rising time, or food. However, residents were not
very satisfied with their control and choice, and nursing assistants recognized that residents were
unlikely to experience control and choice.
The fourth factor, forming connections, describes the humanistic relating process between
a nurse and a patient. Berg et al. (2007) refer to caring connections as an encounter that goes
beyond the individual nurse and patient and includes a reaching out, an engagement, and
showing respect for each other. Kane (2001) argues for 'natural' relationships between residents
and staff to promote quality-of-life domains such as comfort, enjoyment, and well-being.
The last factor, supporting human uniqueness, describes the process of the nurse's search
for the patient's uniqueness and the awareness of the patient's perspective. The particular view of
the patient of his/her experiences, life history, and context leads to a singular viewpoint of seeing
the world. This uniqueness will lead the patient to see, hear, feel, taste and experience the world
in a particular way. Nurses are to recognize this particularity, and through listening and
attentiveness to the patient’s individual uniqueness, will come to a nurse-patient relationship
(Henderson et al., 2007). Through the shared willingness of nurse and patient to search for one’s
uniqueness and becoming aware of one’s view of the world, relatedness is created.
An interesting observation of the conceptualization of the humanistic nurse-patient
relationship is that the dimension of presence is woven throughout most of the other dimensions,
indicating that presence is an essential aspect of every humanistic quality of the nurse-patient
relationship. Paterson and Zderad (1988) portray the moments when nurses are present as a
being-there-for and a being-there-with. To "be with" in its fuller sense requires turning one's
attention toward the patient, being aware of, and open to the here-and-now shared experience.
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This finding has theoretical implications for the refinement of theories or tool development in
order to explore the concept of presence.
Based on the results of the factor analysis, a meaningful operational definition of the
humanistic nurse-patient relationship in CC was developed: The nurse-patient relationship is an
interactive and humanistic process between a unique nurse and patient. This relationship is
ongoing and is distinguished by a reciprocal connection in which the nurse demonstrates
relational availability and recognition of the patient’s choices in order to provide care to
promote the patient’s quality of daily life within a chronic care environment. This operational
definition is a valid description of the nurse-patient relationship and describes concrete concepts
that can be measured; a necessary step in advancing the body of knowledge related to nurse-
patient relationships (Hardy, 1974).
In contrast to the HRIS, the PAA of the HRES resulted in a one-factor solution labeled
humanistic connection. This factor describes purposeful and goal-directed qualities of a nurse-
patient relationship to promote health and well-being. Attributes of this quality are focused on
the establishment of a relationship that involves mutual interactions characterized by respect,
empathy, and validation which are supported in the literature (Coyle, 1999; Lumby & England,
2000) and in all regulatory standards of practice and guidelines for the nursing profession in
Canada.
The five dimensions of the HRIS indicate that patients are able to support these five
distinct factors in reflecting on the importance of humanistic qualities in the nurse-patient
relationship. While patients were able to respond to what dimension was of most importance to
them, they did experience relationships as a whole as reflected in the one factor solution in the
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HRES. The experience of the nurse-patient relationship was not broken down, but experienced as
a combination of parts or factors, resulting in one essential dimension.
Contributions to the Understanding of the Nurse-Patient Relationship in CC
This study aimed at developing scales to identify and assess the qualities of the
humanistic relationships between cognitively competent patients and nursing personnel in CC
settings that were most important to them and were experienced by them. The data collected with
the HRIS indicated that patients perceived all five dimensions (i.e., relational availability,
promoting quality of daily life, recognizing and supporting choice, forming connections, and
supporting human uniqueness) as very important in the relationship with nurses in CC. The
concept relational availability was rated as the most important quality in the nurse-patient
relationships from the patient's perspective.
This perceived importance from a patient’s perspective is consistent with the current
literature on the nurse-patient relationships in CC environments (Liaschenko, 1998; Tuckett,
2005; Jonas-Simpson et al., 2006). Patients strongly value relationships where the nurse is
available and aware of the particularity of the patient. Wadenstein and Carlsson (2003) explore
nursing staff’s descriptions of good encounters with patients and found that staff described their
connection as caring relationships with an emphasis on the uniqueness of each patient. Morse
(1992) and McGilton and Boscart (2007) have documented nurse-patient relationships where
both the nurse and patient relate to each other as persons and experience reciprocity and a caring
and genuine dialogue during their daily encounters. These relationship could be regarded as I-
Thou relationships (Buber, 1958), where nurses place themselves completely in the relationship
and choose to communicate in truly human ways.
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Porr (2009) labels the construct of relational availability as "relational engagement", and
states that this quality is about mindful attentiveness toward another. In being mindful, nurses
ensure that they establish authentic relationships. Turkel and Ray (2000) suggest that nursing is a
practice discipline and as such, nursing is the practice of relatedness. Yet, despite the importance
of relational availability, it is often lacking in the nurse-patient relationship (Bergland &
Kirkevold, 2006). This partial absence could have a detrimental effect on patients' care and
quality of life, as supported by Grau, Chandler, and Saunders (1995) and Mattiasson and
Andersson (1997) who both found that a lack of supportive relationships with caregivers
contributes to residents' non-thriving in nursing homes.
This study also highlighted the patients’ perceived importance of nurses’ recognizing and
supporting choice within the nurse-patient relationship in CC. Although choice is widely
regarded as an essential component of quality of life (Stancliffe & Parmenter, 1999), CC
facilities have made few attempts to evaluate or improve the availability of choice to their
patients. Despite the fact that for most patients, the CC facility is considered to be a home,
research has shown that patients have little say about their daily choices of what to eat, when to
get up in the morning, or with whom to spend their time (Kane et al. 1997, Kane, 2001).
Furthermore, the care delivered in CC facilities is governed by restrictive routines and
regulations that promote institutional efficiency and patient dependency as opposed to patient’s
choice (Kane, 2001). This study indicates that patients strongly value nurses’ awareness of and
respect for their freedom to make choices about their care and their life. Furthermore, several
authors have established the effect of having a choice on patients’ quality of life (Forchuk &
Reynolds, 2001; Kane, 2003; White, Newton-Curtis, & Lyons, 2008). Therefore, nurse-patient
relationships must include the opportunity for and respect of patients’ choices of their care.
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Data collected with the HRES revealed that patients experienced humanistic qualities in
their relationships with nurses occasionally. While these findings do not convey that close,
emotionally involved relationships predominate, they are somewhat more positive than results of
studies undertaken by other researchers. For example, Bowers et al. (2001) found that patients'
perceptions of relational care were negative while Iwasiw, Goldenberg, Bol, et al. (2003)
described the lack of involvement of nurses with their patients. Pietrukowicz & Johnson (1991)
and Robbins, Lloyd, Carpenter, et al. (1992) noted that often the care provider-resident
relationship lacked close emotional bonds.
In environments such as CC, where nurses and patients often spend years in the same
environment, a lack of these relational qualities is problematic. Several qualitative researchers
have reported on patients’ and families’ experiences with nurses. Two ethnographic researchers,
who have conducted a number of studies in nursing home settings, describe nursing personnel
who do not talk to, listen to, or display any caring behaviour towards patients while providing
their daily care (Foner, 1994, 1995; Diamond, 1984, 1986). Rather than truly making themselves
available, these individuals kept patients at a distance and related to the patients as if they were
objects and the tasks they are to complete as functions. These encounters demonstrate the pattern
of an I-It relationship and evidently this paradigm negatively influences the nurse-patient
encounter (Buber, 1958).
If nurses claim to be in a profession in which the fundamental nature is to care and
nurture, then this profession must live up to its expectations and focus on promoting quality of
daily life and supporting the patient's uniqueness. Patients in CC settings desperately need
humanistic and individualized relationships with the nurses in which nurses' interactions are not
only purposeful and goal directed, but encompass acts of nursing to make moments matter.
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Current nursing standards and regulations do not address these types of nurse-patient
relationships and neglect the unique context of chronic care. Findings of this study portray
relationships in a different light then the current standards, one where nurses are not goal focused
or aiming for therapeutic relationships, but instead focused on relational availability.
The power of the Humanistic Relationship Scales resides not only in their statistical
ability to quantify complex facets of humanistic relationships and experiences, but also in their
utility in fostering meaningful, caring relationships in the clinical setting. A potential outcome of
this research is the useful contributions the Humanistic Relationship Scales can offer to nursing
practice. Encouraging staff to use the scales can lead to better practice. Listening to the answers
to these questions with openness and engagement opens a world of opportunity for relationship
building in a caring context and may, in itself foster humanistic relationships. The addition of
one or two open ended questions such as ‘What can a nurse do for you to’ may be useful
adjuncts to the quantitative Humanistic Relationship Scales. These scales are clinically useful
tools to learn ‘what matters’ to patients in a variety of settings. Seeking this information and
integrating it into a patient centered care approach can develop and sustain close nurse-patient
connections to provide nursing care.
Paterson and Zderad’s Humanistic Nursing Theory Revisited
The Humanistic Nursing Theory by Paterson and Zderad (1976, 1988) formed the
foundation for the development of the Humanistic Relationship Scales. This theory is based on
the idea that nursing is an intersubjective transactional relationship between a nurse and a patient
who are human beings existing in the world. The theory is based on existentialism and serves as
a vehicle to describe the real meaning of everyday experiences. Although the Humanistic
Nursing Theory is developed for nurses to reflect on their nursing practice, the underlying
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concepts form an ideal framework to examine and explain particular phenomenon that occur in
nursing, such as the nurse-patient relationship from the patient’s perspective. The literature
review conducted in this study provided support for the stance that the Humanistic Nursing
Theory is highly relevant for the nursing care delivered in CC settings.
The PAA redefined the six original concepts selected from the theory. The simpler HRIS
structure involved five factors: (1) relational availability, (2) promoting quality of daily life, (3)
recognizing and supporting choice, (4) forming connections, and (5) supporting human
uniqueness. Elements of the original six concepts can be found in all five but these final
dimensions are conceptually clearer and permit the humanistic nurse-patient relationship in CC
to be understood from the patient’s perspective. An overview of the distribution of the original
six concepts across the five new five concepts is presented in table 6.1.
Table 6.1. Summary of Concept Clarification and Theory Refinement
Original concepts by Paterson and Zderad (1976, 1988)
Refined concepts
Concepts Domains
Domains Concepts
Awareness of uniqueness and view of the world
Supporting human uniqueness
Recognition of particularity
Being present
Supporting human
uniqueness
Awareness of view of the world and response to it
Supporting
human uniqueness
Freedom to choose to respond
Freedom to choose how to respond
Sustaining choice
Respecting choices
Supporting choice
Recognizing and
supporting choice
Connecting Relational capacity Being available Relational
capacity Nurturing
Living dialogue
Forming connections
Responding Living dialogue
Calling
Supporting human uniqueness
Living
dialogue
Being present
Relational availability
Professional accountability
Availability Reciprocity
Being present
Mutuality
Nurturing well-being and comfort
Fostering well-being and more-being
Accepting Searching
Fostering
well-being and more-being
Helping to recognize
Being present
Promoting quality of daily life
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Even though the fundamentals of the initial theoretical concepts remained present in the
PAA dimensions, the instrument underwent amplification in the process of psychometric testing
(Streiner & Norman, 2004). In this study, each step in the theoretical progression of the
Humanistic Relationship Scales development brought the conceptual dimensions into greater
focus. For example, the dimension of being present is subsumed under three domains (supporting
human uniqueness, relational availability, and promoting quality of daily life), which speaks to
its importance in the humanistic nurse-patient relationship in CC. This reconceptualization of the
nurse-patient relationship results in concrete concepts that can be measured, assessed and
evaluated in order to better understanding the nurse-patient relationship, and support the care,
research, and application of the theoretical knowledge of this relationships in CC.
Limitations of the Study
This study was not without limitations and these have to be taken into account before
drawing final conclusions from the study. A first limitation is related to the study validity. A
second limitation is associated with the context when administering the HRES in the different
phases in the study.
Two aspects of study validity bias are worth discussing in the context of this study:
systematic bias and social desirability bias. Despite attempts to reduce these threats (see Chapter
2), systematic variation or bias could be introduced to the study by sampling participants with
fundamental different demographics or unique characteristics (Burns & Grove, 2005). The data
for this study were collected from a convenience selection of five large CC facilities in the
Greater Toronto Area in Ontario, Canada. The participants of these five CC facilities could have
varied in some specific way, such as their age or values or some other aspect, which makes them
different from the population of CC patients as a whole. For example, the participants in this
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study might have overvalued the importance of nurses supporting their uniqueness compared to
patients residing in smaller CC facilities. However, no differences between patients perception of
humanistic relationships were found between the five facilities, so this threat might be minimal.
Social desirability bias, that is, the tendency of respondents to reply in a manner that will
be viewed favorably by others, could have been induced by the presence of the researcher when
participants completed the Humanistic Relationship Scales (King & Bruner, 2000). Although a
strict data collection procedure was followed to assure that questions were posed in an objective
way (Streiner & Norman, 2004) and the measure was developed to reduce this possibility,
participants might have been influenced by the attendance of the researcher to respond in a more
positive way, that is, to provide higher scores on the HRES then actually experienced. Yet, the
scores on the HRES were quite modest, thereby diminishing the possibility that participants
overrated their experiences of humanistic qualities in the nurse-patient relationship. Future
studies could limit this threat by using data collectors blinded to the purpose of the instrument
and study.
A second limitation is related to the HRES. Patients in phases two (establishing initial
reliability and validity) and three (construct validation through factor analysis) referred to
different contexts in answering the HRES. In phase two, patients were asked to reflect on a close
relationship with a nurse when rating their experience of humanistic qualities in the nurse-patient
relationship. These data revealed a positive skew, indicating that patients experienced all close
relationships as very humanistic, yet limiting the interpretability of the HRES results and raising
the issue of the scale sensitivity (Lewis-Beck, Bryman, & Liao, 2004). Because the HRES was
originally designed to distinguish a range of humanistic qualities in nurse-patient relationship, it
was decided to ask the patients to refer to a different context in answering the HRES in phase
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three of the study. Patients were asked to reflect on the humanistic qualities of the nurses who
generally provided care to them when rating their relationships. In hindsight, it would have been
better to use the context of nurses who generally provided care as the reference group for the
HRES in both phases as this would of allowed for initial psychometric testing of the HRES, and
would have alleviated the need for an additional feasibility test between the two phases.
Furthermore, information about the stability of the HRES rating general nurses would likely be
available, which is now missing.
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Chapter Seven: Summary, Conclusions and Implications
This chapter presents the summary, the conclusions of this study and the implications for
further theory development and research, including recommendations for future refinement of
the Humanistic Relationship Scales.
Summary
The purpose of this instrument development study was to conceptualize and create
reliable and valid tools to examine the nurse-patient relationship from the perspective of patients
who reside in chronic care settings. There was a desire to be able to assess what mattered to
patients about these relationships and separately to measure what their experience was in relating
to nurses. The Humanistic Nursing Theory by Paterson and Zderad (1976) served as a foundation
to develop two Humanistic Relationship Scales, the Humanistic Relationship Importance Scale
(HRIS) to measure importance of a range of elements of a humanistic relationship and the other,
the Humanistic Relationship Experience Scale (HRES), to measure patients’ experiences in
relationships with nurses. The process of scale development and psychometric testing proposed
by Streiner and Norman (2004) was followed in constructing the scales. The initial phase
involved developing 69 items based on six concepts derived from the Humanistic Nursing
Theory. Lynn’s (1986) process for content validation was followed with nurse experts and
patients resulting in a deletion of 20 items. Phase two involved the recruitment of 40 patients in
one CC facility to establish preliminary internal reliability, test-retest stability and construct
validity by comparing the results of the HRES with three other scales that assessed similar
constructs. A further 25 items were deleted following these assessments, resulting in a 24-item
scale. In phase three of the process, 249 patients were recruited from five CC hospitals to
complete the scales. Through the process of principal axis analysis and item reduction
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procedures, a final 23-item HRIS was constituted by five dimensions: (1) relational availability,
(2) promoting quality of daily life, (3) recognizing and supporting choice, (4) forming
connections, and (5) supporting human uniqueness. These five factors were named differently
than the original six theoretical dimensions because of the mixture of items of the original
theoretical dimensions in each of the five factors. Only one factor defined the 23-item HRES
which was labeled humanistic connection, indicating that while the patients could identify what
components of a relationship with nurses mattered to them, they experienced the relationship as a
singular entity rather than as a series of components. The HRIS had a Cronbach′s α of .87, with
subscales ranging from .67 to .90 while the Cronbach’s α for the total HRES was .98 indicating
some redundancy of items.
The analysis of patients’ scores of the HRIS indicated that patients valued all five factors
of a humanistic relationship with relational availability scoring highest followed by recognition
and supporting choice, forming connections, promoting quality of life and supporting human
uniqueness. The analysis of patients’ scores of the HRIS indicated that patients experienced
moderate humanistic qualities in their relationships with nurses.
The HRIS demonstrates properties of a psychometrically sound measure of what matters
to patients in CC and although the HRES demonstrates some redundancy of items, it too
demonstrates good construct validity. Prior to this study, no instruments were available to
measure the nurse-patient relationship from the perspective of the patient in CC settings and the
concept of nurse-patient relationships was poorly understood. This study provides a foundation
for future research in this area by establishing the baseline validity and reliability of the
Humanistic Relationship Scales. The conceptualization of the humanistic nurse-patient
relationship and the Humanistic Relationship Scales are promising new tools to lead to a better
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understanding of the nurse-patient relationship, and will support the care, research, and
theoretical knowledge of nurses and patients in these environments.
Conclusions
On the basis of this study, it can be concluded that:
1. The HRIS is a valid and reliable tool to measure the importance of the humanistic
qualities in a nurse-patient relationship from the perspective of the patient in CC.
2. The HRES is a valid and reliable tool to measure the experience of the humanistic
qualities in these nurse-patient relationships, yet requires further testing to remove
redundancy among its items and to establish its test-retest reliability.
3. Five dimensions, all deemed important by patients, were found within the construct of
the nurse-patient relationship. The order of importance of these dimensions from
highest to lowest was relational availability, recognizing and supporting choice,
forming connections, promoting quality of daily life, and supporting human
uniqueness.
4. This analysis contributed to the understanding of Paterson’s and Zderad’s Humanistic
Nursing Theory by clarifying and simplifying its dimensions.
5. The patients’ scores on the HRES fell into the mid-range indicating that patients
experience a level of humanistic relationships with nursing personnel that could be
considered of medium quality.
6. It is possible to clearly define a humanistic nurse-patient relationship relevant to
chronic care settings that provides direction for education, standard setting and
assessment.
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Implications
Findings of this study have implications for regulatory nursing guidelines and standards,
theory development, nursing practice and education, and future research.
Implications for Nursing Regulations and Standards
From a regulatory perspective, the construct of the nurse-patient relationship is perceived
as purposeful and goal-directed between nurses and clients, and is established and maintained by
the nurse (RNAO, 2006; CNO, 2006). The relationship is described as based on trust, respect,
power and professional intimacy with the client (CNO, 2006); yet concepts such as ‘choice’,
‘uniqueness’, or ‘quality of daily life’ are barely mentioned and the unique dimensions of an
extended relationship is neglected.
Today health care administrators are confronted with a worrisome shortage of nursing
staff, an increased consumerism from the patient’s perspective, and a changing economic
landscape. This climate necessitates a re-evaluation of the existing unilateral nurse-patient
relationship described in the regulatory and professional standards and guidelines. A first
important observation is related to the impact of the current economic restrictions. These
restrictions have resulted in decreased lengths of stay for the patients, implementation of higher
nurse-patient ratios, and a gradual delegation of non-nursing tasks to other health care personnel,
all leading to reductions in the tangible time nurses can spend with patients. Despite these
restrictions, it remains important that nurses acknowledge and value the essential time necessary
to develop a nurse-patient relationship.
The current perspective that a nurse-patient relationship is a goal-directed and purposeful
connection established to address illness-related problems fails to acknowledge that this
relationship extends beyond the illness experience. Patients with extended stays undergo many
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losses, are frequently isolated and lonely, and are well aware of the permanence of their
experiences (Heliker, 2007). Therefore, CC patients seek relationships with nurses that address
their needs beyond their illness-related needs. These patients are looking for a person-to-person
reciprocal connection to help them communicate and negotiate their care, establish a quality of
daily living, and promote everyday well-being. Regulatory and professional standards and
guidelines are to direct and allow nurses to develop these types of relationships in order for them
to professionally enhance the patient’s quality of daily life in CC settings.
A last recommendation for the current standards and guidelines is directed toward the
expansion of the one-sided perspective of the nurse-patient relationship. A relationship is a
mutual and reciprocal process and the patient’s point of view about the value and qualities of
these relationships should not be excluded. Given that this relationship is mutual (CNO, 2006;
RNAO, 2006) patients need to be considered as equal partners and their perspective need to be
reflected in the standards and guidelines.
The Humanistic Nurse-Patient Relationship Scales developed in this study could be of
great interest in reconsidering the regulatory and professional nursing standards and guidelines.
One of the most valuable constituents of these scales is their appropriateness for the CC setting,
which is currently neglected in the standards and guidelines. A growing number of patients
reside in CC or LTC and these patients require opportunities to engage in telling stories, life
experiences, and personal narratives with the nurse. The knowledge acquired during the time
spent together results in a unique knowledge of the patient, necessary to provide patient-centred
care (Kelley, Specht, & Maas, 2000; Williams & Kristjanson, 2009). This uniqueness and
individuality is one of the core concepts of the Humanistic Nurse-Patient Relationship Scales and
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was highly valued by the patients in this study. This important aspect of the nurse-patient
relationship calls for an integration into the nursing standards and guidelines.
Implications for Theory Development
Even though this study is focused on scale development, important implications for
theory can be discussed. This study provides a first step in providing researchers with a clear
conceptual definition to examine humanistic nurse-patient relationships in CC from a patient’s
perspective. This revised conceptualization of the nurse-patient relationship has the potential to
change the understanding of the nurse-patient relationship and to open a new area of
interventions that offer potential for improving the daily life of CC patients by promoting the
nurse-patient relationship.
Theoretical implications of this nurse-patient relationship conceptualization are
numerous. The content of items identified by the factor analysis is of considerable theoretical
interest in the understanding of the nurse-patient relationship. As table 6.1 reveals, almost all
dimensions of the factor analysis are capturing more than one theoretical construct from the
Humanistic Nursing Theory. For example, the dimension of supporting human uniqueness
consists of aspects of awareness and recognition of human uniqueness, but also captures
mutuality from the concept of presence. This conceptualization informs the Humanistic Nursing
Theory and other theories about the complex network of theoretical dimensions underlying the
nurse-patient relationship and could be further explored in future research or theory testing.
A second theoretical implication of this study is directly related to Paterson’s and
Zderad’s theory (1976, 1988). Although Paterson and Zderad do not directly address nursing
care in a chronic care setting in their theoretical descriptions, the strong existential roots of this
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theory and the focus on the human experience and being creates the potential to further inform
this type of nursing. Because the Humanistic Nursing Theory is based on the idea that nursing is
a transactional relationship between a nurse and a patient, the theory is an ideal vehicle to
describe the everyday experiences between nurses and patients and could be suitable for
exploring several other aspects of nursing care delivered in CC settings.
Lastly, the findings of this study challenge the assumption made by Paterson and Zderad
that social, family and friendly relationships differ from nurse-patient relationships. Paterson and
Zderad state that, "I realize that my openness is an openness to a ‘person-with-needs’ and my
availability an ‘availability-in-a-helping-way’. By comparison, my experiences of openness and
availability in social, family, or friend relationships and in nurse-patient relationships differ. In
the latter, I find myself responding with some kind of ‘professional reserve’" (1976, p. 31).
Patients in this study embraced a nurse-patient relationship with the understanding that this is a
long-term commitment that is ongoing and distinguished by a reciprocal connection. This
commitment promotes the patient’s perceived quality of care and quality of well-being and
allows for the nurse to demonstrate relational availability. This availability entails qualities such
as responsiveness, presence, and openness to the other as a person, all of them based on
humanistic person-to-person relating and not necessarily responding to a professional reserve.
Paterson and Zderad’s (1976) distinction between the nurse’s openness and availability in
a nurse-patient relationship and a social relationship was not recognized in the findings of this
study. The dimensionality testing of the nurse-patient relationships in CC did not elucidate
unique concepts of professional reserve and availability-in-a-helping-way. A possible
explanation for this is that the patients were not asked explicitly and therefore, did not consider
the differences between these two kinds of openness in their responses. Alternatively, it could be
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that patients in CC perceive that relational availability not only includes an openness and
availability to a person-with-needs, but also encompasses aspects of an openness and availability
of a social relationship. If the latter, these findings could imply that the reconceptualization of a
nurse-patient relationship in this study assumes that openness and availability are part of acting
in a professional manner as nursing is founded on caring for and relating to individuals in need.
While leaving this particular issue unresolved, this study adds to the understanding of the
CC nurse-patient relationship. Since relationships in these settings are formed between patients
and nurses, the patients perceived the nurses as relational available. It would be especially
interesting to further explore this concept of relational availability and potential limitations of
this type of availability in a nurse-patient relationship from a nursing and patient perspective.
This inquiry would undoubtedly reveal unique aspects of nurses’ views of their responsibility
and restrictions of openness and availability within the setting of CC. Furthermore, this
exploration could provide further material to open up a discussion in relation to Paterson’s and
Zderad’s position on the role of professional reserve within nursing and the tone of the lived
dialogue.
Implications for Nursing Practice and Education
Since the conceptualization of the nurse-patient relationship is a revision of an existing
theoretical framework, discussion related to practice is premature. Nevertheless, the theory
development, the concepts identified as relevant to the nurse-patient relationship and the
Humanistic Relationship Scales can be vigilantly employed to ensure patients achieve the highest
degree of humanistic nurse-patient relationship. The conceptualization of the humanistic nurse-
patient relationship could play a vital role in assisting nurses to design actionable and viable
strategies to address patient’s needs in a more meaningful way and ensure that those qualities
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that matter to the patients are attended to. Furthermore, researchers and advanced practice
specialists could use the conceptualization of the humanistic nurse-patient relationship to design
theory based interventions to enhance the humanistic relationship across the several dimensions.
The study findings also have some potential implications for nursing education. Nurses
pride themselves on being a caring profession and nursing education consistently emphasizes
these skills throughout a variety of educational programs. The findings of this study can add to
the current content of communication and relationship training and emphasize the different
components of the nurse-patient relationship.
Implications for Future Research
This study fulfilled its purpose of developing and testing valid and reliable instruments to
determine what qualities of the humanistic relationships between cognitively competent patients
and nursing personnel in CC settings were most important to patients and what they experience
most frequently. The Humanistic Relationship Scales can now be used as psychometrically
sound instruments to accurately measure these relationships. The Humanistic Relationship Scales
can be used to devise and evaluate effective interventions to enhance the nurse-patient
relationships and nursing care at different levels (e.g., acute, sub-acute, chronic) and in different
settings.
Research using the Humanistic Relationship Scales is recommended to explore how the
construct of humanistic relationships relates to intrapersonal variables such as quality of life and
living, physical health, functional ability, locus of control, well-being and level of comfort, and
satisfaction with nursing care. This study did not explore the relationship between levels of
humanistic relationships and other patient variables while in the CC setting and this would be a
fruitful area for future research.
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Furthermore, the complex interaction between extrapersonal variables, intrapersonal
variables, and person-environment transactions may be better understood using the Humanistic
Relationship Scales. The Humanistic Relationship Scales are measures to assess not only
preferred and experienced qualities in nurse-patient relationships, but also differences across
environmental settings, or differences in humanistic relationships over time within one setting.
Use of the Humanistic Relationship Scales to assess humanistic relationships in a different
setting would provide additional validity testing and their applicability and may inform the
literature on these relationships in different health care settings. This research could also indicate
if patients have different preferences in regards to qualities of the nurse-patient relationship
depending on the care environment or other variables, such as the nurse-patient ratio.
The Humanistic Relationship Scales have not been tested on older adults with significant
cognitive impairment, or patients who are unable to verbally communicate, yet, these
populations represent a large group of patients in CC. A modification of the Humanistic
Relationship Scales to include yes or no response choices or a visual analogue scale, and further
testing in persons with mild to moderate cognitive impairment would add to the growing body of
knowledge related to nurse-patient relationships in chronic care.
Important dimensions of the scale (e.g., promoting quality of daily life, forming
connections) should be examined for their relationship to measures of individual variation. For
example, do CC patients who receive care within a primary care model demonstrate higher
scores on the HRES then patients who receive care in a more task-focused manner? Do patients
score higher on the HRES after being given the opportunity to discuss their care plan and
preferences for treatment and care? Do patients with an extensive support network or regular
visitors differ in terms of importance rating? What is the congruence or divergence between
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experienced and preferred relationships? These are just some of the questions that could be
further explored with the Humanistic Relationship Scales.
The conceptual framework developed for this study acknowledges the patient as an
individual and emphasizes the specific CC circumstances and limitations of relating imposed by
the situation, location, time and complexity of care. A better understanding of these relationships
from a patient's point of view is critical at this point in time. It would be enlightening to have the
nurse-patient dyads complete these scales to capture both the nurses’ and the patients’
perspectives and allow an analysis of similarities and differences between these two
perspectives.
Lastly, further refinement and testing of the Humanistic Relationship Scales is
recommended. The next step in this research is to conduct additional confirmatory factor analysis
of the Humanistic Relationship Scales using a structural equation-modeling method, necessary to
test the current factor structure. This confirmatory analysis should be based on the conceptual
framework developed for this study to confirm or adapt the framework, and to establish the
construct validity of the scales (Streiner & Norman, 2004).
Final Statement
A growing population of patients requires the complex care that is delivered in chronic
hospitals. These patients not only need skillful nursing care to meet their physical needs, they
need a strong nurse–patient relationship through which to communicate and to negotiate their
daily care needs and their quality of life and well-being; sometimes they just need social
interaction. Nurses’ humanistic relationship skills and behaviours are essential in fostering close,
affectionate, family-like, and warm relationships with patients who spend an extended time in
the clinical setting. Despite the importance of these relationships, there is a dearth of
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measurement tools to assess this relationship from a patient’s perspective. The development of
these scales has helped to fill this gap.
As Buber writes:
When I confront a human being as my You and speak the basic word
I-You to him, then he is no thing among things nor does he consist of things.
He is no longer He or She, limited by other He's and She's,
a dot in the world grid of space and time,
nor a condition that can be experienced and described, a loose bundle of named qualities.
Neighborless and seamless, he is You and fills the firmament.
Not as if there were nothing but he;
but everything else lives in his light.
Even as a melody is not composed
of tones, nor a verse of words, nor a statue of lines
—one must pull and tear to turn a unity into a multiplicity—
so it is with the human being to whom I say You.
Excerpted from Kaufmann's translation of I and Thou (Buber, 1970, p. 59).
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Appendix 2.1. Qualitative Empirical Research on Nurse-Patient Relationships
Source & Design Setting & Sample Focus of the study Findings
Bowers, Fibich, & Jacobson, 2001
Grounded Theory design
3 LTC facilities n = 27 residents
To explore how residents define quality of care.
3 categories of descriptions, related to patient’s level of dependency and reputation among nurses: - Care-as-service: focus on instrumental aspects of care (efficiency, competence, value). Independent status/complainer. - Care-as-relating: focus on affective aspects of care (friendship, reciprocity, degree of closeness). Dependent status/’sweeties’. - Care-as-comfort; focus on quality of care (maintain physical comfort). Very dependent status/ complainers.
Caron (2003) Qualitative design for video based research
1 home healthcare agency 10 nurse-patient dyads
To describe the interpersonal contexts and social acts through which negotiation occurs.
- Caregiving activities occurred in a complex environment of 6 interpersonal considerations and contexts”: (1) Negotiating territoriality referred to negotiation of shared space in the patient's home to facilitate caregiving. (2) Negotiating shared perceptions of the situation aimed at creating consensus in perceptions of a patient's well being and progress. (3) Establishing an amicable working relationship involved the development of a friendly collaboration, whereby both nurses and patients recognized the individuality of the other beyond immediate caregiving activities. (4) In synchronizing role expectations, nurses and patients recognized each other's particular expertise. Role boundaries were negotiated, which determined relative autonomy, collaboration, or dependence in caregiving activities. (5) Negotiating knowledge involved obtaining and providing information within an interpersonal context without imposing or demeaning, affirm correct knowledge, and identify and supplant incorrect information. (6) Sensitivity to taboo topics referred to the context in which nurses and patients could address sensitive topics such as pain tolerance, private habits, and personal fears.
147
Chambliss (1996) Ethnography
1 LTC Facility All HCA’s
Social organization of nursing’s ethics
- HCA work is a routine work of completing tasks - The workload and demands on nurse prevent nurse from relating with residents. - HCAs experience ethical dilemma’s on a daily basis
Diamond (1992) Institutional Ethnography
1 LTC Facility All HCA’s and residents observations, interviews and field notes
Sociological account of the everyday lives of HCA’s and residents in a nursing home.
- Job description and expectations of HCAs are horrendous - Lack of support and resources for HCA’s - Difficult relationships between management and HCAs - Despite poor work conditions and low pay, HCAs like to give care to residents.
Gubrium (1975) Ethnography
1 LTC Facility All HCAs
Social organization of a nursing home
- A LTC setting is an organized social entity. - Social relationships between staff and residents are rewarding. - Residents build and maintain relationships with other residents. - Hierarchical relationships between residents.
Heineken & McCoy (2000) Descriptive design
Home care agency To explore the ability of the nurse to promote trust in nurse/client relationship.
- Promoting trust enables the nurse to have a more complete understanding of patient's health care beliefs, practices, and decision-making strategies. - Gaining an understanding of the patient and family's health care beliefs is critical to achieving cost-effective and clinically positive outcomes.
Ladd, Pasquerella & Smith, (2000) Descriptive design
Home care agency To examine the special ethical and legal issues encountered in caring for patients who are dying at home.
- Traditional frameworks for the nurse-patient relationship are inadequate for capturing the richness of the relationship the home health care nurse has with both patient and family. - A new framework for the nurse/patient/family relationship recognizes the patient's decision-making authority and autonomy, allows the exercise of the nurse's moral rights, and recognizes the patient's relationships to significant others.
Li (2004) Ethnomethodolgical – ethnographical design
3 Palliative care units n = 28 (RN)
To understand symbiotic niceness in constructing a therapeutic relationship.
- The nurse-patient relationship is based on a therapeutic existence of symbiotic niceness; patient and nurse have to engage in the process of mutually feeding, absorbing, and niceness work. - Four categories of patients: 1. Trouble-free patients: deserve care and niceness, 2. Troubled patients, 3. Potentially troubled patients, 4. Undeserving patients: deserve obligatory care, minus niceness.
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McGilton & Boscart (2006) Exploratory, descriptive design.
2 units in a LTC facility n = 25 residents, 25 family, 32 care providers
To explore the meaning of a close care-provider-resident relationship in LTC
- Staff perceived close relationships by the degree of reciprocity they experienced with the residents and their emotional connection. - Residents defined close relationships with staff based on the care providers’ caring attitude and behaviours. - Family members viewed close relationships by the positive effects of the staff behaviours on their relatives’ well being. - Staff, residents, and family accredited different factors influencing the closeness of relationship.
McNaughton (2001) Prospective, naturalistic design.
5 nurse-patient dyads
To explore the development of nurse-client relationships in public health nursing based on Peplau's theory.
- Peplau's Theory reflects the development of nurse-client relationships in the home visiting context. - Future research in home visiting can be based on Peplau's Theory to determine how much nursing contact is needed to address specific client problems and to achieve desired health outcomes.
Nussbaum, 1991 Ethnography design
1 LTC unit n=20 residents
To understand the resident’s perspective of the relationship with staff.
- Relationships with minimum 1 staff is a normal occurrence. - Relationship offers companionship, more personal relating. - It’s not the resident’s ‘place’ to develop personal relationship with staff. If staff engages, resident reciprocates with friendly behavior.
Vladeck (1980) Ethnography
2 LTC Facilities Residents and care providers
Implications of public policy on care delivery in LTC Facilities
- Physical care provided is the bare minimum. - Tthere is no time to build relationships with staff. - Standards of the nursing home limit the care delivery and relationships. - Policies and regulations are not realistic, do not take the resident into account and are detrimental for the quality of life. - Lack of resources results in staff burnout.
Welch (2005) Descriptive
n = 6 RNs
To examine therapeutic relationships in psychiatric care
- Empathy, uniqueness, meaning, purpose, and self disclosure are components of a therapeutic relationship. - None of these components are described or defined.
Notes: LTC = Long-Term Care; HCA = Health Care Aide; PSW = Personal Support Worker; RN = Registered Nurse; RPN = Registered Practical Nurse.
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Appendix 2.2. Quantitative Empirical Research on Nurse-Patient Relationships
Study Design Type Setting & Sample Data Analysis Findings Threats to Internal Validity
Threats to External Validity
Limitations
Goldwater & Auerbach (1996) ‘Audience-based reminiscence therapy intervention: Effects on the morale and attitudes of nursing home residents and staff’. Tool: - Attitudes Towards Nursing Staff Scale Reliability: - No testing Validity: - No testing Measurement Issues: - No testing of validity and reliability was reported
Descriptive Convenience Being alert with intact hearing Participant Inclusion Exclusion Criteria: - Inclusion: No - Exclusion: No Sampling Method: Convenience Sample Size with Justification: - 36 - No justification Item Non-Response: Not addressed Measurement Issues: - No clear inclusion and exclusion criteria
Research Question: - Yes: 1) To measure the impact of an audience-based reminiscence therapy intervention Level of Measurement: - Rating scale Statistical Method with Justification: - No P-value Stated: - No Confidence Interval: - No
No Selection: - Potential bias: convenience sample. Instrumentation: - Newly developed scale. Statistical Regression: - None. Attrition: - None.
Interactive Effects of Selection: - Potential threat: No report on how residents were selected for participation. Reactive Effects of Innovation: - None. Multiple program interference:
- None.
- Limited - No clear selection criteria for participants
McGilton, O’Brien-Pallas, Darlington, Evans, Wynn & Pringle (2003) ‘Effects of a relationship enhancing program of care on residents and nursing staff’.
Quasi-experimental
Non random assignment Residents: Medically stable, understood English and able to answer questions. Family: Family member of the resident.
Research Question: - Yes: 1) To examine the influence of the relationship enhancing program of care (REPC) on resident-care provider relationships from the
Yes: 1) Residents on the intervention unit perceived positive changes in holding relationship with care providers; however, residents did not perceive
Selection: - Potential bias: Selection criteria for family not specific, selection of intervention unit was based on elimination. Instrumentation:
Interactive Effects of Selection: - Potential threat: No report on how institutions were selected for
Yes: - Need to increase sample size - No randomization of staff sample - Possibility of Regression to
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Tool: - Care provider – Resident Relationship Scale - Family Care provider – Resident Relationship Scale - Resident VAS – Unit Manager Relationship Scale - Charge Nurse Relationship Scale - Care provider Interactional Behaviours Scale Reliability: - Internal consistency tested by Cronbach′s alpha - Test-retest reliability in 2 weeks, Pearson’s correlation - Inter-rater reliability tested by Kappa coefficient Validity: - Content validity - Face validity
Staff: At least 3 months experience on unit. Participant Inclusion Exclusion Criteria: - Inclusion: Yes - Exclusion: yes Sampling Method: Non-random sampling Sample Size with Justification: - Residents: 44 - Family: 42 - Staff: 19 - Size justified Item Non-Response: - Residents: 9% - Family: 14% - Staff: 5%
perspective of the resident and their family members and on the behaviour of the care provider. 2) To examine the influence of the REPC on resident’s physical status, on care provider’s perceptions of their relationship with the residents and their supervisors, and on care providers levels of expressed empathy. Level of Measurement: - Rating scales: (1-3, 1-5); VAS Statistical Method with Justification: - Independent t-tests - Paired t-tests - Mean Scores and Standard Deviation - ANCOVA - Justification: Yes P-value Stated: - Yes Confidence Interval: - Yes
that close relationships have been developed with care providers. Family members perceived changes in holding relationship between resident and care provider and them as close. 2) care-providers demonstrated improvement in ability to provide holding relationship and continuity of assignment/.
- Family members used a dichotomous item measure, where the residents used a VAS. Statistical Regression: - Comparison group outperformed intervention group at baseline. - Pre and post group means for the outcomes of the intervention group were significantly different. Attrition: - 9% (residents decline in cognitive abilities).
participation. Reactive Effects of Innovation: - None.
the mean: Comparison group outperformed intervention group at baseline.
Nunley, Hall & Rowles (2000) ‘Effects of the quality of dyadic
Descriptive, correlational
Convenience Community dwelling elderly individuals Participant
Research Question: - Yes: 1) What is the effect of the quality of the
Yes: 1) Age, amount of instrumental support needed,
Selection: - Potential bias: Convenience sample.
Interactive Effects of Selection: - Potential
Yes: - existing data set - small
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relationships on the psychological well-being of elderly care recipients’. Tool: - Self Rated Physical Health Scale - Instrumental Support Activities Checklist - Autonomy and Relatedness Inventory (ARI) - Center for Epidemiologic Studies-Depression Scale (CES-D) - Philadelphia Geriatric Center Moral Scale (PGC) - Life Satisfaction and Quality of Life Measured with Cantril Ladder Scales Reliability: - ARI, CES-D, and PCG information on Cronbach′s alpha in previous studies with similar populations Validity: - ARI construct validity was test with the Spanier’s (1976) Dyadic Adjustment Scale with a different
Inclusion Exclusion Criteria: - Inclusion: Yes - Exclusion: No Sampling Method: Convenience Sample Size with Justification: - 37 - No justification Item Non-Response: Not addressed Measurement Issues: - Sample bias from volunteer research pool, no information on non-respondents.
relationships with the primary caregivers on the psychological well-being of elderly care-recipients? Level of Measurement: - Rating scales Statistical Method with Justification: - Multiple regression analyses - Justification: No P-value Stated: - Yes Confidence Interval: - No
perceptions of health and type of support provided by the caregiver are important correlates of the psychological well-being of the elderly care-recipient.
Statistical Regression: - None. Attrition: - None.
threat: Subjects were selected from a research volunteer pool. 64% of subjects had more than a high school education. Reactive Effects of Innovation: - None. Multiple program interference:
- None known.
convenience sample - Cross-sectional nature of the data does not permit the determination of casual relationships.
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population Measurement Issues: - Total of 5 scales: Possible fatigue and unreliable data at end of survey - No information on validity for CES-D and PGC Rieck (2002) ‘The Spiritual Dimension Inventory: Development and testing’. Tool: - SDI - Inventory of Positive Psychological Attitudes (IPPA) Reliability: - Cronbach′s alpha to determine reliability of individual items and item-total correlations Validity: - Predictive validity by regressing SDI in IPPA Measurement Issues: - No information on answer modalities - No information on expert panel
Correlational, predictive, model-testing
Convenience Post-operative patients Participant Inclusion Exclusion Criteria: - Inclusion: No - Exclusion: No Sampling Method: Convenience Sample Size with Justification: - 98 clients - No justification Item Non-Response: Not addressed Measurement Issues: - No clear inclusion and exclusion criteria
Research Question: - Not reported Level of Measurement: - Rating scale (1-5) Statistical Method with Justification: - Confirmatory Factor Analysis P-value Stated: - Yes Confidence Interval: - No
N/A Selection: - Potential bias: Convenience sample. Instrumentation: - No report on construct validity. Statistical Regression: - None. Attrition: - None.
Interactive Effects of Selection: - Potential threat: No report on how institutions or participants were selected. Reactive Effects of Innovation: - None. Multiple program interference:
- None known.
- No clear selection criteria for participants
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Worley-Louis, Schommer & Finnegan (2003) ‘Construct identification and measure development for investigating pharmacist-patient relationships’. Tool: - Self-Administered Survey (Likert Scale) developed by authors Reliability: - Cronbach′s alpha used to determine reliability of subscales Validity: - Face validity established by 5 experts Measurement Issues: - Different answer modalities (5-point, 7-point, 9-point Likert scales) with different anwer options for each subscale - No information on expert panel
Cross-sectional descriptive
Systematic random sample (using data base) Non-institutionalized Age 65 or older Used at least one prescription medication Participant Inclusion Exclusion Criteria: - Inclusion: Yes - Exclusion: No Sampling Method: - Systematic random Sampling (using data base) Sample Size with Justification: - 500 individuals - No justification Item Non-Response: - 43.5% - No possible reasons addressed Measurement Issues: - Possible sample bias because most respondents were female.
Research Question: - Yes: 1) To identify constructs that were important to study in the pharmacist-patient relationship 2) To identify existing measures and scales or to develop measures and scales for the constructs identified in the first objective. 3) To explore the associations among pairs of the identified constructs Level of Measurement: - Rating scales (1-5; 1-9) Statistical Method with Justification: - Exploratory Factor Analysis - Pearson’s Correlation Coefficient - Justification: No P-value Stated: - Yes Confidence Interval: - No
Yes: 1) Identified constructs that were important to study in the pharmacist-patient relationship. 2) No existing measures and scales, developed scale to measure constructs identified in the first objective. 3) Associations among pairs of identified constructs were explored.
Selection: - Potential bias: Participants selected from data base of consumer households who respond to mail surveys. Instrumentation: - Subscale is based on previously used instruments with no psychometric properties being reported - Subscales have high positive correlation, indicating that constructs were not capturing distinctly different constructs. Statistical Regression: - None. Attrition: - None.
Reactive Effects of testing: - Response rate was 66.5%. Interactive Effects of Selection: - Majority of participants were female (70%). Reactive Effects of Innovation: - None. Multiple program interference:
- None.
Yes: - Only perceptions were measures, no actual behaviors. - Majority of sample was female - Majority of respondents were female (70%)
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Appendix 2.3. Concept Utilization of Nurse-Patient Relationships in Regulatory Standards and Professional Guidelines. Agency Document Definition CNO Practice
Standard (2006)
A TR is established and maintained by the nurse and the client, through the use of professional nursing knowledge and skill, and caring attitudes and behaviours to provide nursing services that contribute to the client’s health and well being. It requires the appropriate use of the power inherent in the care provider's role. Components: Power, trust, respect, intimacy
RNAO Best Practice Guideline (2006)
The TR is grounded in an interpersonal process that occurs between the nurse and the client(s). TR is a purposeful, goal directed relationship that is directed at advancing the best interest and outcome of the client. Components: NA
Saskatchewan Registered Nurses Association
Standards and foundation competencies for the practice of RNs (2000)
The R between an RN and client is based on recognition that clients are able to make decisions about their own life and are partners in the decision-making process. The extent a client participates is determined by the client’s health status, willingness and expectations. Components: NA
College of Registered Nurses of Manitoba
Nursing practice expectations: Professional boundaries for TR (2007)
A TR is a planned and goal directed interaction between
a nurse and a client for the purpose of providing care to
the client and their significant others.
Components: Power, choice, trust. Alberta Association of Registered Nurses
Guideline for the NPR (2005)
A TR is a R established and maintained with the client by the nurse through the use of professional knowledge, skills and attitudes in order to provide nursing care expected to contribute to the client’s health outcomes. A NCR is established and maintained by the nurse through therapeutic interventions, which enable an RN to provide safe, competent and ethical nursing care. Components: Power, trust, respect, intimacy
Registered Nurses Association British Colombia.
Standards for nursing practice (2003)
The NPR is professional and therapeutic. This interpersonal R ensures the client’s needs are first and foremost. It meets the needs of the client, not the needs of the RN. It is always the RN who is responsible for establishing and maintaining boundaries with the client. Components: Power, trust, respect, intimacy.
Northwest Standard of A NPR is based on mutual respect, shared objectives
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Territories Registered Nurses Association
practice for RNs (2002)
and the right to self-determination. Components: NA
Registered Nurses of Nova Scotia
Guideline for NCR (2002)
A TR is a purposeful, goal directed R between nurse and clients that is directed at advancing the best interest and outcome of the client. The TR is central to all nursing practice and is grounded in an interpersonal process that occurs between the nurse and the clients. Components: NA
Nurses Association of New Brunswick
Standard for the TNCR (2000)
A NPR is a helping R that is therapeutic in nature, is established to meet the needs of the clients and is based upon trust and respect. A TNPR is established and maintained by the nurse, through the use of professional nursing knowledge, skills, caring attitudes and behaviours in order to provide nursing services that contribute to the client’s health and well-being. The R is based on trust, respect and intimacy and requires the appropriate use of the power inherent in the care provider's role. Components: Power, trust, respect, intimacy.
Notes: R = Relationship; TR = Therapeutic relationship; NPR = Nurse-patient relationship; TNPR = Therapeutic nurse-patient relationship; RN= Registered nurse
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Appendix 3.1. Concept Utilization of Nurse-Patient Relationships in Nursing Theories
Author Theory Definition Peplau (1952)
Interactionism A NPR is a helping relationship and a process by which the nurse can facilitate personal growth in an other by helping the person to identify felt difficulties, experience emotions, and understand his or her own behaviour.
Henderson (1961)
Synergy Model In a NPR, nurses must primarily assist the individual (sick or well) in the performance of those activities contributing to health, or his recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge.
Roy (1970)
Adaptation Model
Persons have mutual relationships with the world and with God. Relating includes acceptance, protection, and fostering of the patient’s independence.
Travelbee (1971)
Interactionism A NPR is a process which can enable a nurse to establish a human-to-human relationship, thereby fulfilling the purpose of nursing - assist individuals and families to prevent and cope with experiences of illness & suffering, & assist in finding meaning in these experiences.
Orlando (1972)
Theory of the Nursing Process Discipline
A NPR is developed to provide direct assistance to individuals in whatever setting they are found for he purpose of avoiding, relieving, diminishing, or curing the individual's sense of helplessness.
Newman (1972)
Theory of Health as an Expanding Consciousness
In a NPR, the nurse will participate in the expanding process of others to become part of the universal process of expanding consciousness – a process of becoming more of oneself, of finding greater meaning in life, and of reaching new dimensions of connectedness with other people and the world consciousness.
Paterson & Zderad (1976, 1988)
Interactionism
A NPR is a meeting (being and becoming) in a goal directed (nurturing well-being and more-being), intersubjective transaction (being-with and doing-with) occurring in time and space (as measured and as-lived by client and nurse) in a world of men and thing.
Note: NPR =Nurse-patient relationship
Appendix 4.1. Content Validation Information Letter for Scholarly Experts
Letterhead
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Dear:
Thank you for agreeing to participate in the evaluation of the Humanistic Relationship
Scales. This purpose of the research study is to examine the nature of the relationships between cognitively competent patients and nursing personnel in chronic care settings based on concepts embedded in the Humanistic Nursing Theory (Paterson & Zderad, 1976, 1988). The scale aims to examine what qualities of the humanistic relationships between cognitively competent patients and nursing personnel in CC settings are most important to patients and what their experience was with these qualities.
I am inviting you to review and rate the relevance of the content of the measure. Your
knowledge and expertise is vital in establishing content validity of the scale and constitutes the first part of my doctoral research. The next step consists of pilot testing the measures with 40 patients in chronic care to examine internal consistency reliability, test-retest reliability, and construct validity. Subsequently, the measure will be administered to a larger sample to further establish psychometric properties.
Please find enclosed: a brief description of the concepts used to develop the measure, as well as a copy of the Humanistic Relationship Scale and the Content Validation
Questionnaire. The measure will be revised based on your responses and the responses from three other scholarly experts and five patients residing in chronic care.
If you have any questions that arise during the process of this evaluation, please do not hesitate to contact me at (905) 655-2467 or my supervisor, Dr. D. Pringle at (416) 929-0700. You can return the Content Validity Questionnaire by using the enclosed stamped, self-addressed envelope, at your earliest convenience. If you wish to discuss your responses in person, please notify me by phone to arrange a suitable time to meet.
Thank you for your willingness to provide me with your valuable time and expertise. Sincerely,
Véronique Boscart Graduate student L. Bloomberg Faculty of Nursing University of Toronto
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Concepts
The conceptual framework was developed based on the Humanistic Nursing Theory (Paterson & Zderad, 1976, 1988) to guide the study. Patients live their lives in these chronic care settings and need relationships to sustain themselves. Humanistic nursing is a portrayed by personalized, humanistic care, and a way of caring for the patient as a unique person. The relationships developed between nurses and patients in chronic care nourish a humanizing connection and patients in residential care rely on nurses to be understood and cared for. Based on the conceptual framework, several concepts were identified as relevant to the nurse-patient relationship in CC and guided the development of the measure.
Supporting human uniqueness is the awareness of self and how one differs from others. Human uniqueness is supported through the process of searching for one’s capacity for uniqueness and becoming aware of one’s view of the world and response to it. Domain 1: Awareness of uniqueness and view of the world. Domain 2: Recognition of particularity. Domain 3: Awareness of view of the world and response to it. Sustaining choice: Patients have the freedom to choose to respond and to choose how to respond to situations. The nurses respect those choices. Domain 1: Freedom to choose to respond. Domain 2: Freedom to choose how to respond. Domain 3: Respecting choices. Relational capacity: is forming a connection between a nurse and a patient through openness and communication of the nurse’s availability to be involved as a person, with the goal of nurturing the patient. Domain 1: Connecting. Domain 2: Being available. Domain 3: Nurturing. Living dialogue: A lived dialogue is a particular form of relating where the dialogue between the nurse and the patient is viewed as communication in terms of a call and a response. The dialogue occurs in response to a perceived need related to the health-illness quality of the patient’s condition. Domain 1: Responding. Domain 2: Calling. Being present: Presence is a personal and professional nursing quality that is brought to the relationship. Professional quality refers to the accountability of the nurse. Personal quality refers to availability (being with in its fullest sense by turning one’s attention toward the other), reciprocity (seeing the other as a person, rather than as objects or functions), and mutuality (the flow between two persons with different modes of being in the shared situation). Domain 1: Professional Accountability. Domain 2: Availability.
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Domain 3: Reciprocity. Domain 4: Mutuality. Fostering well-being and more-being: Humanistic nursing seeks to promote the well-being and comfort of the patient by nurturing the patient’s potential and helping him/her to recognize and accept limitations. Well-being also involves helping the patient search for meaning of life and recognizes reality of death. Domain 1: Nurturing well-being and comfort. Domain 2: Accepting. Domain 3: Searching. Domain 4: Helping to recognize.
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Appendix 4.2. Content Validation Questionnaire for Scholarly Experts
Background
Several researchers point to the concept of the relationship between a nurse and a patient as a prerequisite to deliver quality nursing care to patients in a chronic care setting (Diamond, 1984, 1986, 1992; Sumaya-Smith, 1995; McGilton et al., 2003). However, it’s only recently that scholars and researchers started to pay attention to this construct. Several qualitative studies have identified this relationship as making a difference in the care-giving situation in chronic care (Smith, 1980; May, 1991; Morse, 1992; Messier-Mann, 1995); yet there exists little clarity on what the patient’s perspective of this relationship is (May, Purkis, 1995; Lowenberg, 1994, 1995). Despite the mounting evidence of the importance of these relationships, there were no suitable instruments found to measure this relationship in chronic care.
Therefore, this study developed a tool to measure these relationships in chronic care form the perspective of the patients. Item construction proceeded as suggested by DeVillis (1991). Concepts were selected from the Humanistic Nursing Theory (Paterson & Zderad, 1976, 1988) and for each of the concepts an operational definition was developed (Morse, 1995). This conceptual definition was translated into simpler language and these simplifications were the foundation of item development for the measure (DeVillis, 1991). Each concept was operationalized into 3-4 items (Chinn & Kramer, 1987; Thagard, 1992). The items are presented with an adjective scale where the patients will be asked to indicate the degree of agreement with the proposed items.
The first step in this study is to determine the content validity of the measure. Evaluating the content validity is essential to evaluate how well the measure reflect the dimensions of the nurse-patient relationship. Also, the items on the measure need to represent all possible domains of the nurse-patient relationship.
When a measure is considered to have a high content validation, it can be used in further
research. Understanding the nature of these relationships in a chronic care setting will yield the qualities are that patients find important in this relationship. This knowledge will be important for student nurses to be taught how to form these relationships, and practicing nurses in chronic care can be rewarded for forming and maintaining these relationships. Consequently, interventions can be implemented to enhance these relationships. Sound research is necessary to understand these relationships in a chronic care setting so practice can be guided in these environments and educate and reward the nurses who deliver aspects of daily care in an affectionate relationship.
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Content Validation Questionnaire This questionnaire will help guide the evaluation of the content validity of the measure. You are asked to:
a. Read each item included in the measure b. Determine the extent to which the content of the item is relevant in capturing the
qualities of the relationship in chronic care from the perspective of the patients. c. Identify any aspect of the item that may have been omitted.
Part 1: Relevance of Item Content Please use the following scale to rate the relevancy of the items. 1 = not relevant 2 = unable to assess relevance without item revision
3 = relevant, but needs minor revision 4 = very relevant and succinct How relevant is this item in reflecting on the qualities of the nurse-patient relationship in chronic care from the perspective of the patient?
Not relevant
1
Unable to access without revision
2
Relevant but
minor revision
3
Very relevant
4
Item 1-69 Please explain why or why not suggest any changes:
TOTAL
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Part 2: Additional Comments Consider now the adequacy of the set of items as a whole and respond to the following statement: 1. The items are an adequate representative sampling of all the domains of the nurse-patient
relationship in chronic care from the perspective of the patient. Yes No Please explain and suggest deletions and/or additional domains to the relationship. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2. The items are mutually exclusive. Yes No Please explain and suggest revisions. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. The order in which the items are presented is satisfactory. Yes No Please explain and suggest revisions. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
4. The instructions for completing the measure are clear and provide adequate direction. Yes No Please explain and suggest revisions. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Appendix 4.3. Demographic Sheet for Scholarly Experts
For each question, please mark the one box that best represents your status. 1. What is your highest education?
Baccalaureate Degree Master’s Degree Doctorate/PhD
2. What is your current position title? _________________________________
3. How many years in total have you worked with and/or taught students about
chronically ill patients?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Appendix 4.4. Content Validity Index for the HRIS-69
Ex 1 Ex 2 Ex 3 Ex 4 AVE CVISupporting Human Uniqueness
Awareness of uniqueness and view of the world 1 The nurses recognize that you are different and unique from others. 3 4 1 1 2.25 0.52 The nurses know your likes and dislikes. 4 3 4 4 3.75 13 The nurses understand (where) your values (come from) and beliefs. 4 4 1 3 3 0.754 The nurses recognize the influence of (your family and importance) important (of
others) persons in your life, such as family members and friends (volunteers and patients).
3 3 3 4 3.25 1
Recognition of Particularity 5 The nurses make an effort to (know) ask questions to find out who you are. 4 4 4 4 4 16 The nurses take the time to listen to (your) stories about your life. 3 3 4 4 3.5 1
Awareness of view of the world and response to it. 7 The nurses appreciate (your life) the history of your life/ your past. 2 1 2 1 1.5 08 The nurses value you as a unique individual. 3 3 4 4 3.5 1
9 The nurses respect your (likes and dislikes) . 4 3 4 4 3.75 110 The nurses provide care (for you as a person) about you/that meets your unique needs. 3 4 4 3 3.5 1
Sustaining Choice
Freedom to choose to respond 1 The nurses (ensure) make sure you have the information required to make your own
choices and decisions. 3 4 1 4 3 0.75
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2 The nurses (ensure) make sure you know the (range of choices you can make) different choices available to you.
2 4 1 4 2.75 0.5
3 You believe that the nurses think it is your right to make choices. 1 1 1 1 1 04 The nurses recognize your right to make choices about your life. 3 3 4 1 2.75 0.75
Freedom to choose how to respond 5 The nurses support (you in) your choices and decisions. 4 3 1 4 3 0.756 The nurses help you (in making good) to make choices. 2 3 1 3 2.25 0.57 The nurses support (you in) your right to respond as you choose. 4 4 4 1 3.25 0.75
Respecting choices 8 The nurses respect your choices. 2 4 4 1 2.75 0.59 ((Whenever possible)) the nurses (ensure) make sure you have the (resources)
information/advice/support you need to (act on your) make your own/follow through with your choices.
2 3 3 4 3 0.75
10 The nurses (work hard to see) do their best to make sure that your choices are acted upon (often out of nurses control).
3 2 1 3 2.25 0.5
Relational capacity
Connecting 1 The nurses are comfortable (in your relationship) to be with you/in your presence. 2 1 1 4 2 0.252 You and the nurses enjoy each other's company. 3 2 2 1 2 0.25
3 You and the nurses connect with each other. 3 4 3 4 3.5 1
4 You and the nurses feel close to each other. 1 1 3 1 1.5 0.25
5 The nurses are (personally) involved. 1 4 1 3 2.25 0.56 You have a warm, ((personal)) and open relationship with at least one nurse. 2 4 2 4 3 0.5
Being Available
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7 You and the nurses respect that there are aspects of your lives that are not part of this professional relationship.
2 4 2 3 2.75 0.5
8 The nurses are willing to discuss (your) this professional relationship with you when you have questions.
2 3 1 2 2 0.25
9 The nurses are willing to be involved in the relationship. 1 1 3 2 1.75 0.2510 The nurses respond to you when you want to talk (or be involved in the relationship) . 3 3 3 4 3.25 1
11 The nurses are willing to let you get to know them (as a person). 1 3 3 3 2.5 0.75Nurturing 12 The nurses are there for you when you need them. 4 3 3 4 3.5 113 The nurses help you (by telling you about their own situation) to understand your
issues by sharing experiences from their own life. (often wrong, crossing boundaries) 2 2 1 1 1.5 0
Living Dialogue
Responding 1 The nurses sense when you need your space (?) and time alone . 2 4 4 3 3.25 0.752 The nurses seem to know when you need them to help you.(nurse has to check
impression with pt) 3 1 3 4 2.67 0.75
3 The nurses work with you to learn how to do things in a way you like them done. 3 3 1 4 2.75 0.754 The nurses know how much care you need. 4 4 1 3 3 0.755 The nurses can figure out what you need without you (asking) having to ask them/
after they get to know you. 3 1 4 2 2.5 0.5
6 The nurses know/can guess, figure out, assess how you feel without you having to tell them.
2 1 3 1 1.75 0.25
Being Present
Professional Accountability
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4 4 3 41 The nurses feel (responsible for your care) that your care is their responsibility. 3.75 1
2 The nurses (care for you skillfully) provide skillful care. 4 4 4 4 4 13 The nurses are competent to provide your care. 4 4 4 4 4 14 The nurses know how to do their job. 1 3 2 4 2.5 0.55 The nurses recognize when your health situation is changing and take appropriate
action. 4 4 4 4 4 1
Availability 6 The nurses let you know that they are there for you. 3 4 3 2 3 0.757 The nurses are there for you when you need them. 4 3 3 4 3.5 18 The nurses give you their full attention when they are with you. 2 4 4 4 3.5 0.759 The nurses make you feel that you are important to them. 1 4 4 4 3.25 0.75
Reciprocity 10 The nurses respect you. 4 4 2 4 3.5 0.7511 The nurses (care for you as much more than just a (job) body in a bed and) They see
you as a person and not just a part of their job. 3 4 4 4 3.75 1
12 The nurses (do not) (treat) refer to you by your room number (as a (number or a diagnosis)) person, and not just some number, or diagnosis.
3 4 4 4 3.75 1
Mutuality 13 The nurses like to be (with) around you. 2 3 1 3 2.25 0.514 You and the nurses appreciate each other. 2 2 2 3 2.25 0.25
15 The nurses (work with you to) help to make your day go well. 2 4 3 3 3 0.75
Fostering Well-being and More-being
Nurturing well-being and comfort 1 The nurses try to comfort you when you need it. (may not need it) 3 4 1 1 2.25 0.5
2 When you are feeling low, the nurses try to try to lift your spirits. 2 3 2 3 2.5 0.5
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3 The nurses make sure that you are comfortable. 4 4 1 4 3.25 0.75
4 The nurses make you feel better when they're (here) with you. 2 3 2 3 2.5 0.5
Acceptance 5 The nurses contribute to our (help you to have ) a good quality of life. 2 4 2 4 3 0.5
6 The nurses keep you connected to the world beyond the hospital. 2 2 1 2 1.75 07 The nurses support the fullness of your life despite your health situation 3 4 4 4 3.75 1
Searching 8 The nurses ((are always trying)) try to make things better for you. 3 2 1 3 2.25 0.259 The nurses work with you to help you see how your life can be better. 2 3 3 3 2.75 0.75
10 The nurses support you in recognize/recognizing your potential/ability to help yourself.
2 4 4 4 3.5 0.75
11 With the help of the nurses, you can reach some goals. 3 4 3 3 3.25 112 The nurses (give you) help boost your confidence (in what you can do) . 2 4 2 4 3 0.5
Helping to recognize 13 The nurses help you to achieve a sense of peace (with) about your situation. Qualify
this: Physical situation, social,… Peace? 2 3 4 1 2.5 0.5
14 The nurses help you to find meaning in your life. 1 4 3 4 3 0.7515 The nurses help you to make the best of the situation you are in. 2 4 4 4 3.5 0.75
Notes: Ex = expert; AVE: Average; CVI = Content validity Index
169
Appendix 4.5. Content Validation Information Letter for Patient Experts
Letterhead Dear,
I am undertaking a study whose overall purpose is to understand the nature of the
relationships patients have with nursing personnel in chronic care settings. There are 3 phases in this study. In the first phase, I developed a questionnaire to examine
the relationship that patients have with nurses on the unit. The second phase is testing this questionnaire and the third phase consists of interviewing patients in chronic care hospitals so they can complete the questionnaires and answer questions about their relationships with nurses.
I would like to ask you if you want to help me in testing the questionnaire. If you decide
to do so, I will read each question to you. I will then ask you if the question is important or not. I will also ask you if the question is understandable or not. At the end, I will ask you if there is anything I need to change. I will write down your answers so I can make the changes to the survey. Your answers will help me in making sure the questions are important and understandable.
There are no known risks to participation in this evaluation. However, you may choose
not to participate. If so, this decision will have no impact on your care at this hospital. Your care providers will not be aware of whether you participate or not. You are free to choose not to answer any question during the interview. You may also withdraw from the study at any time.
If you decide to participate, I will help you to complete a consent form. The cost of
participating in this evaluation will be the time needed to answer the questions (30 minutes). You will not receive payment for your participation. To assure confidentiality, your name will not appear in this evaluation. Only a code number will appear on any forms or questions sheets. Data will be kept in an electronic file. Information obtained from you will be reported as a group – never by individual. If you have any questions please contact the Principal Investigator, Veronique Boscart, Toronto Rehabilitation Institute, at 416-597-3422 x. 2246 or [email protected]. You can also contact my supervisor, Dr. Dorothy Pringle, at 416- 929-0700 or [email protected]. If you have any questions about the conduct of this study or your rights as a research subject, you may contact (Name of VP Research at the participating facility).
On behalf of the study team, I thank you for your support. We appreciate your taking the
time to consider participating in this evaluation. This letter is yours to keep for future reference. Sincerely, Véronique Boscart, Graduate Student, L. Bloomberg Faculty of Nursing,
University of Toronto.
170
Appendix 4.6. Consent Form for Patient Experts
Letterhead
Title of the study: Humanistic Nurse-Patient Relationships in Chronic Care Settings.
Principal Investigator: Véronique Boscart, Graduate student, L. Bloomberg Faculty of Nursing, University of Toronto.
I have read the Letter of Information; have had the nature of the evaluation explained to me, including an explanation of any benefits and risks associated with the evaluation. I have also been given an opportunity to ask questions concerning this evaluation, and any questions that I have asked have been adequately answered.
I have been told that I can withdraw my consent and stop taking part in this evaluation at
any time and for any reason. I have been told that my identity will be kept confidential. I understand the information that I have been provided.
I voluntarily consent to participate in this study. ______________________ _____________________ _______ Printed Name of Participant Signature of Participant Date ______________________ _____________________ _______ Printed Name of Person Signature of Person Date Obtaining Informed Consent Obtaining Informed Consent
171
Appendix 4.7. Content Validation Questionnaire for Patient Experts
Content Validation Questionnaire I have developed several questions on the relationship between a patient and a nurse in a facility like this. I would like to know if you think these questions are clear and if they contain ideas that are important to you.
1. I will read every question to you. 2. I will ask if this question is important or relevant to explore the relationship with nurses.
When I ask you to tell me how important the question is, you can choose four different answers.
3. I will ask if this question is understandable. 4. At the end of the questions, I will ask you if there is anything that I left out, or if there are
other questions you would like to add to understand the relationship between the nurse and the patient?
Part 1: Relevance of Item Content a) How relevant is it that (list the item)? 1 = not relevant 2 = unable to assess relevance without item revision
3 = relevant, but needs minor revision 4 = very relevant and succinct b) Is this item understandable (list the item)?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ How relevant is this item in reflecting on the qualities of the nurse-patient relationship in chronic care?
Not relevant
1
Unable to access without revision
2
Relevant but
minor revision
3
Very relevant
4
Item 1-69 Please explain why or why not suggest any changes:
TOTAL Part 2: Additional Comments
172
Consider now the questionnaire as a whole and respond to the following statement: 1. The questionnaire asks questions about all the aspects of the relationship with the nurse.
Yes No Please explain and suggest deletions and/or additional domains to the relationship. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2. The questions are not overlapping.
Yes No Please explain and suggest revisions. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. The order of the questions is fine.
Yes No Please explain and suggest revisions. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
4. The instructions to complete the survey are clear. Yes No Please explain and suggest revisions. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
173
Appendix 4.8. Content Validation Demographic Sheet for Patient Experts
1. How long have you been in this hospital?
________________________________________________________________
2. Why are you here? ________________________________________________________________ 3. What is your age?
________________________________________________________________
174
Appendix 4.9. Content Validity Index for HRIS-52
Scholarly experts
Patient experts Total
AVE CVI AVE CVI AVE CVI Supporting Human Uniqueness
Awareness of uniqueness and view of the world 1 The nurses know your likes and dislikes. 3.75 1 4 1 3.88 1
2 The nurses understand (where) your values (come from) and beliefs. 3 0.75 2.6 0.4 2.8 0.58
3 The nurses recognize the influence of (your family and importance) important (of others) persons in your life, such as family members and friends (volunteers and patients).
3.25 1 1.8 0.2 2.53 0.6
Recognition of Particularity 4 The nurses make an effort to (know) ask questions to find out who you are. 4 1 4 1 4 1
5 The nurses take the time to listen to (your) stories about your life. 3.5 1 3.6 0.8 3.55 0.9
Awareness of view of world and response to it. 6 The nurses value you as a unique individual. 3.5 1 3.8 1 3.65 1
7 The nurses respect your (likes and dislikes). 3.75 1 3.4 0.8 3.58 0.9
8 The nurses provide care (for you as a person) about you/that meets your unique needs.
3.5 1 3.2 0.8 3.35 0.9
Sustaining Choice
Freedom to choose to respond
175
1 The nurses (ensure) make sure you have the information required to make your own choices and decisions.
3 0.75 1.8 0.2 2.4 0.48
2 The nurses recognize your right to make choices about your life. 2.75 0.75 2.6 0.6 2.68 0.68
Freedom to choose how to respond 3 The nurses support (you in) your choices and decisions. 3 0.75 3.4 0.8 3.2 0.78
4 The nurses support (you in) your right to respond as you choose. 3.25 0.75 2.2 0.4 2.73 0.58
Respecting choices 5 The nurses respect your choices. 2.75 0.5 4 1 3.38 0.75
6 ((Whenever possible)) the nurses (ensure) make sure you have the (resources) information/advice/support you need to (act on your) make your own/follow through with your choices.
3 0.75 1.2 0 2.1 0.38
Relational Capacity
Connecting 1 You and the nurses enjoy each other's company. 2 0.25 4 1 3 0.63
2 You and the nurses connect with each other. 3.5 1 4 1 3.75 1
3 You and the nurses feel close to each other. 1.5 0.25 4 1 2.75 0.63
4 You have a warm, ((personal)) and open relationship with at least one nurse. 3 0.5 3.8 1 3.4 0.75
Being Available 5 The nurses are willing to be involved in the relationship. 1.75 0.25 3.6 1 2.68 0.63
176
6 The nurses respond to you when you want to talk (or be involved in the relationship).
3.25 1 3 0.6 3.13 0.8
7 The nurses are willing to let you get to know them (as a person). 2.5 0.75 2.6 0.4 2.55 0.58
Nurturing 8 The nurses are there for you when you need them. 3.5 1 4 1 3.75 1
Living Dialogue
Responding 1 The nurses sense when you need your space (?) and time alone. 3.25 0.75 2.4 0.4 2.83 0.58
2 The nurses seem to know when you need them to help you.(nurse has to check impression with pt)
2.67 0.75 4 1 3.33 0.88
3 The nurses work with you to learn how to do things in a way you like them done.
2.75 0.75 4 1 3.38 0.88
4 The nurses know how much care you need. 3 0.75 4 1 3.5 0.88
5 The nurses know/can guess, figure out, assess how you feel without you having to tell them.
1.75 0.25 3.6 1 2.68 0.63
Being Present
Professional Accountability 1 The nurses feel (responsible for your care) that your care is their responsibility. 3.75 1 3.8 1 3.78 1
2 The nurses (care for you skillfully) provide skillful care. 4 1 3.4 0.8 3.7 0.9
3 The nurses are competent to provide your care. 4 1 4 1 4 1
177
4 The nurses know how to do their job. 2.5 0.5 4 1 3.25 0.75
5 The nurses recognize when your health situation is changing and take appropriate action.
4 1 2.8 0.8 3.4 0.9
Availability 6 The nurses let you know that they are there for you. 3 0.75 3.4 0.8 3.2 0.78
7 The nurses are there for you when you need them. 3.5 1 4 1 3.75 1
8 The nurses give you their full attention when they are with you. 3.5 0.75 3.8 1 3.65 0.88
9 The t nurses make you feel that you are important to them. 3.25 0.75 2.8 0.6 3.03 0.68
Reciprocity 10 The nurses respect you. 3.5 0.75 4 1 3.75 0.88
11 The nurses (care for you as much more than just a (job) body in a bed and) They see you as a person and not just a part of their job.
3.75 1 1.6 0.2 2.68 0.6
12 The nurses (do not) (treat) refer to you by your room number (as a (number or a diagnosis)) person, and not just some number, or diagnosis.
3.75 1 1 0 2.38 0.5
Mutuality 13 The nurses like to be (with) around you. 2.25 0.5 4 1 3.13 0.75
14 The nurses (work with you to) help to make your day go well. 3 0.75 4 1 3.5 0.88
Fostering Well-being and More-being
Nurturing well-being and comfort 1 The nurses make sure that you are comfortable. 3.25 0.75 3.6 1 3.43 0.88
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2 The nurses make you feel better when they're (here) with you. 2.5 0.5 3.8 1 3.15 0.75
Acceptance 3 The nurses contribute to our (help you to have ) a good quality of life 3 0.5 3.6 1 3.3 0.75
4 The nurses support the fullness of your life despite your health situation 3.75 1 1 0 2.38 0.5
Searching 5 The nurses ((are always trying)) try to make things better for you. 2.25 0.25 3.4 1 2.83 0.63
6 The nurses work with you to help you see how your life can be better. 2.75 0.75 2.8 0.6 2.78 0.68
7 The nurses support you in recognize/recognizing your potential/ability to help yourself.
3.5 0.75 2.2 0.2 2.85 0.48
8 With the help of the nurses, you can reach some goals. 3.25 1 2.4 0.2 2.83 0.6
9 The nurses (give you) help boost your confidence (in what you can do). 3 0.5 3 0.8 3 0.65
Helping to recognize 10 The nurses help you to find meaning in your life. 3 0.75 2.4 0.4 2.7 0.58
11 The nurses help you to make the best of the situation you are in. 3.5 0.75 3.4 1 3.45 0.88
Notes: Ex = expert; AVE: Average; CVI = Content validity Index
179
Appendix 4.10. Information Letter for Phase Two Participants
Letterhead
Dear,
We are undertaking a study to examine the relationships you have with the nurses. The overall purpose of this study is to understand the nature of the relationships patients have with nursing personnel in chronic care settings. You have been invited to participate in this study because you are a patient at (Name of facility). If you decide to take part in the study, you will be asked to answer some questions about yourself and your relationship with the nurse.
There are no known risks to participation in this study. However, you may choose not to
participate in this study. If so, this decision will have no impact on your care at this hospital. Your care providers will not be aware of whether you participate or not. You are free to omit any question during the interview. You may also withdraw from the study at any time.
If you decide to participate, the researcher will help you to complete a consent form. The
cost of participating in this study will be the time expenditure needed to answer the questions (30 minutes). You will not receive payment for your participation.
To assure confidentiality, your name will not appear in this research study. Only a code
number will appear on any forms or questions sheets. Data will be kept in an electronic file. Information obtained from you will be reported as grouped responses – never by individual respondent. Furthermore, no grouped responses will be reported for a named hospital.
If you have any questions please contact the Principal Investigator, Veronique Boscart,
Toronto Rehabilitation Institute, at 416-597-3422 x. 2246 or [email protected]. You can also contact my supervisor, Dr. Dorothy Pringle, at 416- 929-0700 or [email protected]. If you have any questions about the conduct of this study or your rights as a research subject, you may contact (Name of VP Research at the participating facility).
The findings of this study may lead to a greater understanding of the nurse-patient
relationship in chronic care and will support the care, research and education of nurses and patients in these environments. On behalf of the study team, I thank you for your support. We appreciate your taking the time to consider participating in this study. This letter is yours to keep for future reference.
Sincerely, Véronique Boscart, Graduate student, L. Bloomberg Faculty of Nursing,
University of Toronto.
180
Appendix 4.11. Consent Form for Phase Two Participants
Letterhead
Title of the study: Humanistic Nurse-Patient Relationships in Chronic Care Settings Principal Investigator: Véronique Boscart, Graduate student, L. Bloomberg Faculty of Nursing, University of Toronto.
I have read the Letter of Information, have had the nature of the study explained to me,
including an explanation of any benefits and risks associated with the study. I have also been given an opportunity to ask questions concerning this study, and any questions that I have asked have been adequately answered.
I have been told that I can withdraw my consent and stop taking part in this study at any
time and for any reason. I have been told that my identity will be kept confidential. I understand the information that I have been provided.
I voluntarily consent to participate in this study. _____________________ ___________________ _______ Printed Name of Participant Signature of Participant Date ______________________ _____________________ _______ Printed Name of Person Signature of Person Date Obtaining Informed Consent Obtaining Informed Consent
181
Appendix 4.12. Relational Care Scale (McGilton, 2003; 2005)
The care provider takes your likes and dislikes into account when she/he is providing care.
Never 1
Seldom 2
Occasionally 3
Often 4
Always 5
The care provider tries to meet your needs, for example in such ways as listening to you if you need someone to talk to and/or comforting you when something bad or unexpected happens.
Never 1
Seldom 2
Occasionally 3
Often 4
Always 5
The care provider knows you well enough to recognize when you are happy, sad, mad, or stressed about something.
Never 1
Seldom 2
Occasionally 3
Often 4
Always 5
You can depend on the care provider to be there for you, for example when you ask for help, and know that they will do what they promise to do.
Never 1
Seldom 2
Occasionally 3
Often 4
Always 5
The care provider tries to make your day go the way you like and helps you with any unexpected changes.
Never 1
Seldom 2
Occasionally 3
Often 4
Always 5
The care provider tolerates you being frustrated or irritable without responding negatively in return
Never 1
Seldom 2
Occasionally 3
Often 4
Always 5
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Appendix 4.13. Presence of Nursing Scale (Kostovich, 2002)
Directions: Please answer the following question by circling your response:
1. Were there one or more NURSES whose presence made a difference to you during this hospitalization? (The difference can be positive or negative).
YES NO If you anwered YES to the above question, please answer questions 2-29. If you answered NO to the above question, please skip to question 29. Answer questions 29-30. Directions: Think only about the NURSE(S) whose presence made a difference to you during this hospitalization. Answer the following question by circling the phrase that tells how often these NURSE(S) did the following:
2. These NURSES were open to my concerns. Never Rarely Occasionally Frequently Always
3. These NURSES taught me what I needed to know. Never Rarely Occasionally Frequently Always
4. These NURSES “checked’ on me. Never Rarely Occasionally Frequently Always
5. These NURSES met my spiritual needs. Never Rarely Occasionally Frequently Always
6. These NURSES made me lonely Never Rarely Occasionally Frequently Always
7. These NURSES physically comforted me. Never Rarely Occasionally Frequently Always
8. These NURSES emotionally comforted me. Never Rarely Occasionally Frequently Always
9. These NURSES understood my feelings. Never Rarely Occasionally Frequently Always
10. These NURSES earned my trust. Never Rarely Occasionally Frequently Always
11. These NURSES were skilled in nursing. Never Rarely Occasionally Frequently Always
12. These NURSES were there if I needed them. Never Rarely Occasionally Frequently Always
13. These NURSES helped my day run smoothly. Never Rarely Occasionally Frequently Always
14. These NURSES created a sense of healing around me. Never Rarely Occasionally Frequently Always
15. These NURSES listened and responded to my needs. Never Rarely Occasionally Frequently Always
183
16. These NURSES caused me to be afraid. Never Rarely Occasionally Frequently Always
17. These NURSES were concerned about me. Never Rarely Occasionally Frequently Always
18. These NURSES were committed to care for me. Never Rarely Occasionally Frequently Always
19. These NURSES made me feel safe. Never Rarely Occasionally Frequently Always
20. These NURSES made me feel peaceful. Never Rarely Occasionally Frequently Always
21. These NURSES took care of me as a person, not as a disease. Never Rarely Occasionally Frequently Always
22. These NURSES made me feel helpless. Never Rarely Occasionally Frequently Always
23. These NURSES made the quality of my life better. Never Rarely Occasionally Frequently Always
24. I had confidence in these NURSES Never Rarely Occasionally Frequently Always
25. I felt a connection between one or more of these NURSES and myself. Never Rarely Occasionally Frequently Always
26. The presence of these NURSES made a difference to me. Very Negatively Negatively Neither Negatively Or Positively Positively Very Positively
27. Overall, how satisfied were you with the care provided by these NURSES? Very Dissatisfied Dissatisfied Neither Satisfied or Dissatisfied Satisfied Very Satisfied
28. What did the presence of a NURSE mean to you? (You may use the back of this paper if you need more space to write your answer).
29. Overall, how satisfied were you with the care provided by all OF YOUR NURSES?
Very Dissatisfied Dissatisfied Neither Satisfied or Dissatisfied Satisfied Very Satisfied
30. What could the NURSES have done differently so that their presence would have made a difference to you? (You may use the back of this paper if you need more space to write your answer).
184
Appendix 4.14. Nursing Home Resident Satisfaction Scale (Zinn, Lavizzo-Mourey & Taylor,
1993).
Note: For the purpose of this study, only the nursing services subscale was used. Using a scale from 1 (not so good) to 4 (very good), please rate your stay here on the following questions: 1 2 3 4 5 Not so good OK Good Very good NA Physician’s Services Do the doctors treat you well? 1 = yes, 2 = no How well do they treat you? (1, 2, 3, 4, 5) Do the doctors come quickly when you ask to see them? 1 = yes, 2 = no How would you rate the time it takes to come see you? (1, 2, 3, 4, 5) Do you have confidence in the doctor’s abilities? 1 = yes, 2 = no How would you rate your confidence? (1, 2, 3, 4, 5) Nursing Services Do the nurses treat you well? 1 = yes, 2 = no How well do they treat you? (1, 2, 3, 4, 5) Do the nurses come quickly when you call them? 1 = yes, 2 = no How would you rate the time it takes to come to you? (1, 2, 3, 4, 5) Do you have confidence in the nurses’ abilities? 1 = yes, 2 = no How would you rate your confidence? (1, 2, 3, 4, 5) Other Services Do you enjoy mealtime? (Presentation, choice, taste) 1 = yes, 2 = no How would you rate mealtime? (1, 2, 3, 4, 5) Do you like your room? (Cleanliness, roommate, space, temperature) 1 = yes, 2 = no How would you rate your room? (1, 2, 3, 4, 5) Do you get enough quiet and privacy? 1 = yes, 2 = no How would you rate the amount of quiet and privacy? (1, 2, 3, 4, 5) Do you like the daily schedule? (Visitation, mealtime, bedtime, wake-up time) 1 = yes, 2 = no How would you rate the daily schedule? (1, 2, 3, 4, 5) General Services 1. Considering everything, how would you rate your overall saisfaction (Doctor, nursing care services, etc.)? (1, 2, 3, 4, 5)
185
Appendix 4.15. Demographic Sheet for Participants
Male (1) Female (2) Question Answer
How long have you been in this hospital?
Why are you here?
In which country where you born?
What is your first language?
When were you born?
186
Appendix 4.16. Inter-Item Correlations for the HRIS-49
Low (<. 30) inter-item correlations High (>.70) inter-item correlations
Supporting Human Uniqueness Item 3 with item 1 (.246)* Item 6 with item 1 (.275)* Item 7 with items 1 (.005) and 4 (.223) Item 8 with items 1 (.336) and 10 (.280)* Item 9 with items 1 (.132) and 4 (.223) Item 10 with items 4 (.182) Item 11 with item 4 (.273)* Sustaining Choice Relational Capacity Living Dialogue Item 26 with item 28 (.216) Being Present Item 31 with item 38 (.167) Item 32 with item 38 (.236) Item 34 with item 38 (.254)* Fostering Well-being and More-being Item 41 with item 48 (.232)
Supporting Human Uniqueness Sustaining Choice Item 12 with items 13 (.859) and 14 (.831) Relational Capacity Living Dialogue Being Present Item 31 with item 32 (.846) Item 33 with item 34 (.830) Item 35 with item 36 (.826) Item 38 with item 31 (.846) Fostering Well-being and More-being
Note: * = retained at this stage of analysis because value rounded up to .30
187
Appendix 4.17. Inter-Item Correlations for the HRES-49
Low (<. 30) inter-item correlations High (>.70) inter-item correlations
Supporting Human Uniqueness Item 9 with item 3 (.223) Item 11 with items 3 (.273)*, 4 (.221) Sustaining Choice Relational Capacity Living Dialogue Item 24 with item 25 (.138) Being Present Item 30 with items 35 (.198), 36 (.237) Item 32 with items 36 (.287)*, 37 (.251)* Item 33 with item 35 (.236) Item 35 with items 37 (.279)* Item 38 with item 36 (.271)* Fostering Well-being and More-being
Supporting Human Uniqueness Item 6 with item 10 (.823) Item 8 with item 9 (.836) Sustaining Choice Relational Capacity Item 16 with item 17 (.842) Item 19 with item 21 (.814) Living Dialogue Item 23 with item 26 (.820) Item 27 with item 26 .(856) Item 29 with items 26 (.811), 33 (.827) Being Present Fostering Well-being and More-being Item 40 with items 46 (.842), 47 (.831) Item 42 with item 43 (.838) Item 44 with item 46 (.819) Item 47 with items 48 (.824) Item 48 with items 46 (.821), 47 (.841) Item 49 with item 46 (.846)
188
Appendix 4.18. Item-to-Total Correlations for the HRIS-49
Low (<. 30) item-to-total correlations High (>.70) item-to-total correlations Supporting human uniqueness Sustaining Choice Relational Capacity Living Dialogue Being Present Fostering Well-being and More-being
Supporting human uniqueness Item 6 Sustaining Choice Item 12 Item 13 Item 14 Item 15 Relational Capacity Item 16 Item 17 Item 21 Living Dialogue Item 29 Being Present Item 35 Item 36 Fostering Well-being and More-being Item 44 Item 47 Item 49
189
Appendix 4.19. Item-to-Total Correlations for the HRES-49
Low (<. 30) item-to-total correlations High (>.70) item-to-total correlations Supporting human uniqueness Item 2 Sustaining Choice Relational Capacity Living Dialogue Being Present Fostering Well-being and More-being
Supporting human uniqueness Sustaining Choice Item 12 Item 13 Relational Capacity Item 16 Item 17 Item 21 Living Dialogue Item 25 Item 28 Item 29 Being Present Item 31 Item 32 Item 36 Item 37 Item 40 Fostering Well-being and More-being Item 41 Item 43 Item 47
Appendix 4.20. ICC Scores for the HRIS-49
Low (<. 40) ICC
Supporting Human Uniqueness Item 2: .236 Item 8: .336 Item 9: .353 Sustaining Choice Item 14: .340 Relational Capacity Item 17: .380 Item 20: .097 Item 21: .322 Item 22: .380 Living Dialogue Item 24: .365 Being Present
Fostering Well-being and More-being
190
191
Appendix 4.21. Construct validity for the HRES-49
Total Score HCE Scale
Total Score NHRSS
Total Score RCS
Total Score PONS
Total Score HCE Scale
1 .77** .79** .86**
Total Score NHRSS
.77** 1 .84** .86**
Total Score RCS
.79** .84** 1 .83**
Total Score PONS
.86** .86** .83** 1
**: Statically significant (p-value < .001)
192
Appendix 4.22. Variability for the HRES-49
Item % of sample scoring
“Always” or “Absolutely”
(highest score) Supporting Human Uniqueness
1. The nurses know your likes and dislikes. 66.7 2. The nurses understand where your beliefs come from. 35.9 3. The nurses recognize the importance of your family and friends in your life. 61.5 4. The nurses understand what your values are. 46.2 5. The nurses make an effort to ask questions to find out who you are. 48.7 6. The nurses take the time to listen to your stories about your life. 53.8 7. The nurses take the time to listen to your concerns. 61.5 8. The nurses appreciate your particular life history. 48.7 9. The nurses value you as a unique person with struggles. 53.8 10. The nurses respect your likes and dislikes. 64.1 11. The nurses show concern for you as a person. 66.7 Sustaining Choice 12. The nurses recognize your right to make choices about your life. 69.2 13. The nurses recognize your right to make choices about your care. 66.7 14. The nurses support you in your choices. 66.7 15. The nurses respect your choices. 64.1 Relational Capacity 16. You and the nurses enjoy each other's company. 53.8 17. You and the nurses connect with each other. 56.4 18. You and the nurses feel close to each other. 48.7 19. You have a warm and personal relationship with the nurses. 59.0 20. The nurses are willing to be involved in the relationship. 46.2
21. The nurses respond to you when you want to talk. 59.0
22. The nurses are there for you when you need him/her. 61.5 Living Dialogue
193
Item % of sample scoring
“Always” or “Absolutely”
(highest score) 23. The nurses respect your need to be alone. 56.4
24. The nurses know when you need them. 53.8
25. The nurses do things in a way you like them done. 66.7
26. The nurses know how much care you need. 66.7
27. The nurses can figure out what you need without you asking them. 51.3
28. The nurses let you know that they are there for you. 56.4
29. The nurses are there for you when you need them. 56.4
Being Present
30. The nurses feel responsible for your care. 64.1 31. The nurses provide skilful care. 76.9 32. The nurses are competent to provide your care. 76.9 33. The nurses recognize when your health situation is changing and take
appropriate action. 59.0
34. The nurses know you so well; they notice even the smallest change in your situation. 66.7
35. The nurses give you their attention when they are with you. 69.2 36. The nurses make you feel that you are important to them. 53.8
37. The nurses respect you. 71.8 38. The nurses use your name when talking with you. 76.9 39. The nurses like to be with you. 41.0 40. The nurses help your day go well. 53.8 Fostering well-being and More-being 41. The nurses make sure that you are comfortable. 71.8 42. The nurses make you feel better when they are with you. 66.7
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Item % of sample scoring
“Always” or “Absolutely”
(highest score) 43. The nurses help you to have a good quality of life. 56.4 44. The nurses try to make things better for you. 53.8 45. The nurses help you see how your life can be better. 46.2 46. With the help of the nurses, you can reach some of your goals. 43.6 47. The nurses help to boost your confidence in what you can do. 53.8 48. The nurses help you to find meaning in your life.
33.3
49. The nurses help you to make the best of the situation you are in. 59.0
Note: Shaded cells are items suggested for deletion.
195
196
Appendix 4.23. Psychometric properties of the HRIS-49
Item Missing % of sample scoring highest score
Item-to-total
Subscale
Test-Retest
Supporting Human Uniqueness 7 .652**
(.000) Awareness of uniqueness and view of the world 1. The nurses know your likes and dislikes. DELETED
0 46.2 .478** (.002)
.641** (.000)
2. The nurses understand where your beliefs come from. DELETED 6 25.6
Not part of
analysis
.236 (.099)
3. The nurses recognize the importance of your family and friends in your life. 0 51.3 .767**
(.000) .637** (.000)
4. The nurses understand what your values are. DELETED 0 41.0 .591**
(.000) .468** (.003)
Recognition of particularity 5. The nurses make an effort to ask questions to find out who you are. 1 43.6 .770**
(.000) .630** (.000)
6. The nurses take the time to listen to your stories about your life. DELETED 0 41.0 .832**
(.000) .611** (.000)
7. The nurses take the time to listen to your concerns. 0 43.6 .679** (.000)
.555** (.000)
Awareness of view of the world and response to it. 8. The nurses appreciate your particular life history. DELETED
0 25.6 .750** (.000)
.336* (.036)
9. The nurses value you as a unique person with struggles. DELETED 0 33.3 .651**
(.000) .353* (.028)
197
Item Missing % of sample scoring highest score
Item-to-total
Subscale
Test-Retest
10. The nurses respect your likes and dislikes. DELETED 0 48.7 .637**
(.000) .403* (.011)
11. The nurses show concern for you as a person. 0 53.8 .731**
(.000) .566** (.000)
Sustaining Choice 0 .569**
(.000) Freedom to choose to respond 12. The nurses recognize your right to make choices about your life. 59.0 .915**
(.000) 582** (.000)
13. The nurses recognize your right to make choices about your care. 0 56.4 .922** (.000)
.641** (.000)
Freedom to choose how to respond 14. The nurses support you in your choices. 0 46.2 .919**
(.000) 340* (.034)
Respecting choices 15. The nurses respect your choices. 0 51.3 .859**
(.000) .406* (.010)
Relational Capacity 0 .613**
(.000) Connecting 16. You and the nurses enjoy each other's company.
0 30.8 .845**
(.000) .624** (.000)
17. You and the nurses connect with each other. DELETED 0 28.2 .811**
(.000) .380** (.017)
18. You and the nurses feel close to each other. 0 23.1 .749** (.000)
.543** (.000)
19. You have a warm and personal relationship with at least one nurse. 0 46.2 .653** (.000)
.562** (.000)
198
Item Missing % of sample scoring highest score
Item-to-total
Subscale
Test-Retest
Being available
20. The nurses are willing to be involved in the relationship. DELETED
5 28.2 .597** (.000)
.097 (.559)
21. The nurses respond to you when you want to talk.
DELETED 1 43.6 .823** (.000) .322*
(.045)
Nurturing 22. The nurses are there for you when you need them. 0 48.7 .739**
(.000) .380* (.017)
Living Dialogue 4 .582**
(.000) Responding 23. The nurses respect your need to be alone.
0 46.2 .771**
(.000) .681** (.000)
24. The nurses know when you need them. DELETED 0 43.6 .774**
(.000) .365* (.022)
25. The nurses do things in a way you like them done. DELETED 0 56.4 .776**
(.000) .525** (.001)
26. The nurses know how much care you need. 1 48.7 .722** (.000)
.500** (.001)
27. The nurses can figure out what you need without you asking them. 2 41.0 .737** (.000)
.463** (.003)
Calling 28. The nurses let you know that they are there for you. 1 38.5 .658**
(.000) .486** (.002)
199
Item Missing % of sample scoring highest score
Item-to-total
Subscale
Test-Retest
29. The nurses are there for you when you need them. DELETED 0 51.3 .801**
(.000) .652** (.000)
Being Present 8 .7543**
(.000) Professional Accountability 30. The nurses feel responsible for your care. 1 46.2 .731**
(.000) .608** (.000)
31. The nurses provide skilful care. DELETED 0 56.4 .660**
(.000) .593** (.000)
32. The nurses are competent to provide your care. DELETED 0 53.8 .762**
(.000) .708** (.000)
33. The nurses recognize when your health situation is changing and take appropriate action. DELETED
0 61.5 .794** (.000)
.739** (.000)
34. The nurses know you so well; they notice even the smallest change in your situations. DELETED
0 61.5 .746** (.000)
.692** (.000)
Availability 35. The nurses give you their full attention when they are with you. 1 46.2 .822**
(.000) .718** (.000)
36. The nurses make you feel that you are important to them. DELETED
2 41.0 .859** (.000)
.627** (.000)
Reciprocity DELETED 37. The nurses respect you.
0 64.1 .680** (.000)
.435** (.006)
200
Item Missing % of sample scoring highest score
Item-to-total
Subscale
Test-Retest
38. The nurses use your name when talking with you. 0 61.5 .610**
(.000) .678** (.000)
Mutuality 39. The nurses like to be with you.
DELETED 4 38.5 .593**
(.000) .695** (.000)
40. The nurses help your day go well. 0 51.3 .769**
(.000)
Fostering Well-being and More-being. 5 .689**
(.000) Nurturing well-being and comfort 41. The nurses make sure that you are comfortable.
DELETED 1
53.8
.596** (.000)
.683** (.000)
42. The nurses make you feel better when they're with you. 1 43.6 .781** (.000)
.761** (.000)
Accepting 43. The nurses help you to have a good quality of life.
0
38.5
.770** (.000)
.583** (.000)
Searching 44. The nurses try to make things better for you.
DELETED
0
35.9 .823**
(.000) .699** (.000)
45. The nurses help you see how your life can be better. DELETED 0 35.9 .747**
(.000) .472** (.002)
46. With the help of the nurses, you can reach some of your goals. DELETED 0 30.8 .739**
(.000) .600** (.000)
201
Item Missing % of sample scoring highest score
Item-to-total
Subscale
Test-Retest
47. The nurses help to boost your confidence in what you can do. 0 30.8 .815** (.000)
.503** (.001)
Helping to recognize 48. The nurses help you to find meaning in your life. DELETED
3
28.2
.688** (.000)
.450** (.004)
49. The nurses help you to make the best of the situation you are in.
0 38.5 .830** (.000)
** Statically significant at the 0.01 level (2-tailed)
* Statically significant at the 0.05 level (2-tailed)
202
Appendix 4.24. Psychometric properties of the HRES-49
Item Missing % of sample scoring highest score
Item-to-total
Subscale
Test-Retest
Supporting Human Uniqueness 18
.873** (.000)
.832** (.000)
Awareness of uniqueness and view of the world 1. The nurses know your likes and dislikes. DELETED
0 66.7 .752** (.000)
.669** (.000)
2. The nurses understand where your beliefs come from. DELETED 8 35.9 .176
(.283) .400* (.012)
3. The nurses recognize the importance of your family and friends in your life. 0 61.5 .748**
(.000) .814** (.000)
4. The nurses understand what your values are. DELETED 2 46.2 .593**
(.000) .566** (.000)
Recognition of particularity 5. The nurses make an effort to ask questions to find out who you are. 0 48.7 .474**
(.000) .518** (.001)
6. The nurses take the time to listen to your stories about your life. DELETED 1 53.8 .622**
(.000) .832** (.000)
7. The nurses take the time to listen to your concerns. 0 61.5 .795** (.000)
.824** (.000)
Awareness of view of the world and response to it. 8. The nurses appreciate your particular life history. DELETED
3 48.7 .538** (.000)
.513** (.001)
9. The nurses value you as a unique person with struggles. DELETED 2 53.8 .586**
(.000) .493** (.021)
203
Item Missing % of sample scoring highest score
Item-to-total
Subscale
Test-Retest
10. The nurses respect your likes and dislikes. DELETED 1 64.1 . 784**
(.000) .479** (.002)
11. The nurses show concern for you as a person. 1 66.7 .755**
(.000) .794** (.000)
Sustaining Choice 2
.918** (.000)
.712** (.000)
Freedom to choose to respond 12. The nurses recognize your right to make choices about your life. 0 69.2 .839**
(.000) .787** (.000)
13. The nurses recognize your right to make choices about your care. 0 66.7 .863** (.000)
.747** (.000)
Freedom to choose how to respond 14. The nurses support you in your choices. 1 66.7 .758**
(.000) .490** (.002)
Respecting choices 15. The nurses respect your choices. 1 64.1 .681**
(.000) .455** (.004)
Relational Capacity 6 .957**
(.000) .690 ** (.000)
Connecting 16. You and the nurses enjoy each other's company.
0 53.8 .803**
(.000) .566** (.000)
17. You and the nurses connect with each other. DELETED 0 56.4 .817**
(.000) .694** (.000)
18. You and the nurses feel close to each other. 0 48.7 .785** (.000)
.661** (.000)
19. You have a warm and personal relationship with at least one nurse. 0 59.0 .774** (.000)
.540** (.000)
204
Item Missing % of sample scoring highest score
Item-to-total
Subscale
Test-Retest
Being available
20. The nurses are willing to be involved in the relationship. DELETED
6 46.2 .533** (.000)
.543** (.000)
21. The nurses respond to you when you want to talk.
DELETED 0 59.0 .849** (.000) .517**
(.001)
Nurturing 22. The nurses are there for you when you need them. 0 61.5 .781**
(.000) .800* (.000)
Living Dialogue 2
.917** (.000)
.737** (.000)
Responding 23. The nurses respect your need to be alone.
1 56.4 .596**
(.000) .613** (.000)
24. The nurses know when you need them. DELETED 1 53.8 .605**
(.000) .803* (.000)
25. The nurses do things in a way you like them done. DELETED 0 66.7 .827**
(.000) .808** (.001)
26. The nurses know how much care you need. 0 66.7 .758** (.000)
.685** (.001)
27. The nurses can figure out what you need without you asking them. 0 51.3 .677** (.000)
.710** (.003)
Calling 28. The nurses let you know that they are there for you. 0 56.4 .810**
(.000) .427** (.002)
205
Item Missing % of sample scoring highest score
Item-to-total
Subscale
Test-Retest
29. The nurses are there for you when you need them. DELETED 0 56.4 .809**
(.000) .579** (.000)
Being Present 10 .962**
(.000) .697** (.000)
Professional Accountability 30. The nurses feel responsible for your care. 1 64.1 .800**
(.000) .607** (.000)
31. The nurses provide skilful care. DELETED 0 76.9 .843**
(.000) .579** (.000)
32. The nurses are competent to provide your care. DELETED 0 76.9 .848**
(.000) .523** (.001)
33. The nurses recognize when your health situation is changing and take appropriate action. DELETED
0 59.0 .744** (.000)
.760** (.000)
34. The nurses know you so well; they notice even the smallest change in your situations. DELETED
0 66.7 .714** (.000)
.761** (.000)
Availability 35. The nurses give you their full attention when they are with you. 1 69.2 .727**
(.000) .789** (.000)
36. The nurses make you feel that you are important to them. DELETED
0 53.8 .888** (.000)
.605** (.000)
Reciprocity 37. The nurses respect you. DELETED
0 71.8 .802** (.000)
.481** (.002)
206
Item Missing % of sample scoring highest score
Item-to-total
Subscale
Test-Retest
38. The nurses use your name when talking with you. 0 76.9 .739**
(.000) .445** (.004)
Mutuality 39.The nurses like to be with you. DELETED
8 41.0 .575** (.000)
.575** (.000)
40. The nurses help your day go well. 0 53.8 .851**
(.000) .536** (.000)
Fostering Well-being and More-being. 11 .935**
(.000) .721** (.000)
Nurturing well-being and comfort 41. The nurses make sure that you are comfortable.
DELETED 0 71.8 .822**
(.000) .650** (.000)
42. The nurses make you feel better when they're with you. 2 66.7 .756** (.000)
.516** (.000)
Accepting 43.The nurses help you to have a good quality of life.
0
56.4 .876** (.000)
.631** (.000)
Searching 44. The nurses try to make things better for you. DELETED
0 53.8 .793**
(.000) .496** (.000)
45. The nurses help you see how your life can be better. DELETED 2 46.2 .646**
(.000) .615** (.000)
46. With the help of the nurses, you can reach some of your goals. DELETED 1 43.6 .761**
(.000) .750** (.000)
207
Item Missing % of sample scoring highest score
Item-to-total
Subscale
Test-Retest
47. The nurses help to boost your confidence in what you can do. 1 53.8 .802** (.000)
.684** (.000)
Helping to recognize 48. The nurses help you to find meaning in your life. DELETED
4 33.3 .575**
(.000) .453** (.004)
49. The nurses help you to make the best of the situation you are in.
1 59.0 .757** (.000)
.553** (.000)
** Statically significant at the 0.01 level (2-tailed)
* Statically significant at the 0.05 level (2-tailed)
208
Appendix 5.1. Information Letters for Phase Three Participants
Letterhead Dear,
We are undertaking a study to examine the relationships you have with the nurses on this unit. The overall purpose of this study is to examine the nature of the relationships patients have with nursing personnel in chronic care settings.
You have been invited to participate in this study because you are a patient at (Name of
facility). If you decide to take part in the study, you will be asked to answer some questions about yourself and your relationship with the nurses.
There are no known risks to participation in this study. However, you may choose not to
participate in this study. If so, this decision will have no impact on your care at this hospital. Your care providers will not be aware of whether you participate or not. You are free to omit any question during the interview. You may also withdraw from the study at any time.
If you decide to participate, the researcher will help you to complete a consent form. The
cost of participating in this study will be the time expenditure needed to answer the questions (30 minutes). You will not receive payment for your participation.
To assure confidentiality, your name will not appear in this research study. Only a code
number will appear on any forms or questions sheets. Data will be kept in an electronic file. Information obtained from you will be reported as grouped responses – never by individual respondent. Furthermore, no grouped responses will be reported for a named hospital.
If you have any questions please contact the Principal Investigator, Véronique Boscart,
Toronto Rehabilitation Institute, at 416-597-3422 x. 2246 or [email protected]. You can also contact my supervisor, Dr. Dorothy Pringle, at 416- 929-0700 or [email protected]. If you have any questions about the conduct of this study or your rights as a research subject, you may contact (Name of VP Research at the participating facility).
The findings of this study may lead to a greater understanding of the nurse-patient
relationship in chronic care and will support the care, research and education of nurses and patients in these environments. On behalf of the study team, I thank you for your support. We appreciate your taking the time to consider participating in this study. This letter is yours to keep for future reference.
Sincerely, Véronique Boscart, Graduate student, Bloomberg Faculty of Nursing,
University of Toronto.
209
Appendix 5.2. Consent Form for Phase Three Participants
Letterhead
Title of the study: Humanistic Nurse-Patient Relationships in Chronic Care Settings. Principal Investigator: Veronique Boscart, Graduate student, Bloomberg Faculty of Nursing, University of Toronto.
I have read the Letter of Information, have had the nature of the study explained to me, including an explanation of any benefits and risks associated with the study. I have also been given an opportunity to ask questions concerning this study, and any questions that I have asked have been adequately answered.
I have been told that I can withdraw my consent and stop taking part in this study at any
time and for any reason. I have been told that my identity will be kept confidential. I understand the information that I have been provided.
I voluntarily consent to participate in this study. _____________________ ___________________ _______ Printed Name of Participant Signature of Participant Date ______________________ _____________________ _______ Printed Name of Person Signature of Person Date Obtaining Informed Consent Obtaining Informed Consent
210
Appendix 5.3. Missing values for the HRIS-24 and HRES-24
HRIS
Missing
values
HRES
Missing
values
Item 1 4 7
Item 2 2 6
Item 3 6 4
Item 4 8 2
Item 5 4 6
Item 6 4 2
Item 7 0 6
Item 8 7 2
Item 9 2 5
Item 10 5 4
Item 11 3 0
Item 12 1 5
Item 13 9 11
Item 14 6 5
Item 15 5 4
Item 16 7 0
Item 17 8 5
Item 18 3 8
211
Item 19 1 7
Item 20 5 8
Item 21 4 5
Item 22 3 4
Item 23 0 2
Item 24 5 5
Total 102 113
212
Appendix 5.4. Unrotated Factor Loading Matrix for the HRIS-24
Scale item/factor 1 2 3 4 5
1. The nurses recognize the importance of your family and friends in your life. .594 .039 .371 .129 .384
2. The nurses make an effort to ask questions to find out who you are. .609 -.208 .158 .278 .389
3. The nurses take the time to listen to your concerns. .691 -.304 -.015 -.168 .271 4. The nurses show concern for you as a person. .722 -.311 -.036 -.133 .074 5. The nurses recognize your right to make choices about
your life. .618 -.005 .518 .020 -.061
6. The nurses recognize your right to make choices about your care. .695 -.185 .398 -.134 -.025
7. The nurses support you in your choices. .710 -.122 .324 .070 -.338 8. The nurses respect your choices. .688 -.115 .335 -.094 -.294 9. You and the nurses enjoy each other's company. .676 -.098 .024 .385 -.286 10. You and the nurses feel close to each other. .613 -.048 -.250 .592 -.108 11. You have a warm and personal relationship with at
least one nurse. .601 -.265 -.319 .362 -.127
12. The nurses are there for you when you need them. .635 -.295 -.147 -.212 -.249 13. The nurses respect your need to be alone. .295 .083 .155 .166 .256 14. The nurses know how much care you need. .647 -.274 -.079 -.187 .070 15. The nurses can figure out what you need without you
asking them. .616 .072 -.271 .207 .083
16. The nurses let you know that they are there for you. .692 -.134 -.167 -.299 -.165 17. The nurses feel responsible for your care. .697 -.151 -.269 -.233 .121
18. The nurses give you their full attention when they are with you. .646 .022 -.205 -.300 .178
19. The nurses use your name when talking with you. .563 .310 .060 .088 .255 20. The nurses help your day go well. .730 .166 -.273 .014 .117 21. The nurses make you feel better when they're with
you. .679 .251 -.264 -.079 -.031
22. The nurses help you to have a good quality of life. .628 .620 .047 -.015 -.117 23. The nurses help to boost your confidence in what you
can do. .656 .586 .027 -.179 -.083
24. The nurses help you to make the best of the situation you are in. .708 .468 -.013 -.024 -.073
Note: Shaded area indicates a factor loading of ≥.33 (CV) for an item.
213
Appendix 5.5. Orthogonal Varimax Rotated Factor Loading Matrix for the HRIS-24
Scale item/factor 1 2 3 4 5
1. The nurses recognize the importance of your family and friends in your life. .178 .214 .295 .061 .698
2. The nurses make an effort to ask questions to find out who you are. .297 .013 .192 .312 .667
3. The nurses take the time to listen to your concerns. .675 .060 .214 .125 .389
4. The nurses show concern for you as a person. .651 .085 .317 .224 .2495. The nurses recognize your right to make choices
about your life. .134 .227 .659 .049 .384
6. The nurses recognize your right to make choices about your care. .394 .140 .635 .034 .340
7. The nurses support you in your choices. .237 .213 .731 .296 .1368. The nurses respect your choices. .315 .225 .714 .146 .1149. You and the nurses enjoy each other's company. .163 .206 .457 .632 .14310. You and the nurses feel close to each other. .131 .207 .122 .826 .21611. You have a warm and personal relationship with
at least one nurse. .367 .055 .136 .718 .094
12. The nurses are there for you when you need them. .623 .113 .375 .259 -.104
13. The nurses respect your need to be alone. .028 .144 .073 .092 .41914. The nurses know how much care you need. .637 .095 .252 .167 .18415. The nurses can figure out what you need
without you asking them. .332 .347 .004 .471 .234
16. The nurses let you know that they are there for you. .656 .285 .312 .173 -.055
17. The nurses feel responsible for your care. .721 .247 .091 .196 .14918. The nurses give you their full attention when
they are with you. .638 .368 .052 .053 .182
19. The nurses use your name when talking with you. .165 .487 .079 .135 .449
20. The nurses help your day go well. .469 .504 .025 .344 .23821. The nurses make you feel better when they're
with you. .424 .578 .076 .273 .079
22. The nurses help you to have a good quality of life. .064 .835 .237 .128 .144
23. The nurses help to boost your confidence in what you can do. .197 .840 .233 .020 .118
24. The nurses help you to make the best of the situation you are in. .211 .746 .238 .193 .177
Note: Shaded area indicates a factor loading of ≥.33 (CV) for an item.
214
Appendix 5.6. Orthogonal Varimax Rotated Four Factor Loading Matrix for the HRIS-24
Scale item/factor 1 2 3 4
1. The nurses recognize the importance of your family and friends in your life. .139 .264 .620 .186
2. The nurses make an effort to ask questions to find out who you are. .250 .066 .506 .440
3. The nurses take the time to listen to your concerns. .652 .092 .355 .197
4. The nurses show concern for you as a person. .662 .100 .359 .2475. The nurses recognize your right to make choices
about your life. .183 .232 .748 .057
6. The nurses recognize your right to make choices about your care. .439 .145 .692 .041
7. The nurses support you in your choices. .330 .193 .655 .2318. The nurses respect your choices. .403 .205 .630 .0849. You and the nurses enjoy each other's company. .226 .197 .425 .58710. You and the nurses feel close to each other. .144 .218 .184 .83011. You have a warm and personal relationship with
at least one nurse. .388 .058 .121 .704
12. The nurses are there for you when you need them. .684 .093 .208 .19013. The nurses respect your need to be alone. -.007 .177 .288 .17514. The nurses know how much care you need. .645 .106 .271 .18415. The nurses can figure out what you need without
you asking them. .314 .368 .097 .507
16. The nurses let you know that they are there for you. .701 .271 .183 .123
17. The nurses feel responsible for your care. .711 .263 .111 .22118. The nurses give you their full attention when they
are with you. .616 .387 .105 .092
19. The nurses use your name when talking with you. .127 .522 .297 .21820. The nurses help your day go well. .448 .525 .111 .38221. The nurses make you feel better when they're with
you. .429 .583 .068 .268
22. The nurses help you to have a good quality of life. .088 .834 .258 .11223. The nurses help to boost your confidence in what
you can do. .218 .838 .237 .005
24. The nurses help you to make the best of the situation you are in. .230 .749 .269 .186
Note: Shaded area indicates a factor loading of ≥.33 (CV) for an item.
215
Appendix 5.7. Inter-Item Correlations for the HRIS-24
Inter-Item Correlations for Factor 1 of the HRIS-24
Factor 1 Item 3 Item 4 Item 12 Item 14 Item 16 Item 17 Item 18
Item 3 1.000 .625 .460 .498 .540 .546 .495 Item 4 .625 1.000 .511 .499 .486 .538 .512 Item 12 .460 .511 1.000 .555 .507 .503 .424 Item 14 .498 .499 .555 1.000 .452 .512 .390 Item 16 .540 .486 .507 .452 1.000 .555 .517 Item 17 .546 .538 .503 .512 .555 1.000 .497 Item 18 .495 .512 .424 .390 .517 .497 1.000
Inter-Item Correlations for Factor 2 of the HRIS-24
Factor 2 Item 20 Item 21 Item 22 Item 23 Item 24
Item 20 1.000 .623 .516 .463 .527 Item 21 .623 1.000 .503 .549 .533 Item 22 .516 .503 1.000 .741 .710 Item 23 .463 .549 .741 1.000 .763 Item 24 .527 .533 .710 .763 1.000
Note: Correlations of ≤ .70 are indicated in grey.
Inter-Item Correlations for Factor 3 of the HRIS-24
Factor 3 Item 5 Item 6 Item 7 Item 8
Item 5 1.000 .578 .562 .519 Item 6 .578 1.000 .599 .563 Item 7 .562 .599 1.000 .666 Item 8 .519 .563 .666 1.000
Inter-Item Correlations for Factor 4 of the HRIS-24
Factor 4 Item 9 Item 10 Item 11 Item 15
Item 9 1.000 .642 .467 .410 Item 10 .642 1.000 .593 .486 Item 11 .467 .593 1.000 .372 Item 15 .410 .486 .372 1.000
216
Inter-Item Correlations for Factor 5 of the HRIS-24
Factor 5 Item 1 Item 2 Item 13 Item 19
Item 1 1.000 .496 .226 .362 Item 2 .496 1.000 .195 .358 Item 13 .226 .195 1.000 .194 Item 19 .362 .358 .194 1.000
Note: Correlations of ≤ .70 are indicated in grey.
217
Appendix 5.8. Overview of Inter-Item Correlations per Factor for the HRIS-24
Low (<. 30) inter-item correlations
High (>.70) inter-item correlations
Relational availability
None None
Promoting quality of daily life
None Item 22 and 23 (.74) Item 22 and 24 (.71) Item 24 and 23 (.76)
Recognizing and supporting choice
None None
Forming connections
None None
Supporting human uniqueness
Item 1 and 13 (.23) Item 2 and 13 (.19) Item 19 and 13 (.19)
None
218
Appendix 5.9. Descriptive Statistics per Item for the HRIS-24
Scale item/factor Range(1-5)
Mean SD
1. The nurses recognize the importance of your family and friends in your life. 4 3.84 1.28
2. The nurses make an effort to ask questions to find out who you are. 4 3.85 1.34
3. The nurses take the time to listen to your concerns. 4 4.24 1.23
4. The nurses show concern for you as a person. 4 4.31 1.07 5. The nurses recognize your right to make choices
about your life. 5 4.20 1.14
6. The nurses recognize your right to make choices about your care. 4 4.21 1.07
7. The nurses support you in your choices. 4 4.18 1.12 8. The nurses respect your choices. 4 4.16 1.14 9. You and the nurses enjoy each other's company. 4 4.14 1.10 10. You and the nurses feel close to each other. 4 3.82 1.30 11. You have a warm and personal relationship with
at least one nurse. 4 4.09 1.27
12. The nurses are there for you when you need them. 4 4.49 0.93 13. The nurses respect your need to be alone. 5 4.09 1.20 14. The nurses know how much care you need. 4 4.47 0.92 15. The nurses can figure out what you need without
you asking them. 4 3.90 1.26
16. The nurses let you know that they are there for you. 4 4.13 1.71
17. The nurses feel responsible for your care. 4 4.35 1.02 18. The nurses give you their full attention when they
are with you. 4 4.37 1.03
19. The nurses use your name when talking with you. 4 3.68 1.36 20. The nurses help your day go well. 4 4.06 1.18 21. The nurses make you feel better when they're with
you. 4 4.18 1.05
22. The nurses help you to have a good quality of life. 4 3.90 1.18 23. The nurses help to boost your confidence in what
you can do. 5 3.83 1.26
24. The nurses help you to make the best of the situation you are in. 5 3.89 1.25
219
Appendix 5.10. Descriptive Statistics per Item for the HRES-24
Scale item/factor Range(1-5)
Mean SD
1. This nurse recognizes the importance of your family and friends in your life. (I) 5 2.78 1.45
2. This nurse makes an effort to ask questions to find out who you are. 5 2.98 1.50
3. This nurse takes the time to listen to your concerns. 5 2.96 1.51
4. This nurse shows concern for you as a person. (I) 5 3.02 1.53 5. This nurse recognizes your right to make choices
about your life. (I) 5 3.04 1.42
6. This nurse recognizes your right to make choices about your care. (I) 5 3.19 1.45
7. This nurse supports you in your choices. 5 2.95 1.60 8. This nurse respects your choices. 5 3.18 1.46 9. You and this nurse enjoy each other's company. 5 2.77 1.45 10. You and this nurse feel close to each other. (I) 5 2.93 1.45 11. You have a warm and personal relationship with
this nurse. (I) 5 3.10 1.49
12. This nurse is there for you when you need him/her. 5 3.32 2.31
13. This nurse respects your need to be alone. 5 3.18 1.49 14. This nurse knows how much care you need. 5 3.03 1.45 15. This nurse can figure out what you need without
you asking him/her. 5 3.18 1.49
16. This nurse lets you know that he/she is there for you. 5 2.89 1.52
17. This nurse feels responsible for your care. 5 2.94 1.53 18. This nurse gives you his/her full attention when
he/she is with you. 5 2.75 1.50
19. This nurse uses your name when talking with you. 5 2.97 1.47 20. This nurse helps your day go well. 5 2.76 1.54 21. This nurse makes you feel better when he/she is
with you. 5 2.73 1.51
22. This nurse helps you to have a good quality of life. 5 2.63 1.43
23. This nurse helps to boost your confidence in what you can do. (I) 5 2.55 1.43
24. This nurse helps you to make the best of the situation you are in. 5 2.69 1.52
(I): items rated with an intensity score
