Srp Arh Celok Lek. 2010 Jan-Feb;138(1-2):79-84 DOI: 10.

2298/SARH1002079V
ОРИГИНАЛНИ РАД / ORIGINAL ARTICLE UDC: 614.253.5:616.83 79

Development and Evaluation of the Nurse Quality

of Communication with Patient Questionnaire
Mira Vuković1, Branislav S. Gvozdenović2, Branka Stamatović-Gajić1, Miodrag Ilić1, Tomislav Gajić1
Health Centre, Valjevo, Serbia;
1

AbC.R.O., Inc. Serbia, Belgrade, Serbia

2

SUMMARY
Introduction Nurse/patient relationship as a complex interrelation or as an interaction of the factor
patient and factor nurse has been a subject of a number of studies during the past ten years. Nurse/
patient communication is a special entity, usually observed within a framework of the wider nurse/
patient relationship. In that regard, we wanted to develop a standardized questionnaire that could reli-
ably measure the quality of communication between nurse and patient, and be used by nurses.
Objectives The main goal of this study was to develop and evaluate construct validity of the Nurse
Quality of Communication with Patient Questionnaire (NQCPQ), as well as to evaluate its reliability. The
goal was also to establish a measure of inter-raters reliability, using two repeated measurements of
results by items and scores of the NQCPQ, on the same observed units by two assessors.
Methods The starting NQCPQ that consists of 25 items, was filled in by two groups of nurses. Each nurse
was questioned during morning and afternoon shifts, in order to evaluate their communication with
hospitalized patients, using marks from 1 to 6. To evaluate construct validity, we used the analysis of
main components, while reliability was assessed using intraclass correlation coefficient and Cronbach-
alpha coefficient. To evaluate interraters reliability, we used Pearson correlation coefficient.
Results Using a group of 118 patients, we explained 86% of the unknown, regarding the investigated
phenomenon (communication nurse/patient), using one component by which we separated 6 items
of the questionnaire. Inter-item correlation (α) in this component was 0.96. Pearson correlation coeffi-
cient was highly significant, value 0.7 by item, and correlation coefficient for scores at repeated measure-
ments was 0.84.
Conclusion NQCPQ is 6-item instrument with high construct validity. It can be used to measure quality
of nurse/patient communication in a simple, fast and reliable way. It could contribute to more adequate
research and defining of this problem, and as such could be used in studies of interaction of psycho-
metric, clinical, biochemical, socio-cultural, demographic and other parameters as well.
Keywords: psychometric scale; nurse; patient; communication

INTRODUCTION patient, it is of crucial importance to conduct

the education of health professionals in order
It has been noticed over the last several years to improve the quality of both treatment and
that nurse-patient communication repre- health care [5]. It has been shown that the
sents the key factor that influences the overall acceptance of pharmacological measures (treat-
outcome of patient treatment both in hospital ment compliance) in psychiatric patients is in
and ambulatory environment. Although nurse- direct correlation with the achieved communi-
patient communication in health institutions is cation of health professionals and patients [5,
defined as a target professional communication 6]. Expanding the field of knowledge of physi-
between nurse and patient during treatment, cians during their specialization or subspe-
this communication is the subject of research cialization, they spend incomparable less time
of particular importance in the recognition of with the patient than nurses do. Therefore, the
the phenomenon of interaction between nurse most of the time such communication with
and patient in monitoring and treatment of patient with health professionals in hospital
pain, anxiety and other conditions where it environment remained on the communica-
could be expected that the factor of nurse, tion by the nurse. Unfortunately, besides the
alone or in combination with the patient as a importance of the communication factor nurse-
factor, can have important effect in the quality patient, there have been no data in medical
of patient treatment [1, 2]. Particularly current literature to date about the possible measuring
is research of correlation assessment of post- instruments for its measurement. That is the
surgery patient pain, as measured by specific reason why we developed the Nurse Quality
patient-related scales and specific instruments of Communication with Patient Questionnaire Correspondence to:
by which the nurse, at the same time, evalu- (NQCPQ), by which nurses would provide their Mira VUKOVIĆ
ates the pain looking at the patient [3, 4]. For own assessment about the achieved communi- Quality Assurance Department,
Health Centre, Sindjelićeva 62,
improvement of communication between cation with inpatients at hospital wards where 14000 Valjevo, Serbia
the nurse and patient or the physician and they perform their professional work. [email protected]
80 Vuković M. et al. Development and Evaluation of the Nurse Quality of Communication with Patient Questionnaire

OBJECTIVE intensive care, and four nurses from the general surgery
department.
The primary aim of this study was to separate and eval-
uate the main components of the NQCPQ, and to esti-
mate the reliability of their particular items. The secondary Developing NQCPQ
aim was to establish measures of repetitiousness from two
repeated measurements of grades per items and scores of The NQCPQ contains 25 items to be filled in by nurses,
the NQCPQ on the same study subjects by two assessors. evaluating the quality of their communication with patients
with a grade from 1 to 6. The content of the items is given
in Table 1.
METHODS In the process of developing the questionnaire, out of
didactic reasons, we initially classified the items by the way
Patients of achieved communication and communication objective.
By the way of achieved communication, the items are
Assessment of NQCPQ by items was performed in 127 classified as those:
adult hospital treated patients of both gender at depart- a. That keep the quality of verbal communication – 1, 2,
ments of surgery, psychiatry and physical medicine and 3, 7, 9, 10, 11, 13, 19, 23, 25;
rehabilitation of the Health Centre Valjevo over the period b. That keep the quality of non-verbal communication –
from October to December 2008. 4, 5, 14, 15, 16, 17, 18, 20, 21, 22; and
c. That keep the quality of communication in general –
6, 8, 12, 24.
Assessors By the quality of communication objective, the items
are classified as those:
Ten nurses – assessors from Health Centre Valjevo partic- a. Related to communication aiming at getting insight into
ipated in the study, two nurses from each of the following severity of general conditions of a patient – 1, 6, 9, 10,
departments – psychiatry, rehabilitation and surgery semi- 11, 12, 17, 20, 21, 22, 25;

Table 1. Starting items for the Nurse Quality of Communication with Patient Questionnaire (NQCPQ)
No. Items
1 Based on the quality of communication with the patient, I evaluate his/her current condition as:
During conversation with me, the patient is showing interest in hospital regimen and the lifestyle he/she should lead in hospital
2
environment, according to his/her illness:
3 From the conversation I conclude that the patient accepts his/her pharmacotherapy:
4 The patient shows me that he/she understands hospital regimen, by respecting it:
5 Based on the patient reactions, I can say that his/her treatment is resulting in:
Generally speaking, the level of my communication with the patient, keeping in mind severity of his/her condition, I can describe
6
as:
The information I receive through talking to patient shows that this pharmacotherapy would be acceptable for application at
7
home settings:
8 Generally speaking, the level of my communication with the patient during care procedures, I can describe as:
9 The patient accepts conversation about his/her illness in the following way:
10 I fully understand the severity of the patient’s illness, and I talk with him/her about it:
11 The patient talks to me about various themes, but avoids or is not able to answer my questions about her/his illness:
I believe the patient has difficulties in communication due to the severity of her/his condition, therefore I understand her/his
12
needs in the following manner:
The patient talks to me about details related to his/her personal hygiene while I assist her/him in changing bedclothes or
13
underwear:
The patient talks to me about details related to his/her nutrition while I help him/her with feeding or supervise food intake
14
during meals:
15 The patient actively participates in maintaining her/his personal hygiene:
16 The patient cooperates, gets up or moves in bed in order to help me in the change of bedclothes:
The patient looks like he/she listens to what I am saying about his/her condition, but avoids or is not able to adequately
17
cooperate with me while talking to him/her:
18 The patient is active during meals and asks for appropriate assistance from me:
19 The patient accepts conversation with me about her/his medication:
20 The patient accepts and understands my presence related to her/his illness:
21 Based on the observation of the patient, I believe that her/his current condition is:
I fully understand the severity of the patient’s illness, therefore only by observing the patient’s gestures I conclude that my
22
communication with him/her is:
23 The conversation with the patient shows that prescribed pharmacotherapy works as:
Generally speaking, the level of my communication with the patient while I carry out or monitor his/her pharmacotherapy, I can
24
describe as:
25 I believe that, due to the severity of the illness, the patient talks to me in such a way that I can understand him/her:

doi: 10.2298/SARH1002079V
Srp Arh Celok Lek. 2010;138(1-2):79-84 81

b. Related to communication aiming at caring of a patient ward, 44 patients in surgery ward and 40 psychiatric
– 2, 4, 8, 13, 14, 15, 16, 18; patients. Analysing the main components per 25 items of
c. Related to communication aiming at carrying on the NQCPQ, one factor was extracted, which explained
prescribed pharmacotherapy by a doctor – 3, 5, 7, 19, 86% of variability of the observed phenomenon – nurse-
23, 24. patient communication quality. With Kaiser-Meyer-Olkin
(KMO) measure of model adequacy, the value of 0.94 was
gained, indicating that the analysis of main components
Research procedures was statistically reasonable and justified. Bartlett’s test for
2=860.071 and df=15 shows the highly statistically signif-
During the forenoon period, 1-2 nurses in each clinical icant spheroid type of the model (p<0.01).
ward gave the grade per items of the NQCPQ. During the Within one extracted component, six items were outlined,
afternoon shift, the nurses from the comparative group of marked in Table 1 with the following numbers: 9, 10, 11,
assessors gave their grades per items on the same patients. 17, 22 and 24. From the communality scheme of each item,
All assessors gave their grades completely independently we can see that the contributions of the mentioned 6 items
from each other so that measurements could be objective. in the extracted component are almost equal (Table 2), so
For each patient on the interview sheet, there is a full from the practical reasons we have decided to get the score
name of a nurse given, date and time of interview, patient by simple adding of grades per mentioned 6 items.
number, gender and age. The intra-class correlation coefficient for the mentioned
6 items was highly statistically significant (F=29.63; p<0.01)
and was CIC=0.96 with the confidence interval (0.95-0.97)
Statistical analysis at the significance level of 95%. Cronbach’s  coefficient
for 6 items and 118 patients was 0.97.
Assessment of main components and defining of the way Student’s testing of differences between grades of two
of scoring per items of the Questionnaire with reduction assessors in 6 items of the main component revealed signif-
of data was done through analysis of main components. icant differences in items 17 and 22 (Table 3), whereas in
Reliability, i.e. internal consistency of items per extracted other items no significant difference was found. Descriptive
main components of the Questionnaire is expressed with statistics for grade pairs per items are shown in the Table 4.
Cronbach’s alpha coefficient (Cronbach’s α) [7] and with There was no significant difference between the Questionnaire
intraclass correlation coefficient. Repetitiousness of items scores between the first and second assessors (t=-1.28;
and NQCPQ scores were evaluated by the Student’s t-test for df=117; p=0.2). The values of the first and second measure-
paired-samples and by the Pearson’s correlation coefficient. ments for the score were 27.85±7.02 and 28.31±6.73.
Pearson’s correlation coefficients per items of the extracted
main component were highly statistically significant and
RESULTS
Table 4. Descriptive statistics of grades for 6 items of the main
NQCPQ component in two measurements derived from two diffe-
The analysis included 118 patients (56 men and 62 women) rent assessors (N=118)
of average age 60±17 years. The quality of communica- Differences between pairs per item X SD
tion was measured in 43 patients in the rehabilitation 9I 4.55 1.38
Pair 1
9 II 4.55 1.36
Table 2. Communalities per 6 items of one extracted component- 10 I 4.57 1.27
Pair 2
factor derived through the analysis of main components of the NQC- 10 II 4.57 1.32
PQ in 118 patients 11 I 4.52 1.23
Pair 3
Item number Extracted 11 II 4.63 1.24
11 0.826 17 I 4.63 1.28
Pair 4
17 0.795 17 II 4.81 1.23
22 0.836 22 I 4.67 1.26
Pair 5
24 0.867 22 II 4.87 1.01
9 0.901 24 I 4.89 1.16
Pair 6
10 0.908 24 II 4.88 1.05

Table 3. Statistics of the Student t-test for paired samples derived from two assessors for 6 items of the main component (N=118)
Pair difference
I–II 95% CI t df p
X SD SE
Lower limit Upper limit
Pair 1 9-9 0.00 0.94 0.09 -0.17 0.17 0.00 117 1.000
Pair 2 10-10 0.00 0.97 0.09 -0.17 0.17 0.00 117 1.000
Pair 3 11-11 -0.10 0.85 0.08 -0.25 0.05 -1.29 117 0.197
Pair 4 17-17 -0.17 0.91 0.08 -0.3442 -0.01 -2.12 117 0.036
Pair 5 22-22 -0.20 0.86 0.08 -0.3607 -0.04 -2.56 117 0.012
Pair 6 24-24 0.02 0.74 0.07 -0.1179 0.15 0.249 117 0.804
X – arithmetic mean; SD – standard deviation; SE – standard error; CI – confidence interval

http://srpskiarhiv.sld.org.rs
82 Vuković M. et al. Development and Evaluation of the Nurse Quality of Communication with Patient Questionnaire

Table 5. Pearson’s correlation coefficient (r) of grade per items of the

main NQCPQ component by two assessors (N=118) dynamics of his/her recovery. During the work with hospi-
I–II r
talized patients, a nurse carries out care, therapy, monitors
Pair 1 9-9 0.76 the patient’s condition, takes nurse history and participates
Pair 2 10-10 0.72 actively in feeding heavier patients. A part of relevant data
Pair 3 11-11 0.76 that should be filled out when taking history, a nurse gets
Pair 4 17-17 0.74 from the conversation with the patient, or during verbal
Pair 5 22-22 0.73 communication. Cooperation of a nurse with a patient
Pair 6 24-24 0.78 during his/her hospitalized treatment mostly depends on
p=0.000 the quality of verbal communication that nurse makes
with the patient.
had the values over 0.7 (Table 5). Pearson’s correlation The results of our study show that the quality of nurse/
coefficient between the scores of two assessors was highly patient communication is one unique factor that incorpo-
statistically significant and had the value 0.84. Details of rates strongly correlated verbal and non-verbal commu-
the NQCPQ with grading scale from 1 to 6 are given in nication as unity, even in relation to the communication
the Table 6. objective itself (Table 6). We can also see that the quality
of nurse/patient communication is related to the patient’s
degree of acceptance/rejection of disease or condition.
DISCUSSION Based upon the contents of the extracted factor items from
the NQCPQ, the quality of nurse/patient communica-
Experience and medical competence of a nurse, as well as tion can be defined as a measure of nurse’s perception on
ability of observation, empathy and professional skills are the quality of verbal and non-verbal established personal
the basic elements for establishment of non-verbal commu- contact with the patient, during realization of her profes-
nication between a nurse and a patient [8, 9], which exists sional activities and based upon information received on
even in silence, when no verbal communication is ongoing. the patient’s acceptance/rejection of his/her condition,
That even silence is a sort of communication between a nurse disease, appropriate nurse’s care and pharmacotherapy
and a patient confirms the fact that one of the measures during his/her hospitalization.
recommended to nurses when treating the patient is to Analyzing the NQCPQ construct validity, in 6 items we
pay a special attention to the look of a nurse (neatness, explained 86% of variability of the evaluated phenomenon
high level of hygienic habits, avoiding strong scents and – nurse-patient communication quality. The mutual rela-
too much make up, discretion in behaving and dressing, tionship of items in the component received is extremely
etc.). Silence, or non-verbal communication that flows as high (Chronbach =0.96), which proves that these items
information energy between patients and nurses, can be mutually measure the quality of nurse-patient communi-
potentially disturbed by various factors that can divert cation with high reliability. The highly significant Pearson
nurse’s attention from the target – professional commu- correlation coefficients with values over 0.7, when measuring
nication, directed to monitor the patient’s condition and repeated with the changed assessor, point out that the

Table 6. Questionnaire of the constructed NQCPQ with appropriate increasing graduating modalities of answers from 1 to 6
Grades
No. Item
1 2 3 4 5 6
The patient accepts conversation with Doesn’t accept Very difficult Hampered Good Very good Excellent
1 me about her/his illness in the following
way:
I fully understand the severity of the Conversation Very difficult Hampered Good Very good Excellent
2 patient’s illness, and I talk with him/her impossible
about it:
Conversation Answers my Answers my Answers Answers Answers
The patient talks to me about various
impossible, as questions questions my my my
themes, but avoids or is not able to
3 he/she does extremely hampered questions questions questions
answer my questions about her/his
not answer my difficult very well very well excellent
illness:
questions
The patient looks like he/she listens He/she resists Does not resist, Cooperates, Cooperates Cooperates Cooperates
to what I am saying about his/her or does but doesn’t but with well very well excellent
4 condition, but avoids or is not able to opposite from do what I am difficulties
adequately cooperate with me while what has been telling him/her
talking to him/her: told
I fully understand the severity of Not possible Extremely Hampered Good Very good Excellent
patient’s illness, therefore only by at all difficult
5 observing the patient’s gestures I
conclude that my communication with
him/her is:
Generally speaking, the level of my No Extremely Hampered Good Very good Excellent
communication with the patient communication difficult
6
while I carry out or monitor his/her
pharmacotherapy, I can describe as:

doi: 10.2298/SARH1002079V
Srp Arh Celok Lek. 2010;138(1-2):79-84 83

assessor can be more or less strict, but thanks to the high “sympathize” is not the same. So, the approach to learn
internal test-retest reliability in the total score the differ- about the interaction between a nurse and a patient,
ence was not significant, although there was a significant measuring of correlations between the nurse pain scale
difference in answers between two assessors in two items and patient pain scale, makes sense to the extent to which
(Table 3). The correlation coefficient of scores in two it is assumed that a nurse is capable to sympathize with the
measurements was 0.84, which is also very high grade of patient’s pain, which the patient is not willing to feel. Such
inter-raters reliability. approach of pain measuring, as we see it, ignores a natural
Bad communication between medical staff and the need of every human being to protect and defend himself/
patient is related to the patient’s mistrust and doubt that herself from aversion stimulants that he/she perceives, and
during the hospitalization he/she is not getting the adequate certainly does not significantly clarify nurse/patient rela-
medical treatment [10, 11]. Patients who show bad commu- tions and/or interaction.
nication usually express bad feelings about medical system Measuring the quality of nurse/patient communication
and do not like to stay in medical institutions. Often they by using the NQCPQ enables fast and simple insight into
are aggressive and unfriendly towards medical staff. We the quality of this communication. In further research, this
believe that, having in mind our results, the issue here is scale can be used for assessment of correlation of nurse/
not trust/mistrust of patients about the health system and/ patient communication with success of pharmacological
or medical staff, but rather the ability of a patient to accept treatment and other interventions, especially of health and
or not his/her disease and all that disease brings as a new educational nature, as well as alternative measures that are
aspect of reality to live with. We are of the opinion that directed to improving the communication quality, such
patients with bad communication with medical staff, espe- as music therapy, poetry, video-presentations, etc. [9] It
cially with nurses, actually deny their disease expressing is especially interesting to assess the relations of nurse/
animosity towards those who use the professional activ- patient communication quality with the type of disease,
ities to face them with the reality which they are not ready group pathology in psychiatric patients, terminal patients,
to accept as their own. patients with malignancy, and relation with demographic,
Bearing in mind that lately there have been intensive cultural and social characteristics of the patient. Measuring
efforts made on the development and evaluation of scales the quality of nurse/patient communication could contribute
for measuring of quality of treatment and care of patients to better recognition of the patient needs phenomenology
[11], we believe that our instrument (Table 6) can provide [14-19], like treatment compliance, patient satisfaction,
additional important information on the level of quality nurse satisfaction and health-related quality of life.
of the nurse/patient communication, because this measure
is expressed by the nurse who uses her own observations,
perception, professional knowledge and who is profession- CONCLUSION
ally motivated to achieve good quality of communication
with the patient, so that she can direct her medical knowl- NQCQP is a measuring instrument with six items, with
edge and communication skills to the more adequate treat- a high constructive validity that simply, fast and reliably
ment and care [12, 13]. It is well known that the nurse’s measures the quality of nurse/patient communication,
perception of an actual patient’s condition in some cases contributing to the more adequate defining of this problem,
correlates and in some cases does not correlate at all with and which can be potentially useful both in interventional
the patient’s perception [3, 4]. In case of extremely painful health studies that evaluate improvement of nurse/patient
conditions, it is demonstrated that the nurse’s and patient’s communication, and in studies which, as a subject of
statements measured by nurse pain scale and patient pain research, have evaluation of relationship of psychometric
scale do not correlate. This is logical, as “to feel” and to with other relevant parameters.

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Конструкција и оцена Сестринског упитника квалитета

комуникације с пацијентом
Мира Вуковић1, Бранислав С. Гвозденовић2, Бранка Стаматовић-Гајић1, Миодраг Илић1, Томислав Гајић1
1
Здравствени центар, Ваљево, Србија;
2
AbC.R.O., Inc. Serbia, Београд, Србија

KRATAK SADRŽAJ komponenti, a pouzdanost je određena koeficijentom intra-

Uvod Odnos između medicinske sestre i pacijenta, kao slo- klasne korelacije i Kronbahovim koeficijentom α. Za pro-
žen uzajamni odnos ili kao interakcija fak tora „pacijent” i veru međuposmatračke pouzdanosti korišćen je Pirsonov
fak tora „sestra”, predmet su izučavawa mnogih studija pro- koeficijent korelacije.
teklih desetak godina. Komunikacija između pacijenta i se- Rezultati U grupi od 118 pacijenata objašweno je 86% nepo-
stre je poseban entitet koji se razmatra u okviru široke znatog od ispitivane pojave (kvalitet komunikacije sestre
relacije ova dva subjek ta, a o woj se govori i zakqučuje in- i pacijenta), i to s jednom komponentom, kojom je izdvojeno
direktno, bez odgovarajuće merne skale koja može da odre- šest pojedinih stavki upitnika. Međusobna povezanost stav-
di nivo i kvalitet te komunikacije. S tim u vezi želeli smo ki (α) u dobijenoj komponenti bila je 0,96. Vrednosti Pirso-
da uspostavimo instrument koji bi pouzdano merio kvalitet novog koeficijenta korelacije veće od 0,7 bile su visoko
ove komunikacije. značajne po pojedinim stavkama upitnika, a koeficijent ko-
Ciq rada Ciq ovoga rada bili su konstrukcija i procena relacije skorova pri ponovqenim merewima bio je 0,84.
validnosti „Sestrinskog upitnika kvaliteta komunikacije Zakqučak SUKKP je merni instrument sa izdvojenim jedin-
s pacijentom” (SUKKP) i utvrđivawe wegove pouzdanosti. Ta- stvenim fak torom od šest pojedinih stavki i visokom kon-
kođe su se želele utvrditi mere međuposmatračke pouzdano- strukcionom validnošću, koji jednostavno, brzo i pouzda-
sti iz dva ponovqena merewa dobijenih ocena po pojedinim no meri kvalitet komunikacije između sestre i pacijenta.
stavkama upitnika i skorova SUKKP na istim jedinicama po- On može doprineti adekvatnijem proučavawu i definisawu
smatrawa od strane dva proceniteqa. ovoga problema, a u perspek tivi može biti koristan u inter-
Metode rada Početni upitnik SUKKP sadrži 25 stavki, na vencionim zdravstvenim studijama jednako kao i u izučava-
koje su odgovarale medicinske sestre svrstane u dve grupe. wu povezanosti psihometrijskih, kliničkih, biohemijskih,
Sestre su ocewivale kvalitet komunikacije sa bolnički le- sociokulturoloških, demografskih i drugih parametara.
čenim pacijentima ocenama od 1 do 6. Za procenu konstruk- Kqučne reči: psihometrijska skala; sestra; pacijent; komu-
cione validnosti upitnika korišćena je analiza glavnih nikacija

Примљен • Received: 29/05/2009 Прихваћен • Accepted: 03/09/2009

doi: 10.2298/SARH1002079V