Which early nursing theorist defined nursing in interpersonal terms by stating that nursing is a significant therapeutic and interpersonal process?

Nurs Sci Q. Author manuscript; available in PMC 2018 Apr 1.

Published in final edited form as:

PMCID: PMC5831243

NIHMSID: NIHMS944753

Thomas A. Hagerty, RN; PhD, Adjunct Professor,1 William Samuels, PhD, Director of Assessment and Accreditation,2 Andrea Norcini-Pala, PhD, Postdoctoral Fellow,3 and Eileen Gigliotti, RN; PhD, Professor4

Abstract

A confirmatory factor analysis of data from the responses of 12,436 patients to 16 items on the Consumer Assessment of Healthcare Providers and Systems–Hospital survey was used to test a latent factor structure based on Peplau's middle-range theory of interpersonal relations. A two-factor model based on Peplau's theory fit these data well, whereas a three-factor model also based on Peplau's theory fit them excellently and provided a suitable alternate factor structure for the data. Though neither the two- nor three-factor model fit as well as the original factor structure, these results support using Peplau's theory to demonstrate nursing's extensive contribution to the experiences of hospitalized patients.

Keywords: confirmatory factor analysis, HCAHPS, patient experience, Peplau

Patients' experiences in hospitals are important indicators of the quality of hospital care [Epstein, Fiscella, Lesser, & Stange, 2010]. Patients' experiences are defined as their perceptions of phenomena for which they are the best or only sources of information, such as personal comfort or effectiveness of discharge planning. A primary way in which patients' experiences are measured in the United States [US] is by the Consumer Assessment of Healthcare Providers and Systems–Hospital [HCAHPS] survey. This survey was created to facilitate public reporting of patient experience data so that consumers could compare hospital scores and make informed choices and hospitals could see their strengths and weaknesses with regard to patients' experiences [Centers for Medicare and Medicaid Services [CMS], 2012].

Only 4 of the 32 items on the HCAHPS survey explicitly are given the heading: “your care from nurses.” However, other HCAHPS items arguably reflect the work of nurses and ask about, for example, how patients' pain was managed, how responsive staff were to requests for help, environmental quietness and cleanliness, medication teaching, and discharge planning. These items refer only to “hospital staff,” even though it is likely that patients' answers largely reflect nurses' contributions to patients' care.

The conceptual framework used in developing the HCAHPS survey is derived from the Institute of Medicine [IOM]. Though a latent structure following the IOM's conceptual framework should fit most sets of HCAHPS data well, it was hypothesized that a latent structure reflecting a middle-range nursing theory would provide a comparably good fit to the data, given the large role nurses play in many aspects of patients' hospital experiences. Demonstration of a comparable factor structure based on a middle-range nursing theory would more fully reflect nurses' wide contributions to patients' experiences, as measured by the HCAHPS survey.

Peplau's [1952/1991/1997] middle-range theory of interpersonal relations in nursing was chosen as a suitable nursing theory for this research because Peplau frequently acknowledged the importance of patients' experiences of nursing care. In the theory of interpersonal relations in nursing, Peplau emphasized patients' experiences and the effect that nurse-patient relationships have on those experiences. Peplau asserted that the focus of scientific research in nursing should be patients, their needs, and their perceptions about the care they received from nurses [Gastmans, 1998]. The purpose of this paper is to report the results of a confirmatory factor analysis done to compare the factor structure of HCAHPS data using both the IOM [2001] conceptual model and Peplau's middle-range theory of interpersonal relations in nursing.

Conceptual Frameworks

Institute of Medicine Framework

The conceptual framework for the HCAHPS is guided by Institute of Medicine's [IOM's] domains of quality healthcare, taken from the 2001 report Crossing the Quality Chasm. These domains include respect for patients' values and attention to patients' preferences, expressed needs, physical comfort, and emotional support. The IOM's framework is one that emphasizes patient-centered care and places patient dignity at the forefront. The HCAHPS survey has nine underlying factors: [a] communication with nurses [operationalized by HCAHPS items 1-3], [b] communication with doctors [items 5-7], [c] responsiveness of hospital staff [items 4 and 11], [d] pain management [items 13 and 14], [e] communication about medicines [items 16 and 17], [f] discharge information [items 19 and 20], [g] physical environment [items 8 and 9], [h] transition of care [items 23-25], and [i] overall experience [items 21 and 22] [Rothman, Park, Hays, Edwards, & Dudley, 2008].

Theory of Interpersonal Relations in Nursing

In Peplau's [1952/1991/1997] theory, nursing is defined as an interpersonal, therapeutic process that takes place when professionals, specifically educated to be nurses, engage in therapeutic relationships with people who are in need of health services. Peplau theorized that nurse-patient relationships must pass through three phases in order to be successful: [a] orientation, [b] working, and [c] termination.

During the brief orientation phase, hospitalized patients realize they need help and attempt to adjust to their current [and often new] experiences. Simultaneously, nurses meet patients and gain essential information about them as people with unique needs and priorities [Peplau, 1997]. Among the many roles that nurses assume in their interactions with patients, the first role during the orientation phase is that of stranger. Initially, nurses are expected to greet patients with the “respect and positive interest accorded a stranger” [Peplau, 1952/1991, p. 44]. Patients and nurses quickly pass through this phase and nurses must continue to display courtesy and respect throughout the three phases. Given that characteristics of the orientation phase are continued in the other two phases; in the current study, the orientation phase was not initially hypothesized to be a latent factor.

The next phase is the working phase, which accounts for the majority of nurses' time with patients. In this phase, nurses make assessments about patients to use during teaching and when contributing to the interdisciplinary plan of care [Peplau, 1952/1991/1997]. During the working phase, the roles of nurses become more familiar to patients; they begin to accept nurses as health educators, resource persons, counselors, and care providers. Nurses practice “nondirective listening” to facilitate patients' increased awareness of their feelings regarding their changing health [Peplau, 1952/1991, p. 43]. Using this therapeutic form of communication, nurses provide reflective and nonjudgmental feedback to patients for the sake of helping them clarify their thoughts. In this study, the working phase was operationalized by measuring the ratings on HCAHPS Items 1, 2, 3, 4, 8, 9, 11, 13, 14, 16, and 17 [see Figure 1].

Path Diagram of 16 HCAHPS Items That Correspond to Peplau's Phases.

The final phase is the termination phase, which is more commonly thought of as discharge planning [Peplau, 1992]. The success of the termination phase is dependent on how well patients and nurses navigated the orientation and working phases. A major part of the termination phase occurs when nurses teach patients about symptom management and recovery at home. In this study, the termination phase was operationalized by measuring the ratings on HCAHPS Items 19, 20, 23, 24, and 25 [see Figure 1].

Related Literature

Nurses contribute enormously to patients' experiences. The first published, nation-wide evaluation of the HCAHPS, which included data collected over 1 year [2006-2007] from 2,429 hospitals [with a 36% response rate], found that patients who rated their overall experiences as most positive were significantly more likely to have had higher numbers of nurses per patient days [Jha, Orav, Zheng, & Epstein, 2008]. Hospital characteristics and HCAHPS ratings were examined using multivariate regression models that adjusted for potential confounding variables such as numbers of beds in hospitals or percentages of patients receiving Medicaid health benefits. The sample was divided into quartiles, and among the quartile reflecting the lowest ratio of nurses to patients, only 60.5% of patients reported the highest global ratings. However, among the quartile reflecting the highest ratio of nurses to patients, 66.7% reported the highest global ratings category [p < .001; the exact value of χ2 is not reported for this chi-square test].

Likewise, the HCAHPS items reflecting the communication with nurses' factor have been found to correspond strongly with patients' perceptions about their hospital experiences. Investigating the relations between putative factors on the HCAHPS survey with overall patient experience scores, Wolosin, Ayala, and Fulton [2012] found that higher nurse communication factor scores were significantly related to achieving the highest possible overall HCAHPS scores [OR = 1.05; 95% CI not provided; p < .001]. This study used binary logistic regression and controlled for age, gender, race, education, preferred language, and self-reported health status of randomly sampled subjects [N = 136,546] and had an overall average response rate of 34%. More recently, a Canadian study that utilized the HCAHPS survey items with 27,492 discharged, English-speaking patients over a 3-year period found that of all the HCAHPS factors, the nurse communication factor had the strongest Pearson correlation with overall experience ratings [r = .45, p < .001] [Kemp, McCormack, Chan, Santana, & Quan, 2015]. Additionally, it was found that the factors of pain management, room cleanliness, and room quietness were also significantly related to overall experience ratings [r = .31 to .42, p 800 subjects to ensure sufficient precision to compare two models of the same data. Additionally, this sample size was consistent with recommendations for CFAs conducted using weighted least squares means and variance adjusted estimation.

Demographic Data

Characteristics of the retained sample [N = 12,436] are reported in Table 1. Mean age was 57.26 years [SD = 19.03, range = 18-102]; 42.36% [n = 5,268] were men, and 57.64% [n = 7,168] were women. Mean length of stay [LOS] in the hospital was 4.31 days [SD = 5.84, median = 3, range = 1-142]; LOS was not normally distributed. Age, sex, and LOS data were provided by the hospital and are not required by the HCAHPS survey; none were missing.

Table 1

Frequency Table—Demographic Variables.

The 3,320 [21.07%] deleted surveys showed significant differences on some demographic variables compared to surveys without missing data. To determine differences, t tests were used for continuous variables [age, perceptions about physical and mental health, and educational levels], and cross-tabulation chi-squares were used for categorical variables [race and ethnicity, language spoken at home, and LOS]. The results showed that patients whose surveys were deleted due to incompleteness were more likely to be older, with a LOS of only 1 day, Black or Hispanic or of multiple race, mainly Spanish-speaking at home, less well-educated, and having lower levels of physical and mental health.

Confirmatory Factor Analyses

Peplau Model

The two-factor Peplau model performed sufficiently well. Factor loadings were standardized so that loading values could be compared. This was necessary because of the differing question formats on the HCAHPS survey, where 2, 4, or 11 answers are possible depending on the question. No outliers—that is very influential items—were found [Cook's Ds < 1.00; range = 0.0-0.21].

All items loaded rather well onto the factors hypothesized by the Peplau model [see Figure 2]. The lowest loading was .490, and the highest was .903. All loadings were statistically significant at p < .0001. Indicators of model fit for the two-factor structure were acceptable. The RMSEA was 0.071, 90% CI [0.069-0.072], and the calculated probability of the population RMSEA to be lower than 0.05 was