International Journal of Nursing Sciences xxx (2016) 1e5

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International Journal of Nursing Sciences

journal homepage: http://www.elsevier.com/journals/international-journal-of-
nursing-sciences/2352-0132

Perceptions of nurses in Japan toward their patients' expectations of

care: A qualitative study
Mayumi Uno a, *, Tomomi Tsujimoto b, Tomoko Inoue b
a
Yamato University Health Faculty of Nursing, Osaka, Japan
b
Osaka University Graduate School of Medicine, Division of Health Sciences, Osaka, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: This study aimed to investigate ideal nurse involvement based on the expectations of pa-
Received 22 June 2016 tients. Data on conflicts between nurses and patients were obtained. The patient situation involved
Received in revised form standard nursing treatment, rather than acute phase or palliative care.
17 November 2016
Methods: Questionnaires were distributed among senior nurses attending a series of trainings in 2012
Accepted 9 December 2016
Available online xxx
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 anony-
Keywords:
Emotions
mously to 57 questions about non-acute (stable) psychiatric or physical nurseepatient scenarios.
Empathy Qualitative data analysis was conducted using these responses.
Humans Results: We received 41 completed responses (response rate ¼ 17.1%). The expectations of patients and
Nurseepatient relations their families were reflected in five categories, namely, inference, empathic understanding, listening
Patient care attitude, individual treatment, and reliable skills and explanations. Inference was independently cate-
Qualitative study gorized 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.
© 2016 Chinese Nursing Association. Production and hosting by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction similar to those generally provided in hotels. The evaluation of

overall service quality often emphasizes sub-services that are
Advancements in medical technology have improved patient neither experienced by clients in hotels, nor are reflected in hos-
care. As medical practitioners become increasingly specialized, pital costs. By contrast, core-services, including technology pro-
people have emphasized the value of healthcare, such that the visions, are often reflected in these costs [5]. Establishing
standard of medical care as a high-quality service is currently being relationships between medical care providers and patients, which
scrutinized. However, although medical service quality must not be is considered a sub-service, has become increasingly difficult with
determined by patient satisfaction alone [1], such quality has been the increasing number of specialized medical care core-services [6].
increasingly evaluated by measuring the quality of hospital and Maintaining favorable relationships between patients and medical
nursing services, from the perspective of patients, since the 1980s care providers requires the “cultivation of mutual relationships and
[2e4]. mutual understanding,” and conflicts inevitably arise in the event
Hospital services include core-services and sub-services that are that the harmony in such personal relationships cannot be main-
tained [7].
Robbins defined conflict as “a process that begins when one
party perceives that another party has negatively affected, or is
* Corresponding author. Yamato University Health Faculty of Nursing, Katayama about to negatively affect, something that the first party cares
2-5-1, Suita, Osaka 564-0082, Japan.
about” [8]. Marquis and Huston asserted that conflicts arise from
E-mail addresses: [email protected] (M. Uno), [email protected].
ac.jp (T. Tsujimoto), [email protected] (T. Inoue). differences in perceptions, values, expectations, and backgrounds
Peer review under responsibility of Chinese Nursing Association. [9]. Since 2000, studies on conflicts in clinical practice have

http://dx.doi.org/10.1016/j.ijnss.2016.12.005
2352-0132/© 2016 Chinese Nursing Association. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Uno M, et al., Perceptions of nurses in Japan toward their patients' expectations of care: A qualitative study,
International Journal of Nursing Sciences (2016), http://dx.doi.org/10.1016/j.ijnss.2016.12.005
2 M. Uno et al. / International Journal of Nursing Sciences xxx (2016) 1e5

proposed various methods for dealing with such clashes in specific they would not be disadvantaged in any way if they did not consent
circumstances, including hard to please patients [10], patients in to participate, and that this study was not related to the NMT
acute psychiatry wards [11], and patients in elderly nursing and workshop. We distributed self-administered anonymous ques-
care homes [12]. tionnaires, and the completed questionnaires were returned to a
Nurses deal with conflicts by adopting strategies that lead to secure collection box after two weeks. The participants provided
solutions through discussion [13]. Nurseepatient relationships are their informed consent by returning complete responses. This
fundamental to the therapeutic partnership [14], where showing study was conducted with the approval of the ethics committee of
interest in the daily moods of patients is essential [15]. our university.
Nursing care is related to patient satisfaction [16]; however, the
concept of patient satisfaction continues to evolve [17]. Several 2.4. Survey content
studies have defined such concepts, and developed scales for
assessing patient satisfaction with nursing care [18,19] by The questionnaire included 57 questions about non-acute (sta-
addressing the technicaleprofessional, trust, and educational as- ble) psychiatric or physical nurseepatient scenarios. The ques-
pects of nurseepatient relationships. Service marketing studies tionnaire was structured based on the Robbins conflict process, was
have also focused on the relationship between the service expec- translated from English to Japanese, and included items related to
tations and perceptions of customers toward the actual services potential disagreement or incompatibility-causing conflicts,
they receive [20e24]. cognition and personalization-causing conflicts, and behavior-
In this study, we used a qualitative and inductive approach to causing conflicts in nursing scenarios, the actions and outcomes
analyze the contents of conflicts that occur in daily nursing prac- related to nurseepatient relationships, and the demographic
tice, particularly the interpersonal elements between patients and characteristics of the participants.
experienced nurse managers. To improve patient and nurse satis- To ensure the validity of the questionnaire, a pretest was per-
faction, we identified the elements of ideal nursing treatment formed among five university students with at least seven years of
based on how nurses viewed the expectations of their patients. To nursing experience. The pretest results confirmed the validity of
provide data for developing the concept of ideal nurse treatment in the questionnaire items. The participants were able to answer the
accordance with the expectations of patients, we performed an pretest questions without experiencing undue burden.
inductive analysis of conflict-arousing situations.
2.5. Data analysis
2. Materials and methods
We used 41 of the 57 Robbins conflict process questions. The
2.1. Study design other 16 questions were excluded because they dealt with conflicts
involving medical professionals other than nurses. These 41 items
We performed content analysis using a qualitative and inductive assessed the situations that clearly described the elements that
approach in reference to Polit and Beck [25]. were thought to have caused the conflict, the situations in which
conflicts emerged, the responses to these conflicts, and the status of
2.2. Study subjects nurseepatient relationships after dealing with conflicts. These
situations were written down and read by two university staff
Nurses attending Nursing Management Training (NMT) pro- members specializing in nursing management studies. We then
vided by the Nursing Professional Association in Osaka, Japan were extracted information related to ideal nurse treatment, in accor-
selected as participants. All participants held the position of either dance with the expectations of patients, using a qualitative and
head nurse or deputy to the head nurse, and were affiliated with or inductive approach. First, the data for each description were sum-
were working for various hospitals or health care institutions in marized so as not to change the content. Second, the ideal treat-
Osaka. We focused on this group of nurses because they were well ment methods applied by nurses that resulted in favorable
established within the nursing field and were capable of expressing relationships with their patients were grouped together. For those
their knowledge and experiences. The NMT session lasted for 10 cases in which the treatment methods were considered inadequate,
months, during which the participants worked in hospitals for five we reversed the data for these methods for them to be categorized
days and attended lectures for one day each week. as desired and ideal. Third, the trends in the ideal treatments
The workplaces of these nurses varied greatly, from outpatient applied by nurses were categorized.
departments to hospital wards and operation rooms. Similar to
nurses working in other prefectures throughout Japan, those nurses 3. Results
who were working in the medical care facilities in Osaka were
affiliated with the Nursing Professional Association of the 3.1. Descriptive data
prefecture.
The questionnaires were distributed among 240 nurses, and 41
2.3. Study procedure, data collection, and ethical considerations 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
This study was performed in August 2012, November 2012, and of 19.5 ± 3.38 years.
January 2013 at the end of the course. The person responsible for
conducting the NMT workshop explained the purpose of the study 3.2. Data synthesis and category creation
to the participants. After receiving their consent, we provided the
participants with oral and written explanation of the study during We grouped those ideal treatments that improved nurse-
their rest period. At this time, we guaranteed participants that their epatient relationships into five categories, namely, inference,
identities would not be disclosed, and that their data would not be empathic understanding, listening, individual treatment, and reli-
used outside of the research, would be carefully handled, and able skills and explanations. Inference refers to the state of well-
would be destroyed upon completion of the study. Afterward, the being that is attuned to the unspoken feelings of patients and their
nurses were informed that their participation was voluntary, that family members, and how nurses respond to their patients

Please cite this article in press as: Uno M, et al., Perceptions of nurses in Japan toward their patients' expectations of care: A qualitative study,
International Journal of Nursing Sciences (2016), http://dx.doi.org/10.1016/j.ijnss.2016.12.005
 M. Uno et al. / International Journal of Nursing Sciences xxx (2016) 1e5 3

according to these perceived feelings. Patient/family member ex- 3.2.2. Empathic understanding
pectations are related to what the patients or their family members Eight respondents emphasized the importance of providing
hope to receive from the nursing interventions, including unde- treatment while showing understanding and respect for the
fined feelings. Nurse treatment encompasses the judgments, re- thoughts and feelings of patients and their family members. One of
actions, and behaviors of nurses during conflict situations. the respondents narrated:
Those items that contrasted the ideal treatment methods were
“A fetal abnormality was detected in a pregnant woman after
marked with # in the list of subcategories (Table 1). Table 2 lists the
fertility treatment. The patient was told that there was no medical
five categories and their definitions, and some typical data for each
problem, but we respected the patient's decision of not continuing
category are provided in the following sections.

Table 1
Ideal nurse treatment in accordance with patient expectations during conflicts.

Categories Subcategories

Inference (n ¼ 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 ¼ 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 ¼ 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 ¼ 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 ¼ 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

3.2.1. Inference with the pregnancy. Thereafter, the patient's trust in her nurse grew
Being well attuned to the unspoken feelings of patients and deeper.” (ID 4)
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, 3.2.3. Listening
but the patient appeared to be sleeping, so I just set the table and Listening to the thoughts and feelings of patients and their
went to the next room. Thereafter, the patient woke up and com- family members was identified as an important characteristic by
plained to another nurse that ‘It was left just like that, and the seven respondents. One of the respondents explained:
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 “Even though the family member told the nurse that the contact
and apologized to the patient. The patient accepted the apology and person for the patient had been changed, the hospital did not
said that he only wanted us to be more careful in the future; respect the contact route as requested. Furthermore, the details
subsequently, we have maintained a favorable relationship with became very troublesome upon the patient's sudden discharge
that patient.” (ID 49) from the hospital, and the family member lost his trust in the nurse.
To deal with this situation, the nurse listened earnestly to the

Please cite this article in press as: Uno M, et al., Perceptions of nurses in Japan toward their patients' expectations of care: A qualitative study,
International Journal of Nursing Sciences (2016), http://dx.doi.org/10.1016/j.ijnss.2016.12.005
4 M. Uno et al. / International Journal of Nursing Sciences xxx (2016) 1e5

feelings of the family member, and their relationship was improved identified some similarities between the expectations and service
as a result.” (ID 12) 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 generaliz-
3.2.4. Individual treatment ability of these findings.
Going beyond the general guidelines of the hospital or institu-
tion and prioritizing the wishes of the patient whenever possible 4.2. Relevance of the findings
were identified as necessary characteristics by five respondents.
One of the respondents narrated: Among the five identified categories, inference was particularly
“Immediately before the surgery, the patient's anxiety intensified characteristic of the feelings of the Japanese people. For instance,
and he eventually refused the surgery. In response, the nurse the anecdote of ID 49 in the Results section indicated that the pa-
contacted the attending physician to inform him/her that the sur- tient did not clearly request how his meal was to be prepared;
gery could not be performed on schedule, after which the surgery instead, the patient expected that the nurse would know (or make
time was delayed, and the patient's anxiety was eased.” (ID 20). an inference based on) his wishes, even without communicating
them. When the nurses acted contrary to his expectation, the pa-
tient felt abandoned and became dissatisfied with the service. Such
instance is a common feature of the omotenashi (hospitality) cul-
3.2.5. Reliable skills and explanations ture of Japan.
Four respondents emphasized the importance of treatment The service expectations of patients are rooted in traditional
based on expert nursing knowledge. According to one of the Japanese culture, such that patients from Japan are influenced by
respondents: their culture. Kondo claimed that as part of the Japanese hospitality
“A patient was concerned that the application of the interferon concept, the omotenashi and omoi sassuru cultures facilitate an
injection technique differed depending on the nurse. In response, unspoken agreement and mutual understanding between nurses
the facts were confirmed with the patient, and the nurse immedi- and patients without explicitly stating their expectations [31].
ately apologized for the mistake. An interferon injection manual Leininger further described the influences of cultural diversity and
was also created, which was acknowledged by the patient, and the universality on patientenurse relationships [32e35].
injections were applied for one month by highly experienced staff.” The Japanese term, amae, indicates a lack of self-reliance;
(ID 57) 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 in-
dependent characteristic of the Japanese population. By contrast,
4. Discussion those items marked with # in Table 2 (i.e., responses contrary to the
ideal treatment methods) included eight items concerning
The ideal treatments during conflicts that improved the nurse- detachment from the feelings of patients and their family mem-
epatient relationship were categorized into inference, empathic bers, which indicates that despite retaining their values, patients
understanding, listening, individual treatment, and reliable skills also respected the need for nurses to concentrate on expert treat-
and explanations. The results demonstrated that patients, espe- ment during clinical practice.
cially those in Japan, want and expect their nurses to understand Regarding the role of culture in our daily lives, D'Andrade pro-
their feelings [26]. Unfortunately, patients rarely communicate posed four functions, namely, representational, constructive,
these expectations to their nurses. directive, and evocative [36]. Culture is related to the fundamental
components of the human mind, including knowledge (represen-
4.1. Patient satisfaction tational and constructive functions), passion (evocative function),
and will/intent (directive function). Given that the Japanese people
We divided the service qualities specific to nursing care into five are inclined to be emotionally dependent, Japanese patients tend to
categories, namely, inference, empathic understanding, listening, depend on others for responsive care.
individual treatment, and reliable skills and explanations. Recent Therefore, nurses must detach themselves from the feelings of
nursing and management studies reveal that nursing quality and their patients and their stable family members. However, with re-
patient satisfaction characteristically depend on specific situations gard to interpersonal relationships in other countries, inference is a
and the underlying environmental culture. A survey of service universal phenomenon that forms the basis for the other cate-
quality from the perspective of outpatients in Finland revealed that gories, including empathic understanding, listening, individual
nurses and nursing departments used a service quality instrument treatment, and reliable skills and explanations.
that generated valuable information for improving service quality Those patients who suffer from various illnesses do not expect
[27]. A separate survey in a tertiary care setting that utilized a to establish a relationship with their nurses. Simple acts of kind-
service quality scale identified reliability as the most expected and ness, such as providing care with a smile and saying thank you, can
perceived dimension among all nursing service quality character- make a difference to these patients. The results emphasize the
istics [28]. importance of accommodating the thinking of patients to help
A survey using SERVQUAL, a well-established and widely used nurses engage in inference.
measurement of customer perceptions toward received service,
revealed that patients in Korea were more satisfied with their 4.3. Relevance to clinical practice
nursing and medical care than their nurses were [29]. The actual
nursing performance of these nurses was relatively lower than Based on the five identified categories, we propose several ways
expected, thereby resulting in poor-quality nursing care. However, to prevent or deal with the conflicts that may arise between nurses
the nurses and patients showed some similarities in their percep- and patients. Japanese individuals with traditional cultural values
tions and expectations. A survey using SERVQUAL in Taiwan are often subject to modern nursing care in Japan, which is

Please cite this article in press as: Uno M, et al., Perceptions of nurses in Japan toward their patients' expectations of care: A qualitative study,
International Journal of Nursing Sciences (2016), http://dx.doi.org/10.1016/j.ijnss.2016.12.005
 M. Uno et al. / International Journal of Nursing Sciences xxx (2016) 1e5 5

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Please cite this article in press as: Uno M, et al., Perceptions of nurses in Japan toward their patients' expectations of care: A qualitative study,
International Journal of Nursing Sciences (2016), http://dx.doi.org/10.1016/j.ijnss.2016.12.005