Peplau's Theory of Interpersonal Relations: An Alternate Factor Structure for Patient Experience Data?
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Peplau's Theory of Interpersonal Relations: An Alternate Factor
Structure for Patient Experience Data?
Thomas A. Hagerty, RN; PhD1 [Adjunct Professor], William Samuels, PhD2 [Director of
Assessment and Accreditation], Andrea Norcini-Pala, PhD3 [Postdoctoral Fellow], and
Eileen Gigliotti, RN; PhD4 [Professor]
1LaGuardia Community College, New York, NY, USA
2College of Staten Island, Staten Island, NY, USA
3New York State Psychiatric Institute and Columbia University, New York, NY, USA
4College of Staten Island, Staten Island, NY, USA
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).
Reprints and permissions: sagepub.co.uk/journalsPermissions.nav
Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the authorship and/or
publication of this review.
HHS Public Access
Author manuscript
Nurs Sci Q. Author manuscript; available in PMC 2018 April 01.
Published in final edited form as:
Nurs Sci Q. 2017 April ; 30(2): 160–167. doi:10.1177/0894318417693286.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
Structure for Patient Experience Data?
Thomas A. Hagerty, RN; PhD1 [Adjunct Professor], William Samuels, PhD2 [Director of
Assessment and Accreditation], Andrea Norcini-Pala, PhD3 [Postdoctoral Fellow], and
Eileen Gigliotti, RN; PhD4 [Professor]
1LaGuardia Community College, New York, NY, USA
2College of Staten Island, Staten Island, NY, USA
3New York State Psychiatric Institute and Columbia University, New York, NY, USA
4College of Staten Island, Staten Island, NY, USA
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).
Reprints and permissions: sagepub.co.uk/journalsPermissions.nav
Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the authorship and/or
publication of this review.
HHS Public Access
Author manuscript
Nurs Sci Q. Author manuscript; available in PMC 2018 April 01.
Published in final edited form as:
Nurs Sci Q. 2017 April ; 30(2): 160–167. doi:10.1177/0894318417693286.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
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
Hagerty et al. Page 2
Nurs Sci Q. Author manuscript; available in PMC 2018 April 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
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
Hagerty et al. Page 2
Nurs Sci Q. Author manuscript; available in PMC 2018 April 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
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).
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
Hagerty et al. Page 3
Nurs Sci Q. Author manuscript; available in PMC 2018 April 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
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).
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
Hagerty et al. Page 3
Nurs Sci Q. Author manuscript; available in PMC 2018 April 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
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 <.001). These factors largely reflect practices under the influence of
nursing.
Two other recent studies have also linked the quality of nursing services with patients'
hospital experiences. The first study, which utilized 2009 to 2011 nurse staffing and patient
experience data from 311 California hospitals, found that higher levels of nurse staffing and
less utilization of per-diem or
travel nurses (as opposed to full time staff) are significantly,
positively correlated with better patient experiences (Hockenberry & Becker, 2016). The
second study compared 2010 patient experience data from almost identically matched
Magnet (
n = 212) and non-Magnet (
n = 212) hospitals; patients in Magnet hospitals had
significantly better experiences than those in non-Magnet hospitals (Stimpfel, Sloane,
McHugh, & Aiken, 2016). Due to mandated nurse staffing ratios in the first study and
Magnet designation in the second, two natural experiments occurred that demonstrated
nursing's influence on patient experience.
Methods and Procedures
This study was a secondary data analysis of one hospital system's HCAHPS survey results
using confirmatory factor analyses (CFAs). Confirmatory factor analysis is a type of
structural equation modeling that measures the relation of observed variables (survey items),
known as indicators, to unobserved or latent variables, known as factors. Observed variables
that theoretically should have relations with latent factors will have stronger correlations
than those that theoretically should not have relations (Kääriäinem, Kanste, Pölkki,
Miettunen, & Kyngäs, 2011).
This study consisted of three parts. In Part 1, a CFA tested a model in which patients'
responses to 16 HCAHPS survey items were the observed variables and Peplau's
(1952/1991/1997) working and termination phases were the latent factors. It was
hypothesized that this model would present a significant fit to the data and therefore support
Hagerty et al. Page 4
Nurs Sci Q. Author manuscript; available in PMC 2018 April 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
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 <.001). These factors largely reflect practices under the influence of
nursing.
Two other recent studies have also linked the quality of nursing services with patients'
hospital experiences. The first study, which utilized 2009 to 2011 nurse staffing and patient
experience data from 311 California hospitals, found that higher levels of nurse staffing and
less utilization of per-diem or
travel nurses (as opposed to full time staff) are significantly,
positively correlated with better patient experiences (Hockenberry & Becker, 2016). The
second study compared 2010 patient experience data from almost identically matched
Magnet (
n = 212) and non-Magnet (
n = 212) hospitals; patients in Magnet hospitals had
significantly better experiences than those in non-Magnet hospitals (Stimpfel, Sloane,
McHugh, & Aiken, 2016). Due to mandated nurse staffing ratios in the first study and
Magnet designation in the second, two natural experiments occurred that demonstrated
nursing's influence on patient experience.
Methods and Procedures
This study was a secondary data analysis of one hospital system's HCAHPS survey results
using confirmatory factor analyses (CFAs). Confirmatory factor analysis is a type of
structural equation modeling that measures the relation of observed variables (survey items),
known as indicators, to unobserved or latent variables, known as factors. Observed variables
that theoretically should have relations with latent factors will have stronger correlations
than those that theoretically should not have relations (Kääriäinem, Kanste, Pölkki,
Miettunen, & Kyngäs, 2011).
This study consisted of three parts. In Part 1, a CFA tested a model in which patients'
responses to 16 HCAHPS survey items were the observed variables and Peplau's
(1952/1991/1997) working and termination phases were the latent factors. It was
hypothesized that this model would present a significant fit to the data and therefore support
Hagerty et al. Page 4
Nurs Sci Q. Author manuscript; available in PMC 2018 April 01.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
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