Development and validation of a patient-centered communication scale for nurses

Communication is a vital component for nurses to establish therapeutic relationships with patients and their families, as well as to maintain cooperative relationships with other healthcare providers [1]. According to the Beryl Institute, key elements in the nursing experience of consumers include effective communication, which encompass active listening and clear conversations between healthcare providers and patients, and using understandable language when interacting with patients and their families [2]. However, in clinical practice, nurses often encounter challenges in communicating with patients, their families, and other healthcare providers. These difficulties not only diminish the quality of care but also elevate the risk of medication errors, potentially resulting in adverse outcomes or even fatalities [3]. Recent studies have shown that improved communication skills among nurses correlate with reduced medical errors, enhanced quality of care, better nursing performance, increased job satisfaction, stronger organizational commitment, and higher self-efficacy [2, 4, 5].

Current trends in the healthcare system emphasize the importance of nurses providing patient- and family-centered care (PFCC). This approach represents a philosophical shift in medical care, emphasizing collaboration between healthcare providers and patients along with their families [6]. PFCC represents the ideal direction for healthcare systems and policies, as it promotes active involvements of patients and their families in decision-making based on their values, preferences, and needs [7]. Previous studies have emphasized nurses’ communication competency as the primary factor in performing PFCC. Additionally, communication has been identified as a significant associating factor [8, 9]. To align with this trend, a number of communication programs have been developed by healthcare providers to enhance PFCC, such as the situation, background, assessment, recommendation (SBAR) tool and assertiveness training programs for nurses [10]. These programs not only improve communication skills, the level of clinical performance, critical thinking skills, job satisfaction, and self-efficacy but also reduce turnover intention in nurses [11, 12].

In clinical practice, nurses’ communication should be goal-oriented and focus on enhancing patients’ physical and mental health, which is consistent with patient-centered communication (PCC) [13]. PCC aims to prevent disease and promote well-being by actively involving patients in their treatment and decision-making that is based on respecting patients and their families [14]. However, there is no study evaluated nurses’ level of PCC, who communicate the most with patients and their families in clinical settings. Furthermore, the commonly used scales to measure PCC were not developed for clinical nurses.

Thus far, the scales developed for measuring general communication skills or for communication competencies of nursing students in simulation courses have been used [11, 15]. For example, Hur [15]’s global interpersonal communication competence scale is often utilized to assess clinical nurses’ communication skills, although it was not designed specifically for nurses in clinical settings. Some PCC scales that assess the patient’s perspective have been developed [16, 17]. Moser et al. [16]'s PCC scale evaluated patients' experiences of PCC, while Reeve et al. [17] validated communication measures specifically from colorectal cancer patients. However, these instruments solely reflect the patient’s viewpoint and not that of the providers. There exists a instrument primarily developed by researchers for their own studies that evaluates nurses’ perspectives, yet it has not been validated [18]. Furthermore, another instrument evaluates nurses' attitudes towards patients communication [19], while a tool specifically assesses PCC in older patients with acute myeloid leukemia [20], limiting its applicability. Moreover, these existing instruments have limitations in evaluating PCC from the perspective of nurses, as they do not fully capture the attributes of the therapeutic relationship between nurses and patients. Therefore, it is necessary to develop and analyze the psychometric properties of an instrument that comprehensively measures PCC in nurses.

This study aimed to develop and validate a Patient-Centered Communication Scale (PCCS) for clinical nurses, comprising three factors and 12 items. The PCCS demonstrated good reliability and validity as a measure of PCC in clinical nurses. The scale could be considered as a useful tool for evaluating and designing improvements of clinical nurses’ skill of PCC. This study developed the scale based on the domains of PCC, which including biopsychosocial, patient-as-person, sharing power and responsibility, therapeutic alliance, and provider-as-person [14].

Regarding the validity of the instrument, study findings showed an adequate content validity for the questionnaire. Thus, the items that make up the instrument accurately and clearly reflect what it is meant to measure and the domain in which it is meant to measure. In terms of construct validity, factor analysis was conducted. In the EFA, 12 items and three dimensions were extracted. The factor loadings of the items were all greater than 0.4. In the CFA, a well-fitting model was obtained, with all indices in the acceptable range. The three-factor structure of the scale had an appropriate fit.

The first subscale extracted in the EFA was the information sharing, which is consistent with the biopsychosocial perspective domain in the PCC conceptual framework [14]. The factor consists of five items and has the most explanatory power among the three factors at 38.17%. The items are related to explaining interventions and procedures about medical treatment and nursing care. The Institute of Patient- and Family-Centred Care (IPFCC) emphasized the importance of delivering information which is timely, complete, and accurate [37]. According to these items, the biopsychosocial domain was a large portion of nurses’ communication with patients and their families, primarily addressing acute biomedical issues such as vital signs, technical matters, medical history, and nursing interventions [14]. Therefore, it is an essential component and considered as one of the core concepts in PCC. Additionally, this factor consists of items wherein nurses assess patients’ and families’ understanding and allowing them sufficient time to ask questions. This emphasizes the bidirectional communication of patient-centered care. Furthermore, patients are not solely providing information about their medical symptoms and illness, they are actively participating in a reciprocal exchange of disease-related information [16].

The second subscale of the PCCS was patient-as-person, which has four items. This factor is consistent with the patient-as-person domain in the PCC conceptual framework, which emphasizes the aspects of caring that include sharing emotions and understanding individual worries and concerns related to the disease rather than focusing only on curing the disease [14]. Open ended questions are used to encourage patients and families to express their emotions. PCC includes eliciting the patient’s agenda through open-ended questions and engaging in focused active listening. The key features of PCC involve understanding the patient’s perspective on the illness and demonstrating empathy [38]. This understanding encompasses exploring the patient’s feelings, ideas, concerns, and experiences related to the impact of the illness, as well as recognizing the patient’s expectations from health care providers [39].

Non-verbal communication is critically important to express empathy and achieve patient-centered communication [40]. However, some preliminary items in this study about using non-verbal communication methods (e.g., touch and non-verbal expressions of empathy) and casual conversation with patients were deleted during factor analysis due to their low communality. This finding may be derived due to barriers on patient-centered care and communication. In previous studies, nurses spent less time on interactions with patients due to poor staffing ratios, higher workload, and lack of institutional and healthcare system support [1, 8]. This may be reflected in the relatively lower performance of PCC, such as having a daily conversation with a patient or understanding their feelings, because nurses frequently experience a great amount of pressure to accomplish a large amount of work within their duty hours [41, 42].

The third subscale of the PCCS was therapeutic alliance, which is consistent with the therapeutic alliance and provider-as-person domains in the PCC conceptual framework [14]. The factor consists of three items regarding introductions of other departments or organizations to the patient or family, collaborating across disciplines, and communicating and sharing emotions with colleague. However, in the PCCS, 3 items were correlated to alliance between healthcare providers, without including collaboration with patients and their families. According to the IPFCC, alliance refers not only to the care of patients and families, but also to health care providers involved in the development, implementation, and evaluation of policies beyond patients’ basic care [37]. Despite this expanded definition, there remains a lack of consensus between patients and healthcare providers [43], and Interprofessional collaboration among healthcare providers is more commonly addressed than collaboration between patients and healthcare providers in clinical settings [44]. This alliance ultimately occurs as a result of patient centered communication and enhances the quality of patient-and family-centered care [43]. Further studies are recommended for clearly establishing the concept and strategies to enhance the alliance between patients and health care providers.

Two domains, provider-as-person and sharing power and responsibility, were conceptually validated but did not ultimately emerge as final domains; corresponding items were removed through the EFA process. Following clinical nursing circumstances likely influenced the exclusion of these domains from the final PCCS.

The provider-as-person domain, which assesses healthcare providers' self-evaluation of communication skills and participation in training programs, was removed. Nurses faced challenges in dealing with aggressive patients, communicating with seriously ill patients, and encountered barriers to training participation [45]. To address this, tailored communication education programs addressing actual clinical difficulties and incentive strategies for participation should be adopted for nurses.

Another excluded domain, sharing power and responsibility, promotes mutual equality between healthcare providers and patients, emphasizing active patient involvement in decision-making and consideration of their personal experiences [14, 21]. However, nurses often felt distant from such interactions, deferring decisions to doctors perceived as having superior knowledge [46]. Additionally, nurses believed this domain was more prominent between patients, families, and physicians rather than nurses [15].

In this study, 70 initial items were developed; however, only 12 items were finally confirmed as part of PCCS. Initial items were developed to encompass a broad range of attributes related to PCC, with the aim of distinguishing them from existing PCC instruments and to maximize coverage of therapeutic relationships between patients and nurses in clinical settings. Despite recognizing PCC as crucial component in healthcare, paternalistic values persist, and nurses may lack perception of collaboration among healthcare providers, patients, and families. Various clinical situations and factors, including nurses' personal values and workplace culture, could influence the study results [44]. We recommend developing additional items for removed domains and conducting validity testing again.

Convergent validity was assessed by analyzing the correlation with GICC and PCCS, which yielded a value of 0.68. Based on the criterion that a correlation coefficient between 0.40 and 0.80 ensures convergent validity [47], this value was considered to be sufficient. The reliability was assessed using Cronbach's alpha for all the items, resulting in 0.84, and each subscale ranged from 0.60 to 0.77. Cronbach's alpha tends to decrease with fewer items, and the therapeutic alliance scale, comprised of three items, exhibited the lowest alpha value of 0.60. However, for both the overall scale and each subscale, values were above the criterion of 0.60 [47], indicating satisfactory internal consistency and reliability of the instrument.

This study has several limitations. Firstly, this study used convenience sampling, which may have contributed to sampling bias. Secondly, during the process of obtaining content validity from experts, we did not send revised items back for a second round of feedback. Re-evaluation could enhance the robustness of initial item development. Therefore, it may be necessary to consider incorporating this step in future tool development. Thirdly, the reliability coefficient of the therapeutic alliance factor is low, possibly due to the small number of items. Therefore, the reliability requires further evaluation using larger sample size. Fourthly, as this study was conducted in South Korea, cultural background may have influenced the study results. Therefore, further study is recommended to test the psychometric properties of the PCCS in various countries.

The PCCS developed in this study showed good validity and reliability. The scale consists of three factors and 12 items: information sharing (five items), patient-as-person (four items), and therapeutic alliance (three items). The scale can be used to assess the level of PCC in nurses, increase nurses’ understanding of PCC in a hospital setting, and promote patient-centered care. Further studies are recommended to test the validity of the PCCS in various hospital settings with a larger sample size and to explore factors associated with PCC in nurses.