Validation of the defining characteristics of body image disturbance in Japan
PURPOSE. To examine the validity of the nursing
diagnosis body image disturbance and to
specify its major and minor defining
characteristics in Japanese culture.
METHODS. A qualified sample of 149 RNs with an
average of 10 years of clinical experience and
knowledge of nursing diagnosis was given a
questionnaire consisting of 21 defining
characteristics from NANDA, 8 additional items
from the literature, and 2 distracting characteristics.
FINDINGS. Four major diagnostic content
validation (DCV) scores of 0.75 and higher and
15 minor defining characteristics with DCV
scores from 0.60 to 0.74 were identified.
CONCLUSIONS. This study provides a foundation
for further study of culturally appropriate
defining characteristics for use in Japan.
Key words: Body image disturbance, defining
The defining characteristics of diagnoses on NANDA’s list are used by nurses to identify accurate diagnoses. The defining characteristics of body image disturbance, however, were not previously validated for use in Japan. Body image disturbance is defined as a “disruption in the way one perceives one’s body image” (NANDA, 1996, p. 68) and it has 21 defining characteristics. In Japan, there is anecdotal evidence that nurses use a variety of defining characteristics that differ from those listed by NANDA.
One reason to conduct this study is to show that the influence of culture needs to be considered to determine the validity and reliability of defining characteristics. Generally, Japanese adults do not express themselves verbally in terms of self-concept. This cultural trait may mean some defining characteristics listed by NANDA are not valid for use with people from the Japanese culture.
According to NANDA, the defining characteristics of “verbal response to actual or perceived change in structure and/or function” or “non-verbal response to actual or perceived change in structure and/or function” (NANDA, 1996, p. 68) must be present to justify the diagnosis of body image disturbance. These defining characteristics are not observable. It was unknown how they would present in Japanese patients.
Considering the need to develop valid diagnoses for use, the authors surveyed Japanese nurses to determine which defining characteristics they use to diagnose body image disturbance. The purposes of this study were to describe the validity of body image disturbance for use in Japan and to specify major and minor defining characteristics for the diagnosis as it relates to Japanese culture.
An initial sample (N = 554) was drawn from 10 hospitals in Japan in June 1996. The subjects were RNs with more than 3 years clinical experience who had learned about nursing diagnosis through continuing education in hospital settings and nursing associations and had used nursing diagnosis in hospitals. The purpose was to select from this sample a group of practicing nurses who had sufficient general knowledge of nursing diagnosis, frequently used the diagnosis body image disturbance, and had sufficient clinical experience to be considered expert judges. This information was determined through a mailed questionnaire. The sample for the study was 149 nurses who stated they diagnose body image disturbance “often” or “very frequently,” had knowledge of nursing diagnosis, and had an average of 10 years’ clinical experience (Table 1).
The questionnaire consisted of 21 items representing NANDA’s defining characteristics, 8 additional items from the literature, and 2 distracting characteristics (Wake, Fehring, & Fadden, 1991). A Likert scale was used to rank each item (5 = very frequent, 4 = often, 3 = sometimes, 2 = seldom, 1 = never). The authors asked subjects to check each item they use in clinical practice, add other signs and symptoms, and identify the physical condition of their clients for whom they were most likely to diagnose body image disturbance. The seven categories of physical conditions were loss of body part, postoperative, receiving chemotherapy/radiation, critical injury, chronic illness, eating disorder, and “other.” Nurses were able to select more than one condition and were asked to identify any defining characteristics in the list that were difficult to understand. Subjects were asked to document what they found from clients with body image disturbance related to “verbal response to actual or perceived change in structure and/or function” and “non-verbal response to actual or perceived change in structure and/or function.”
Fehring’s Diagnostic Content Validation (DCV) model (1987) was used in this research of defining characteristics for the diagnosis body image disturbance. Defining characteristics that received DCV scores of 0.75 and higher were considered major defining characteristics. Minor defining characteristics were determined by scores from 0.60 to 0.75 following DCV score evaluation by Sparks and Lien-Gieschen (1994).
The results of this study are reported below in five categories: frequency of use of the nursing diagnosis body image disturbance by expert Japanese nurses, DCV scores of 21 defining characteristics, variations in ratings of defining characteristics according to types of physical conditions, understanding the wording of defining characteristics listed by NANDA, and additional defining characteristics identified by subject to clarify the defining characteristics of nonverbal and verbal responses to actual or perceived changes in structure and or function.
Frequency of Use
The frequency of use of body image disturbance by 554 Japanese nurse experts from the initial sample was: very frequent (n = 52; 9.3%), often (n = 193; 34.9%), seldom (n = 287; 51.9%), never (n = 22; 3.9%). From the final sample (N = 149), the nursing diagnosis body image disturbance was used by 76% of nurses (n = 113) for clients with loss of body part, 66% of nurses for postoperative clients (n = 97), 40% of nurses for clients who were having radiation/chemotherapy treatment (n = 60), 32% of nurses for clients in critical condition (n = 47), 20% of nurses for clients with chronic diseases (n = 29), 13% of nurses for psychiatric clients with eating disorders, and 11% of nurses for clients in other physical conditions (n = 20).
The DCV scores of 21 possible defining characteristics ranged from 0.51 to 0.81 (Table 2). In this study, four items were found to be major defining characteristics with DCV scores above 0.75: “inability to accept body changes,” “missing body part,” “actual change in structure and/or function,” and “verbal response to actual or perceived change in structure and/or function.” Fifteen items were found to be minor defining characteristics. The remaining 10 items did not reach the designated score of 0.60 for consideration as defining characteristics. The minor defining characteristic, “verbalization of negative feelings about body,” had an overall DCV score of 0.74, and DCV scores were higher than 0.75 in six separate situations.
There were variations in ratings of defining characteristics according to the types of physical conditions that nurses treated. In the case of psychiatric patients with eating disorders, there were eight defining characteristics with DCV scores >=0.75. The DCV scores of five defining characteristics were, however, considered minor characteristics for the total sample. These were verbalization of negative feeling about body; verbalization of feelings of helplessness, hopelessness, or powerlessness; focus on past strength, function, or appearance; preoccupation with change or loss; and verbalization of fear of rejection or reaction by others. Another variation occurred in reference to clients with critical conditions or chronic disease. With these two types of physical conditions, the DCV scores for “feeling of helplessness and hopelessness” were 0.82 and 0.80, respectively.
Wording of Defining Characteristics
Findings indicated the wording of defining characteristics listed by NANDA and other sources is difficult to apply in Japan. The percentage of nurses who were unclear about the meaning of “change in ability to estimate spatial relationship of body to environment” was 43.9%; “extension of body boundary in incorporate environmental objects” was 31.0%; “unable to d ate if the source of stimuli is internal or external” was 24.2%; “personalization of part or loss by name” was 20.4%.
Additional Defining Characteristics
In response to requests to list additional evidence of body image disturbance, especially nonverbal and verbal responses to actual and perceived changes in structure or function, 101 nurses (67.8%) provided 182 free descriptions of nonverbal responses they see with body image disturbance. The most frequent descriptions were: clients do not want to see changed body part (n = 37), change in interpersonal relationship (n = 34), negative attitude and behavior (n = 18), concealing changed body part (n = 17), behavior and attitude that cannot accept appearance of body change (n = 11), unable to control self-emotion (n = 11), sleeplessness (n = 9), and clients don’t want to touch changed body part (n = 8).
One hundred seventeen nurses (78.5%) gave 184 free descriptions of types of verbal responses. Most of the free descriptions were similar to the defining characteristics of the 21 items. Verbal responses that were described but were not one of the 21 listed items were anger, envy, and jealousy. New descriptors included anxiety, frustration, and low self-esteem with negative feelings toward self. One descriptor that was difficult to translate into English was “shikataganai.” This Japanese expression refers to a feeling that the person can do nothing but accept the situation as is. Table 3 shows the comparison between NANDA and our validation results. The highest DCV score was “inability to accept body image,” which was not listed in NANDA’s defining characteristics and the DCV scores of “missing body part” and “actual change in structure and/or function” were high.
In this study, four defining characteristics were identified as major (see Table 2), with DCV scores of 0.75 or more (Sparks & Lien-Gieschen, 1994). The authors believe, however, that some defining characteristics identified as “minor” may be observable characteristics of the major defining characteristics. For example, numbers 5 and 18 as verbal responses and numbers 7,10,11,12, and 20 as nonverbal responses (see Table 2) could be considered subcategories of the defining characteristic “inability to accept body change.” This indicates a need for concept clarification of body image disturbance for use of this diagnosis in Japanese culture.
With additional research, it may be shown that the defining characteristic of “verbalization of negative feeling about body” may meet the requirements as a major defining characteristic. This minor defining characteristic had a DCV score over 0.75 in six separate physical conditions; however, the overall DCV score was lower because of the responses in the “other physical conditions” category. In addition, 26 subjects in the study also wrote this defining characteristic in the free description section of the questionnaire. Gordon (1997) also included this defining characteristic in the Manual of Nursing Diagnosis. Therefore, this “negative feeling about body” should be included as a major defining characteristic of body image disturbance.
Based on other case studies (Ohira, Tanaka, Kobayashi, Matsutake, & Kita, 1993) and this research, some minor defining characteristics were upgraded to major defining characteristics for psychiatric clients and critical condition clients. This result suggests that these minor defining characteristics change depending on the client’s condition. Further study is required to distinguish the relationships of defining characteristics to the types of physical conditions.
Some of the defining characteristics of body image disturbance identified by NANDA and other research were difficult for Japanese nurses to understand. The nurses in this study used more informal terminology and more observable evidence than the abstract concepts used by NANDA. This may be explained by the nature of nursing education in Japan. Japanese nurses have limited opportunities to learn the meaning of psychological terms such as body image disturbance. Based on case studies (Horita, Tsukahara, & Takamune, 1993; Moriyama, Ohta, Fujisawa, & Hatagami, 1992) and this research, the authors recommend revision of the defining characteristics of body image disturbance so they are more concrete and observable for use by practicing nurses.
Some Japanese expert nurses also identified anxiety, frustration, and low self-esteem as defining characteristics for body image in the free descriptions. It seems that Japanese see self-concept and body image as the same. Champion, Austin, and Tzeng (1982) reported that body image and self-concept may be interrelated. Further study, such as clinical validation studies and factor analysis, is needed to explain these perceptions.
In studies such as this, translation of diagnosis, definitions, and defining characteristics from one language to another may explain some of the findings. This is especially relevant with psychosocial concepts/diagnoses such as body image disturbance. For example, the free description “shikataganai” could not be translated easily into English. Besides language, other cultural differences need to be considered in order that diagnoses such as body image disturbance are valid and reliable for use by nurses from Japan and other cultures. The feeling of shame in Japan is expressed frequently and fit a separate category from guilt, although Gordon (1997) lists shame and guilt in the same defining characteristic category. According to the comparison between NANDA’s defining characteristics and our results, Japanese nurses may emphasize more objective and concrete descriptions.
Four major defining characteristics and 15 minor defining characteristics for body image disturbance met the criteria as defining characteristics. There was strong evidence that one of the minor defining characteristics may be a major defining characteristic. This study provides a foundation for further study of culturally appropriate defining characteristics for use in Japan.
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Author contact: email@example.com with a copy to the Editor: firstname.lastname@example.org
Chie Ogasawara, PhD, RN, is Professor of Nursing, Osaka University; Mitsuko Matsuki, PhD, RN, is Professor of Nursing, Fukui University; Takako Egawa, PhD, RN, is Professor of Nursing, Osaka University; Yuko Ohno, PhD, RN, is Professor of Nursing, Osaka University; Eiko Masutani, MSEd, RN, Yuko Yamamoto, MSN, RN, and Yasuko Kume, MSN, RN, are Research Assistants, Osaka University, Japan.
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