In consideration of the influence of Japanese culture, introduce studies for resolving conflict between nurses and patients. Japanese have a culture that does not express their thoughts in words. That elegant culture sometimes cannot attract each other’s ideas. When it is driven in a busy environment or spiritually, Doi calls it “the structure of amae.” However, there seems to be no English equivalent to this “Amae”. However, I think that it is very important to understand the concept of “Amae” in considering the relationship between a nurse and a patient. Therefore, from the conflict between the nurse and the patient, in particular here we introduce Japanese traditional art “intervention study using tea ceremony: in Japanese Chadoh” and “avoidance of veteran nurses conflict”. In addition, although these findings are unique to Japan, they can be said to be universal from the viewpoint of human relations.
- nurse-patient relation
- cultural background
Based on an abundance of available information, patients select a preferred medical institution, from which they receive medical services doi analyzes Japanese expectations from the perspective of "amae" . The Donabedian  framework is often referred to in discussions relating to quality of medical care and patient satisfaction. While a patient has certain fixed goals regarding the completeness of care and restoration of health, satisfaction during the treatment period is, in many cases, influenced by the patient’s relationship with nurses.
Patient satisfaction is generally influenced by various factors, including technological elements, interpersonal factors, costs, and the environment. Although the measurement of patient satisfaction in different nursing situations might be complex [3, 4, 5, 6], it is generally accepted that patient satisfaction is an important indicator of the quality of the nursing service. Patient satisfaction correlates positively with nursing care and perceptions of the quality of patient service . There is also a strong correlation between satisfaction with nursing care and general satisfaction . Therefore, quality of nursing care, as perceived by patients.
According to Uno et al. , patients assume that nurses are bound to utilize appropriate techniques and expressions within the nurse-patient relationship.
In nursing practice, studies by inductive content analysis of cases where conflict has occurred present the conflict situation according to two (2) axes, namely, “impact on the patient” and the “patient’s response.” The latter suggest that, in the absence of clear patient communication, paying attention to “the effect (of interaction) on the patient’s daily mood” is an important sub-service in nursing.
We also compared expectations regarding nursing sub-services, using Parasuraman et al.’s SERVQUAL (Multiple Item Scale for Measuring Consumer Perceptions of Service Quality) [10, 11]. The results showed that patients’ expectations of nurses are influenced by the Omotenashi culture of “consideration of others,” which is characteristic of Japanese people .
In an interview with a person who, after serving as a nursing director, still felt it important to be involved with patients , we learned that a good nurse deduces the expectations of patients and, interpreting such in terms of nursing science, performs nursing care accordingly. Thus, in this instance, we focused on Gold Nurses or Expert Nurses. To our knowledge, there are no studies focusing on the words (in the form of text) of subjects, to determine aspects of conflict avoidance between nurses and patients. In view of this, we set out to determine this in the specified manner.
In recent years, the clinical practice, education, and research capabilities of nurses have increased; however, there remain complaints from patients and their family members concerning their interactions with nurses. To promote a sense of patient satisfaction during medical treatment, nurses should be aware of subservices that provide insight into the feelings of patients and that facilitate appropriate nurse-patient interactions . Although the goals of nursing include consideration, compassion, and empathy toward patients, there is no concrete method of engendering these in a nurse.
Henderson noted that in the nurse-patient relationship, “getting under his/her skin” is a way to understand a patient . Erikson considered empathy to be “feeling concern for suffering,” and showed that a nurse must acknowledge a patient’s suffering to make the patient feel they are respected as a person . To alleviate a patient’s suffering, a nurse should discover the patient’s desires, and the patient’s feelings of trust, hope, powerlessness, guilt, and shame . A nurse needs to understand each patient’s unique experience of his or her disease, knowledge, and feelings [16, 18]. Such a nurse-patient relationship is considered the foundation of a therapeutic relationship.
Keenan reported that the Japanese tea ceremony is useful for stress management in nurses , and Donnelly reported that by placing participants within a natural setting , the tea ceremony allows participants to enjoy the life that is universally shared by humans and to maintain harmony with others. Uno reported on the importance of hospitality (in Japanese: omotenashi) in the Japanese culture as a characteristic of the nursing interactions that were desired by patients . Although the Japanese tea ceremony is a part of the traditional Japanese culture, few Japanese individuals practice the art daily, and reports concerning the role of the tea ceremony in the field of nursing are rare. Thus, in this study, nurses who worked in a clinical practice participated in the Japanese tea ceremony to evaluate changes in their awareness with respect to their interactions with patients. I focused on the Japanese tea ceremony as a method to form peaceful interpersonal relationships during patient interactions.
2. Conflict occurring between nurse and patient
2.1. Nurse - patient relationship and conflict
High-quality nursing is based on good nurse-patient relationships. Watson described that this relationship is dependent on the nurse’s ability to be genuine, authentic, and open . Conventionally, one of the main concepts in nurse-patient relationships is empathy. The concept of “empathy” on the part of nurses replaced the previous concept of “sympathy,” which was advocated by Nightingale. For nurses to provide quality care, one researcher advocated that “the nurse must always be kind and sympathetic, but never emotional” . Sympathy in the nurse-patient relationship was recognized as being helpful during the therapeutic process [24, 25]. Henderson described “getting under his/her skin” as a method for nurses to better understand patients . Bissell et al. suggested that good nurse-patient relationships were maintained by building mutual understanding, and described that conflict might arise when this did not occur . Robbins defined conflict as “a process which starts when an individual recognizes that an important matter to him/her was, or would be, adversely affected by another individual,” and described that the common point of the definition of conflict in various researchers was “opposition” or “disagreement.” Robbins also suggested that conflict exists in four stages. Specifically, these stages are (1) potential opposition, (2) recognition and individualization, (3) behavior, and (4) result . Unoet al. examined conflict that occurred between nurses and patients and reported that recognizing subtle changes patient’s feelings might improve nursing . Furthermore, Uno emphasized that what patients expected most during conflict was the concept of empathy, specifically in terms of empathy being defined as the inference of feelings . It was then proposed by Uno et al. that expert nurses would be more likely to exhibit sufficient levels of empathy and revealed that these individuals avoided conflict by guarding the patient’s soul and committing to it deeply, while simultaneously keeping appropriate distance .
In a study focusing on the circumstances leading to conflict between nurses and patients that was performed by Uno et al. nurse perceptions of patient’s expectations under conflict were analyzed both qualitatively and inductively . A total of five categories were extracted: Inference, Empathic understanding, Listening, Individual treatment, and Reliable skills and explanations. Specifically, it was reported that Inference was abnormal in Japanese culture. Thus, it seems that such patient expectations may influence the quality of nursing perceived by patients.
2.2. Understanding of the phenomenon within the clinical setting
Interviews are one method to search for unclear issues within qualitative studies. In an interview, questions and responses exist coincidentally, and the response reflects each interviewee’s subjective feeling or thoughts at that time. Conversely, in a descriptive questionnaire survey, as compared to an interview, the response is obtained from subjects after sufficient recollection, which achieves more objective data.
It is difficult to quantify phenomena in clinical settings where nurses face patients. Patient’s informal expression of symptoms, such as onomatopoeia (i.e., “zukizuki” (describes headache), which is commonly used in clinical settings, can be understood by nurses with experience. In other words, nurses understand and address the phenomenon (patient’s complaint) as it deviates from the concept.
3. Compassion for others based on Japanese culture
3.1. “Doh” or “OMOTENASHI” symbolizing Japanese culture
There is Doh” as a traditional technique in Japan. Typical examples are Japanese tea ceremony, flower arrangement, calligraphy and so on.
There is a “hospitality (in Japanese OMOTENASHI)” that treats you with a flexible attitude.
3.2. Japanese tea ceremony
This study provided foundational data for use in nursing interventional methods for improving nurse-patient relationships. This was a descriptive study on the effectiveness of a Japanese tea ceremony (in Japanese: chado) intervention for improving nurse-patient relationships. I conducted a Japanese tea ceremony and examined changes in nurses’ awareness regarding interactions with patients after this intervention. The tea ceremonies were conducted with the cooperation of an Urasenke tea ceremony lecturer. A quiet environment with chairs and tables was provided for all participants while they provided written answers to a descriptive survey, which was administered before and after the intervention; they required approximately 20 min to complete the survey. The mean length of each nurse’s description was 800 characters. The tea ceremony was effective in bringing about definite changes in nurses’ awareness concerning interactions with patients. This study is useful in that it suggests how nurses can maintain good interpersonal relationships with patients.
This study provided basic data to explore interventional methods for nurses to improve nurse-patient relationships. I examined the manner in which awareness of the nurses regarding their patient interactions changed after participating in the Japanese tea ceremony.
3.3. How to arrange the minds of nurses; introduce a study about to use Japanese tea ceremony
This study was a descriptive survey of a Japanese tea ceremony intervention. In 2014, I conducted a similar intervention involving three participants and descriptive surveys, similar to those used in the present study. I confirmed that there were no mental or physical burdens on the participants and that there was a change in nurses’ awareness.
I initially mailed 100 regional medical care support hospitals in the Kinki region of Japan to explain the purpose and methods of the study and to request their cooperation. Four hospitals agreed to cooperate. A total of 14 nurses expressed an interest in participating in the present study; however, only 12 nurses were included for analysis because two dropped out during the study. Twelve was the maximum number of individuals who agreed to cooperate. However, the 800 words provided in total by these individuals were sufficient for qualitative summarization.
3.3.3. Data collection
The study period was from March to May 2015. Interventions were performed once per week over a 4-week period (i.e., a total of four times). Interventions were performed in a tea ceremony room located in a temple in the Osaka Prefecture, Japan.
3.3.4. Operational definitions of the terminology
The “Japanese tea ceremony” (in Japanese: chado) is a traditional Japanese art that has been referred to as a “composite art form.” “Tactfulness in silence” refers to the insight of sensing the thoughts and feelings of others that are not expressed in words.
3.3.5. Study design
I administered a pre-intervention survey to assess the individual characteristics of the nurses (age, years of experience as a nurse, affiliated hospital wards, and experience participating in tea ceremonies) and the following items:
Interactions with nurses believed to be desired by patients,
Awareness of daily interactions with patients,
Interactions believed to improve the quality of nursing, and
Image of the tea ceremony.
A quiet environment with chairs and tables was provided for the participants while they provided written answers to the survey.
The tea ceremonies were conducted with the cooperation of an Urasenke tea ceremony lecturer. The tea ceremony lecturer acted as the tea master during the ceremonies.
The guests were the participants, who were divided into groups of six individuals; each experienced the same program content for approximately 1 h in each session. To ease the tension of the participants who were participating in the tea ceremony for the first time, the researchers, who had participated in a tea ceremony before, presented a partial example of a ceremony. However, to avoid influencing the study results, the participants were allowed to act naturally during the tea ceremony (Figures 1 and 2). The tea ceremony steps are listed below.
3.4.1. Individual characteristics
The mean age of the 12 participants, all of whom were female, was 48 years (SD = 6.6). The mean years of nursing experience was 23 (SD = 5.8). The nurses worked in the Department of Internal Medicine (chronic disease ward), and no participants had previous experience participating in a tea ceremony. Four of the nurses qualified at a university and eight were qualified as nurses at a vocational school.
3.4.2. Nurse’s consciousness of interactions with patients before and after intervention
The participants required approximately 20 min to write their descriptions. The mean length of each nurse’s description was 800 characters. The descriptions of items A through D were qualitatively analyzed and compared before and after the intervention
Interactions nurses believed to be desired by patients. Prior to the intervention the interactions desired were thought to be smiling, kindness, communication, providing explanations, and so forth. After the intervention, the desired interactions were considered to be not superficial gentleness, but rather treating the patient as a person. Patients were believed to expect nurses to stare at them deeply, as it could help them in realizing who that patient is.
Awareness of daily interactions with patients. Before the intervention points raised were interacting gently and kindly, interacting safely, providing science-based explanations and having a science-based skillset, and displaying an empathetic attitude. After the intervention, the goal was to interact without pressure, such as by providing appropriate space (distance) for the patient.
Interactions believed to improve the quality of nursing. Before the intervention, the issues raised were to keep learning, learn and practice ways of communicating regarding disease, always think about the patient’s feelings, do not make medical mistakes, and so forth; essentially, to provide a good recuperative environment. After the intervention, the participants raised the points: Always tell yourself to be casual (which was helpful for easing their tension), and to “catch precisely, as soon as possible.” Furthermore, touch according to the patient’s desire. In this way, the participants were transformed such that they could recognize their natural involvement as a person before their involvement as a nurse.
Image of tea ceremony. Prior to the intervention, the ceremony was considered stiff, difficult, and unfamiliar; only something that rich people learn. After the intervention, it transformed into something that the participants felt they could incorporate into daily life. It was noted that “my own heart calms down.”
Results of the pre-intervention awareness analysis revealed an awareness of appropriate professional interactions, such as “interacting gently and kindly,” “interacting safely,” “explanations and skills with a scientific basis,” and “empathetic attitude.” The Japanese tea ceremony involves silent communication between the host and guests, as the guests “sensitively feel the intentions of the tea master, who takes great pains to provide an atmosphere of hospitality.” The post-intervention comments were related to peaceful interactions, such as “interacting without pressure,” “interacting while maintaining an appropriate distance,” “interacting with a sincere attitude,” and “insight in sensing feelings that are not expressed in words.” These categories were based on an awareness of the interactions with patients that were not limited to their status as a professional nurse.
Considering three aspects, I assessed how participant’s awareness changed regarding interactions with patients after the tea ceremony. The first aspect was related to changes in feelings because of being in a teahouse and the formal interpersonal relationships that were created. After the intervention, categories related to calmness of mind were suggested by the nurses. For the nurses who were busy with daily nursing tasks, the Japanese tea ceremony was a place where they could relax and find peace of mind. The second aspect was that the participants (nurses) received polite hospitality and were cared for. People tend to be rude to others when they are treated rudely themselves. The work of nurses constitutes emotional labor, that is, the management of emotions in the workplace . After the intervention, the categories “interacting with a sincere attitude” and “insight in sensing feelings that are not expressed in words” were observed. Therefore, the tea ceremony is useful for controlling emotions through polite hospitality and caring for guests.
The third aspect was the way in which the five senses were utilized. Nurses should have a high degree of sensitivity while working in a hectic and highly stressful environment. However, here the participants were given a chance to return to nature by appreciating seasonal flowers. That is, the participants were able to relax in a beautiful environment that could be experienced through the five senses. These findings are important for managing the working environment of nurses, who are likely busy with numerous other daily tasks when interacting with patients.
The program used in this study exceeded the limits of the field of nursing, but it appeared useful for creating favorable nurse-patient relationships. Specifically, this method effectively relaxed the nurses, which suggests that relaxation is one way to improve interpersonal relationships. In summary, the intervention method used in this study is useful for nurses to maintain good interpersonal relationships with patients.
Changes in nurses’ awareness related to interactions with patients were noted after the tea ceremony intervention. I observed changes related to increased functional beauty and spirituality, as exemplified by the categories “interacting without pressure,” “interacting while maintaining an appropriate distance,” “interacting with a sincere attitude,” and “insight in sensing feelings that are not expressed in words.” Thus, participating in the tea ceremony was effective in bringing about definite changes in nurses’ awareness concerning interactions with patients. However, a future study with an increased sample size is needed to verify the present study’s results, and a survey of patients who received nursing care from the participants is also necessary.
4. How to arrange the minds of nurses; introduce a study about aspects of avoidance of conflict between nurses and patients, according to gold nurses, expert or veteran nurses: A program for raising the quality of nursing
The purpose of our study was to ascertain, via language (text), methods of avoiding conflict that could have an impact on the quality of the nursing provided by nurses to patients, with a special focus on Gold Nurses (or Expert Nurses).
4.2. Operational definitions
“Gold Nurses”: Nursing professionals who have served as, for example, managers of clinical nurses, public health nurses, and so forth, who continue to work as nursing professionals after retirement, upon registration with the Osaka Municipal Government nursing professional organization. No other prefectures in Japan use this specific term. This term is used to distinguish such nurses from “Expert Nurses,” who are still employed (i.e., not yet retired).
Subjects were five persons registered as “Gold Nurses” with the Japan Nursing Association. Data collection was performed in May 2015, a time that suited the schedule of the Regional Public Health Division. Semi-structured interviews were conducted with the subjects, based on an interview guide. The mean interview time was approximately 50 min per person. After obtaining consent from the subjects, the interviews were recorded using an IC (integrated circuit) recorder.
The interview guide, which was based on Robbins’s conflict processes, was concerned with the settings and situations (including latent elements) of conflict occurrence within clinical practice, ways of responding to and avoiding conflict, and methods of handling conflict .
4.3.2. Data analysis
The interview contents were transcribed verbatim, and morphological analysis was conducted on the textual data. To ensure that there were no discrepancies in meanings, the words were ordered and a dictionary was created; thereafter, using IBM SPSS Text Analytics for Surveys 4.0.1, the data were analyzed with Statics ver. 22, R ver. 3.1.3.
To ensure accuracy during the analysis process, we were supervised by a university professor who is an expert in text mining.
4.3.3. Ethical considerations
Prior to the interviews, a briefing meeting was held with the subjects, where the aspects of the study were explained verbally and in writing; interviews were conducted with subjects who consented to participate, with the guarantee that the said consent could be withdrawn at any time, without any penalties. The ethics committee at the researcher’s affiliate institution (Consent Number 1) granted approval for the commission of the study.
4.4.1. Demographic characteristics
All the participants were female, with a mean age of 63.5 ± 0.48 years, and mean work experience of 40.5 ± 0.38 years as nurses
4.4.2. Data analysis
18.104.22.168. Frequency analysis
Frequency analysis is the frequency of the appearance of words in morphological analysis. The top five words in order of frequency, from 1 to 5, were “Nurse,” “Patient,” “Care,” “Guard,” and “Soul.”
22.214.171.124. Cluster analysis
“Cluster analysis” comprises a variety of mathematical methods, used to identify similar items in a dataset.
In this instance, distance between items was determined using the Jaccard method and, on the basis of the dissimilarities found, clustering was performed using Ward’s method. The numbers in the upper portion of Figure 1 show the bond distance between the clusters.
It should be noted that the greater the similarity between clusters, the smaller the number indicating distance, thus, one can see the unique closeness of the clusters, “Mind-Body-Soul・Commit” and “Distant・Appropriate.” (Figure 1 Cluster analysis where gold nurses avoid conflicts).
126.96.36.199. Co-occurrence network analysis
Our fundamental network analysis is one widely used in various fields, including sociology and communication networks, and is based on the mathematical graph theory; as shown in the figure. It comprises V: Vertex (vertices), depicted in the form of a circle, and E: Edge (edges), depicted as a line.
Specifically, expressed words that were in a co-occurrence relation are shown as lines, the size of the circle shows appearance frequency, and the thickness of the line shows the relative strength or weakness of the co-occurrence. In this figure, the darker the color, the greater the emphasis. In addition, the separate figure shows the characteristics of co-occurring words.
In relation to “Bed・Accidents,” one can identify concern regarding an accident involving falling from a bed. “Consider・Doctor・Differences” a concept that differs from “medical doctor.” The cluster, “Trouble・Solution・Physical Restriction・Together,” indicates nurses wondering whether physical restriction (restraint) of patients would lead to the resolution of problems. “Nursing・Novice・Nurse・Output・Trouble” indicates problems that could occur in relation to novice nurses. “Appropriate・Distant” and “Customer・Family” show the nurse maintaining an appropriate distance from the patient and his/her family. “Commit・Mind-Body-Soul” clearly shows a commitment to both the physical and mental aspects of patients. “Helping・Soul・Life・Guards” means that assistance in the patient’s life constitutes “guarding” (protecting) the soul, or does it perhaps mean that if one’s life is under guard, then it follows that the soul is also under guard? In “Daily Living・Create・Accomplish,” we learn that there is “creation” of daily life. “Nursing staff・Believe” indicates that the Expert Nurse has trust in her staff (Figure 2 Co-occurrence network analysis where gold nurses avoid conflicts).
4.4.3. Excerpts from the text (language) data
As a foundation for securing nursing quality, the avoidance of an accident in a nursing situation is most important. Such a situation causes mental discord within a nurse. Although it is possible to restrain a patient, so as to prevent injury to the patient or to prevent an accident, can one really guard a patient and his or her family’s soul?
We, nurses, are proud to be guarding the souls of our patients.
Doctors protect (guard) life as their first priority. We, nurses, protect (guard) the soul as well as the body.
The most prominent concern in the mind of a novice nurse is to avoid causing an accident; she (he) might even, at times, forget that the patient is a person. However, that would cause problems between the nurse and the patient, or the patient’s family. Yet, I still carry on with my work, while trusting novice nurses and our staff.
We are deeply committed to our patients. Meanwhile, we discern aspects within our patients and their lives that we should not delve into.
Nurses have an awareness relating to the question, “What can I do, as a nurse?” (or, “What can we do, as nurses?”). The authors believe that it is precisely such dedicated thinking that raises nursing quality. The Gold Nurses in our study each have very substantial experience working as nurses. The amount of experience in this regard not only shows an accumulation of years, but also indicates refinement of the nurses’ theories and conceptualizations, as a result of facing numerous actual situations .
The concrete meaning of “guarding the patient’s soul” is the fact that the nurse continues to provide care, from the emergency (acute) period through to social rehabilitation; in other words, a nurse’s pride is the fact that she (or he) never saves only a life, even in emergency situations. Further, the fact that nurses are deeply committed to their patients indicates insights about their consideration of others, from feelings cultivated during training, to their working together with patients and their families, so as to create and nurture everyday lives, while also recognizing areas that a nurse should not delve into. On this basis, these nurses can avoid conflict in their relationships with patients and families.
Research on customer satisfaction is quite established in business management studies; SERVQUAL is a popular scale for measuring the gap between expectations of general services and customer satisfaction. The five service dimensions comprising this concept are identified as Reliability, Tangibles, Responsiveness, Assurance, and Empathy [33, 34]. Meanwhile, in a study focusing on nurses, Koerner states that, while the conceptual zones of service quality are clarified in Parasuraman et al. ., these are not completely accurate for nursing services provided to inpatients. Rather, Compassion, Individual Care, Close Relationships, Uncertainty Reduction, and Reliability are appropriate for the latter instance. Beltrán went on to state the following: “The interaction between patients and nurses goes through various stages until achieving the necessary empathy, compassion, affection, and familiarity to account for humanized care .”
In our study, Guarding the Soul, Deep Commitment, and Determining an Appropriate Distance from Patients, were cited as important elements in the configuration of nursing services, the type that Gold Nurses are especially proud of. Although there are reports concerning “Spiritual Care,” a concept with a meaning similar to that of Guarding the Soul [37, 38], with regard to the idea that “life” includes the “soul” of the patient in the nurse-patient relationship, we found the following quote by Cumbie to be especially relevant: “Reflected self-awareness is the key to perception of self within the context of human experience.” 
Gold Nurses (or Expert Nurses) guard their patients’ souls, and while deeply committed, they maintain an appropriate distance, thus, avoiding conflict with patients and enhancing the quality of nursing.
4.7. Relevance to clinical practice
The methods that Gold Nurses (or Expert Nurses) have devised to interact with, and give satisfaction to their patients, raise the quality of nursing. Such can serve as references for novice nurses still worrying about their relationships with patients, in that, if training is provided in such methods, then nurses would be able to gain such valuable experience without having to rely on working as a nurse for many years.
A limitation of our study was the fact that we investigated only the perspectives of nursing service providers. In future, there will be a need to consider issues relating to nursing services from patients’ perspective, as well. I appreciate those concerned who cooperated until the completion of the author. To consider nursing service from the Japanese culture. This idea represents the characteristics of interpersonal culture of the Japanese. At the root of the research, we think that the human relationship between nurses and patients is universal.
I deeply appreciate my friends who supported me.
Conflict of interest
There is no conflict of interest concerning this writing.