Perceptions of nurses in Japan toward their patients' expectations of care: A qualitative study.

OBJECTIVES: This study aimed to investigate ideal nurse involvement based on the expectations of patients. Data on conflicts between nurses and patients were obtained. The patient situation involved standard nursing treatment, rather than acute phase or palliative care.
METHODS: Questionnaires were distributed among senior nurses attending a series of trainings in 2012 and 2013. The nurses were requested to return their completed questionnaires within two weeks. We ensured the effectiveness of the interview process to obtain accurate answers.The sample comprised 240 head nurses and assistant head nurses who were asked to respond anonymously to 57 questions about non-acute (stable) psychiatric or physical nurse-patient scenarios. Qualitative data analysis was conducted using these responses.
RESULTS: We received 41 completed responses (response rate = 17.1%). The expectations of patients and their families were reflected in five categories, namely, inference, empathic understanding, listening attitude, individual treatment, and reliable skills and explanations. Inference was independently categorized as a particularly strong characteristic of Japanese patients' expectations.
CONCLUSIONS: Nursing care in situations where conflicts or misunderstandings may arise can be improved by encouraging nurses to be attentive to the moods, feelings, and expectations of patients and their families. The findings from this study can improve the quality of Japanese nursing care with regard to sensing (inferring) and reacting to the expectations of patients.

Introduction

Advancements in medical technology have improved patient care. As medical practitioners become increasingly specialized, people have emphasized the value of healthcare, such that the standard of medical care as a high-quality service is currently being scrutinized. However, although medical service quality must not be determined by patient satisfaction alone [1], such quality has been increasingly evaluated by measuring the quality of hospital and nursing services, from the perspective of patients, since the 1980s [2], [3], [4].

Hospital services include core-services and sub-services that are similar to those generally provided in hotels. The evaluation of overall service quality often emphasizes sub-services that are neither experienced by clients in hotels, nor are reflected in hospital costs. By contrast, core-services, including technology provisions, are often reflected in these costs [5]. Establishing relationships between medical care providers and patients, which is considered a sub-service, has become increasingly difficult with the increasing number of specialized medical care core-services [6]. Maintaining favorable relationships between patients and medical care providers requires the “cultivation of mutual relationships and mutual understanding,” and conflicts inevitably arise in the event that the harmony in such personal relationships cannot be maintained [7].

Robbins defined conflict as “a process that begins when one party perceives that another party has negatively affected, or is about to negatively affect, something that the first party cares about” [8]. Marquis and Huston asserted that conflicts arise from differences in perceptions, values, expectations, and backgrounds [9]. Since 2000, studies on conflicts in clinical practice have proposed various methods for dealing with such clashes in specific circumstances, including hard to please patients [10], patients in acute psychiatry wards [11], and patients in elderly nursing and care homes [12].

Nurses deal with conflicts by adopting strategies that lead to solutions through discussion [13]. Nurse–patient relationships are fundamental to the therapeutic partnership [14], where showing interest in the daily moods of patients is essential [15].

Nursing care is related to patient satisfaction [16]; however, the concept of patient satisfaction continues to evolve [17]. Several studies have defined such concepts, and developed scales for assessing patient satisfaction with nursing care [18], [19] by addressing the technical–professional, trust, and educational aspects of nurse–patient relationships. Service marketing studies have also focused on the relationship between the service expectations and perceptions of customers toward the actual services they receive [20], [21], [22], [23], [24].

In this study, we used a qualitative and inductive approach to analyze the contents of conflicts that occur in daily nursing practice, particularly the interpersonal elements between patients and experienced nurse managers. To improve patient and nurse satisfaction, we identified the elements of ideal nursing treatment based on how nurses viewed the expectations of their patients. To provide data for developing the concept of ideal nurse treatment in accordance with the expectations of patients, we performed an inductive analysis of conflict-arousing situations.

Materials and methods

Study design

We performed content analysis using a qualitative and inductive approach in reference to Polit and Beck [25].

Study subjects

Nurses attending Nursing Management Training (NMT) provided by the Nursing Professional Association in Osaka, Japan were selected as participants. All participants held the position of either head nurse or deputy to the head nurse, and were affiliated with or were working for various hospitals or health care institutions in Osaka. We focused on this group of nurses because they were well established within the nursing field and were capable of expressing their knowledge and experiences. The NMT session lasted for 10 months, during which the participants worked in hospitals for five days and attended lectures for one day each week.

The workplaces of these nurses varied greatly, from outpatient departments to hospital wards and operation rooms. Similar to nurses working in other prefectures throughout Japan, those nurses who were working in the medical care facilities in Osaka were affiliated with the Nursing Professional Association of the prefecture.

Study procedure, data collection, and ethical considerations

This study was performed in August 2012, November 2012, and January 2013 at the end of the course. The person responsible for conducting the NMT workshop explained the purpose of the study to the participants. After receiving their consent, we provided the participants with oral and written explanation of the study during their rest period. At this time, we guaranteed participants that their identities would not be disclosed, and that their data would not be used outside of the research, would be carefully handled, and would be destroyed upon completion of the study. Afterward, the nurses were informed that their participation was voluntary, that they would not be disadvantaged in any way if they did not consent to participate, and that this study was not related to the NMT workshop. We distributed self-administered anonymous questionnaires, and the completed questionnaires were returned to a secure collection box after two weeks. The participants provided their informed consent by returning complete responses. This study was conducted with the approval of the ethics committee of our university.

Survey content

The questionnaire included 57 questions about non-acute (stable) psychiatric or physical nurse–patient scenarios. The questionnaire was structured based on the Robbins conflict process, was translated from English to Japanese, and included items related to potential disagreement or incompatibility-causing conflicts, cognition and personalization-causing conflicts, and behavior-causing conflicts in nursing scenarios, the actions and outcomes related to nurse–patient relationships, and the demographic characteristics of the participants.

To ensure the validity of the questionnaire, a pretest was performed among five university students with at least seven years of nursing experience. The pretest results confirmed the validity of the questionnaire items. The participants were able to answer the pretest questions without experiencing undue burden.

Data analysis

We used 41 of the 57 Robbins conflict process questions. The other 16 questions were excluded because they dealt with conflicts involving medical professionals other than nurses. These 41 items assessed the situations that clearly described the elements that were thought to have caused the conflict, the situations in which conflicts emerged, the responses to these conflicts, and the status of nurse–patient relationships after dealing with conflicts. These situations were written down and read by two university staff members specializing in nursing management studies. We then extracted information related to ideal nurse treatment, in accordance with the expectations of patients, using a qualitative and inductive approach. First, the data for each description were summarized so as not to change the content. Second, the ideal treatment methods applied by nurses that resulted in favorable relationships with their patients were grouped together. For those cases in which the treatment methods were considered inadequate, we reversed the data for these methods for them to be categorized as desired and ideal. Third, the trends in the ideal treatments applied by nurses were categorized.

Results

Descriptive data

The questionnaires were distributed among 240 nurses, and 41 completed responses were received. At the time of the conflicts, the nurses had a mean age of 40.5 ± 2.38 years and nursing experience of 19.5 ± 3.38 years.

Data synthesis and category creation

We grouped those ideal treatments that improved nurse–patient relationships into five categories, namely, inference, empathic understanding, listening, individual treatment, and reliable skills and explanations. Inference refers to the state of wellbeing that is attuned to the unspoken feelings of patients and their family members, and how nurses respond to their patients according to these perceived feelings. Patient/family member expectations are related to what the patients or their family members hope to receive from the nursing interventions, including undefined feelings. Nurse treatment encompasses the judgments, reactions, and behaviors of nurses during conflict situations.

Those items that contrasted the ideal treatment methods were marked with # in the list of subcategories (Table 1). Table 2 lists the five categories and their definitions, and some typical data for each category are provided in the following sections.

Table 1

Ideal nurse treatment in accordance with patient expectations during conflicts.

Categories	Subcategories
Inference (n = 17)	Quick response while being mindful of the feelings of the patients and their family members (3)
	Paying close attention to the feelings of patients and their family members (2)
	Tactfulness of nurses
	Detachment from the feelings of patients and their family members (8)#
	Ignoring the feelings of family members and prioritizing expertise (2)#
	Nurses failing to consider their normal lives and responsibilities#
Empathic understanding (n = 8)	Empathy for the feelings of family members and implementation (3)
	Respect for the choices of patients
	Involvement in the expression of the feelings of family members
	Understanding and showing gratitude to the feelings of patients
	Lack of respect for the values of patients (2)#
Listening (n = 7)	Listening closely to the feelings of patients (4)
	Listening to the feelings of family members
	Giving sufficient time to listen
	Listening carefully to concerns
Individual treatment (n = 5)	Provision of treatment beyond the general guidelines
	Treatment with deliberate third-party intervention
	Offering suggestions that respect the wishes of patients and their family members
	Provision of treatment that respects the feelings of patients
	Manual treatment#
Reliable skills and explanations (n = 4)	Reliable provision of skills
	Applying knowledge and treatment that suit the needs of patients
	Appropriate treatment and explanations
	Appropriate explanations and suggestions for patients

#Indicates those items that contrast the ideal treatment methods.

Table 2

Categories of ideal nurse treatment and their definitions.

Category	Definition
Inference	Being well attuned to the unspoken thoughts and feelings of patients and acting accordingly
Empathic understanding	Respecting and understanding the intentions and decisions of patients and their family members
Listening	Listening carefully to the thoughts of patients and their family members
Individual treatment	Prioritizing the wishes of patients beyond the general guidelines of hospitals or institutions
Reliable skills and explanations	Treating patients based on expert knowledge as a nurse

Inference

Being well attuned to the unspoken feelings of patients and their family members was identified as an important characteristic by 17 respondents. One of the respondents explained:

“When setting the breakfast table, I called out the patient's name, but the patient appeared to be sleeping, so I just set the table and went to the next room. Thereafter, the patient woke up and complained to another nurse that ‘It was left just like that, and the nurse should have woken me up and set the table so that I could eat easily.’ In response, the other nurses stopped what they were doing and apologized to the patient. The patient accepted the apology and said that he only wanted us to be more careful in the future; subsequently, we have maintained a favorable relationship with that patient.” (ID 49)

Empathic understanding

Eight respondents emphasized the importance of providing treatment while showing understanding and respect for the thoughts and feelings of patients and their family members. One of the respondents narrated:

“A fetal abnormality was detected in a pregnant woman after fertility treatment. The patient was told that there was no medical problem, but we respected the patient's decision of not continuing with the pregnancy. Thereafter, the patient's trust in her nurse grew deeper.” (ID 4)

Listening

Listening to the thoughts and feelings of patients and their family members was identified as an important characteristic by seven respondents. One of the respondents explained:

“Even though the family member told the nurse that the contact person for the patient had been changed, the hospital did not respect the contact route as requested. Furthermore, the details became very troublesome upon the patient's sudden discharge from the hospital, and the family member lost his trust in the nurse. To deal with this situation, the nurse listened earnestly to the feelings of the family member, and their relationship was improved as a result.” (ID 12)

Individual treatment

Going beyond the general guidelines of the hospital or institution and prioritizing the wishes of the patient whenever possible were identified as necessary characteristics by five respondents. One of the respondents narrated:

“Immediately before the surgery, the patient's anxiety intensified and he eventually refused the surgery. In response, the nurse contacted the attending physician to inform him/her that the surgery could not be performed on schedule, after which the surgery time was delayed, and the patient's anxiety was eased.” (ID 20).

Reliable skills and explanations

Four respondents emphasized the importance of treatment based on expert nursing knowledge. According to one of the respondents:

“A patient was concerned that the application of the interferon injection technique differed depending on the nurse. In response, the facts were confirmed with the patient, and the nurse immediately apologized for the mistake. An interferon injection manual was also created, which was acknowledged by the patient, and the injections were applied for one month by highly experienced staff.” (ID 57)

Discussion

The ideal treatments during conflicts that improved the nurse–patient relationship were categorized into inference, empathic understanding, listening, individual treatment, and reliable skills and explanations. The results demonstrated that patients, especially those in Japan, want and expect their nurses to understand their feelings [26]. Unfortunately, patients rarely communicate these expectations to their nurses.

Patient satisfaction

We divided the service qualities specific to nursing care into five categories, namely, inference, empathic understanding, listening, individual treatment, and reliable skills and explanations. Recent nursing and management studies reveal that nursing quality and patient satisfaction characteristically depend on specific situations and the underlying environmental culture. A survey of service quality from the perspective of outpatients in Finland revealed that nurses and nursing departments used a service quality instrument that generated valuable information for improving service quality [27]. A separate survey in a tertiary care setting that utilized a service quality scale identified reliability as the most expected and perceived dimension among all nursing service quality characteristics [28].

A survey using SERVQUAL, a well-established and widely used measurement of customer perceptions toward received service, revealed that patients in Korea were more satisfied with their nursing and medical care than their nurses were [29]. The actual nursing performance of these nurses was relatively lower than expected, thereby resulting in poor-quality nursing care. However, the nurses and patients showed some similarities in their perceptions and expectations. A survey using SERVQUAL in Taiwan identified some similarities between the expectations and service experience of patients in other Asian countries. Empathy was also identified as the most significant dimension for predicting positive patient experiences [30]. Similar research must be conducted in other Asian countries, including China, to improve the generalizability of these findings.

Relevance of the findings

Among the five identified categories, inference was particularly characteristic of the feelings of the Japanese people. For instance, the anecdote of ID 49 in the Results section indicated that the patient did not clearly request how his meal was to be prepared; instead, the patient expected that the nurse would know (or make an inference based on) his wishes, even without communicating them. When the nurses acted contrary to his expectation, the patient felt abandoned and became dissatisfied with the service. Such instance is a common feature of the omotenashi (hospitality) culture of Japan.

The service expectations of patients are rooted in traditional Japanese culture, such that patients from Japan are influenced by their culture. Kondo claimed that as part of the Japanese hospitality concept, the omotenashi and omoi sassuru cultures facilitate an unspoken agreement and mutual understanding between nurses and patients without explicitly stating their expectations [31]. Leininger further described the influences of cultural diversity and universality on patient–nurse relationships [32], [33], [34], [35].

The Japanese term, amae, indicates a lack of self-reliance; however, this expression does not have a corresponding English translation. Most of the data used in this study were related to the concept of inference; therefore, we identified inference as an independent characteristic of the Japanese population. By contrast, those items marked with # in Table 2 (i.e., responses contrary to the ideal treatment methods) included eight items concerning detachment from the feelings of patients and their family members, which indicates that despite retaining their values, patients also respected the need for nurses to concentrate on expert treatment during clinical practice.

Regarding the role of culture in our daily lives, D'Andrade proposed four functions, namely, representational, constructive, directive, and evocative [36]. Culture is related to the fundamental components of the human mind, including knowledge (representational and constructive functions), passion (evocative function), and will/intent (directive function). Given that the Japanese people are inclined to be emotionally dependent, Japanese patients tend to depend on others for responsive care.

Therefore, nurses must detach themselves from the feelings of their patients and their stable family members. However, with regard to interpersonal relationships in other countries, inference is a universal phenomenon that forms the basis for the other categories, including empathic understanding, listening, individual treatment, and reliable skills and explanations.

Those patients who suffer from various illnesses do not expect to establish a relationship with their nurses. Simple acts of kindness, such as providing care with a smile and saying thank you, can make a difference to these patients. The results emphasize the importance of accommodating the thinking of patients to help nurses engage in inference.

Relevance to clinical practice

Based on the five identified categories, we propose several ways to prevent or deal with the conflicts that may arise between nurses and patients. Japanese individuals with traditional cultural values are often subject to modern nursing care in Japan, which is characterized by internationalization and cross-cultural communication. From the perspective of patients, the conflicts arising from nurse–patient relationships can be addressed by ensuring better quality nursing services, which in turn can be achieved by acknowledging the expectations of patients and implementing changes to the nursing practice based on these expectations.

Highly qualified nursing care depends on humanistic literacy, illness-related knowledge mastery, and adequate nursing skills. Therefore, to meet the expectations of his/her patients or avoid nurse–patient conflicts, a nurse must be equipped with these relevant skills, qualities, and knowledge.

Limitations

Our data were limited by the descriptive cross-sectional design of our study and by the fact that we only included nurses. These nurses were recruited from a workshop in Osaka, thereby suggesting that our findings do not apply to all nurses in Japan. In the future, we hope to increase our sample to include interviews with participants and the opinions of patients. These data can help us investigate the importance of inference in nursing in Japan. A longitudinal investigation into the expectations of patients must also be conducted by focusing on nurse–patient conflicts and the establishment of causal relationships between nursing care and patient perceptions.

Conclusion

Patients and their family members expect nurse–patient relationships to comprise five factors, including inference, empathic understanding, listening, individual treatment, and reliable skills and explanations. Inference is a characteristic of the Japanese people that underpins the expression of the four other factors throughout other cultures. Therefore, the unspoken feelings of patients must be respected by improving the intuition of nurses.

Author contributions

INOUE and TSUJIMOTO supervised the trial implementation and the data collection. UNO and INOUE recruited the participants, managed the data, and completed a quality control process to ensure data accuracy. UNO, INOUE, and TSUJIMOTO designed the study and analyzed the data. UNO drafted the manuscript, and all authors contributed substantially to its revision. UNO takes responsibility for the paper as a whole.

Funding sources

This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sectors.