Nurses’ Attitudes Towards Physical Health Care of Psychiatric Patients Scale

1. Abstract

Individuals diagnosed with severe and persistent psychiatric illnesses experience profound health disparities, leading to a premature mortality gap ranging from 10 to 25 years compared to the general population. This premature mortality is largely attributable to modifiable and treatable somatic comorbidities, including metabolic syndrome, cardiovascular pathology, diabetes mellitus, respiratory diseases, and infectious illnesses. Despite their frequent contact with healthcare services, the physical health conditions of psychiatric patients are systematically underdiagnosed and undertreated. Psychiatric and mental health nurses occupy a strategic front-line position within clinical settings to assess, detect, monitor, and coordinate physical health interventions. However, historical role dichotomization, systemic barriers, and negative professional dispositions frequently impede the delivery of holistic care. To address these systemic measurement challenges, the Nurses’ Attitudes Towards Physical Health Care of Psychiatric Patients Scale (NATPHCPPS) was conceptualized and psychometrically validated.

The NATPHCPPS is a self-report psychometric instrument comprising 16 items designed to evaluate psychiatric nurses’ cognitive evaluations, affective reactions, and behavioral dispositions toward incorporating somatic healthcare into specialized mental health practice. Built upon the foundational architecture of the Tripartite Model of Attitudes, the scale operationalizes professional attitudes across three distinct, theoretically cohesive subscales: Motivation, Emotional Challenge, and Responsibility Awareness. Responses are recorded on a five-point Likert response scale ranging from 1 (Strongly Disagree) to 5 (Strongly Agree), with negatively worded items in the Emotional Challenge subscale reversed to yield a total summated score ranging from 16 to 80.

Psychometric evaluation of the Turkish validation cohort (N = 225) established exceptional measurement properties. The overall scale demonstrated internal consistency reliability with a Cronbach’s alpha coefficient of 0.94, while individual subscale coefficients ranged from 0.86 to 0.93. Two-week test-retest reliability across a designated subsample (n = 100) demonstrated intraclass correlation coefficients exceeding 0.80, confirming excellent temporal stability. Construct validity was corroborated through exploratory factor analysis and confirmatory factor analysis, yielding superior goodness-of-fit metrics (Normed $\chi^2 < 5$, CFI $ge 0.95$, IFI $ge 0.95$, and RMSEA $< 0.08$). Convergent validity was substantiated by composite reliability values exceeding 0.70 and average variance extracted indices surpassing 0.50. The NATPHCPPS serves as an evidence-based diagnostic, evaluative, and research tool for clinical nurse managers, healthcare administrators, and nurse educators seeking to implement targeted training initiatives and improve integrated mental health delivery.

2. Keywords

psychiatric nursing, physical health comorbidity, attitude measurement, integrated care, psychometrics, scale development, somatic healthcare, mental health nursing, severe mental illness, Tripartite Model of Attitudes

3. Authors

The Nurses’ Attitudes Towards Physical Health Care of Psychiatric Patients Scale was constructed and validated by an interdisciplinary research team specializing in psychiatric nursing, clinical education, and educational measurement:

• Nurcan Düzgün, PhD, RN (Corresponding Author)
  Department of Psychiatric Nursing, Faculty of Nursing, Gazi University, Ankara, Türkiye.
  Email: [email protected]
• Satı Demir, PhD, RN
  Department of Psychiatric Nursing, Faculty of Nursing, Gazi University, Ankara, Türkiye.
• Adnan Kan, PhD
  Department of Educational Measurement and Evaluation, Gazi Faculty of Education, Gazi University, Ankara, Türkiye.

4. Purpose

The primary purpose of the Nurses’ Attitudes Towards Physical Health Care of Psychiatric Patients Scale (NATPHCPPS) is to provide an empirically substantiated, methodologically sound, and psychometrically robust measurement instrument capable of quantifying nurses’ underlying beliefs, emotional impediments, and professional obligations toward delivering somatic care to individuals hospitalized in psychiatric environments. Epidemiological research consistently documents an alarming longevity disparity affecting individuals with severe psychiatric diagnoses, including schizophrenia spectrum disorders, bipolar affective disorder, and major depressive disorder. These individuals experience premature death attributable primarily to preventable chronic medical illnesses rather than unnatural causes. The pathogenesis of this mortality differential involves multifaceted etiologies, including the adverse metabolic and endocrine side effects of second-generation psychotropic medications, elevated rates of nicotine dependence, sedentary lifestyles, socioeconomic deprivation, and institutional diagnostic overshadowing. Diagnostic overshadowing occurs when clinicians misattribute somatic signs and symptoms to a patient’s underlying psychiatric condition, resulting in diagnostic delays, inadequate physiological surveillance, and therapeutic neglect.

Within inpatient and community-based mental healthcare settings, psychiatric nurses represent the primary clinical personnel maintaining sustained, daily contact with patients. Consequently, they are positioned to execute basic physiological monitoring, administer routine somatic screenings, identify acute physiological deterioration, champion lifestyle modifications, and coordinate multidisciplinary interventions. In clinical reality, psychiatric nursing practice has frequently separated psychological interventions from physical body monitoring. This divide is perpetuated by inadequate undergraduate clinical preparation, ambiguous professional job descriptions, perceived lack of institutional resources, and deep-seated attitudinal barriers. Clinicians may view physical assessment as outside their professional remit, or experience significant professional anxiety regarding their medical-surgical competencies.

Prior to the establishment of the NATPHCPPS, instruments evaluating these constructs—most notably early instruments developed in the United Kingdom—exhibited psychometric limitations. Earlier measurement tools accounted for approximately 42% of total construct variance, failing to achieve the conventional 50% threshold recommended by psychometricians for construct representation in the social and behavioral sciences. This low explained variance suggested that substantial dimensions of nurses’ professional attitudes remained unmeasured. The NATPHCPPS was engineered to bridge this empirical and methodological gap. By offering high conceptual fidelity and explanatory power, the instrument allows researchers to dissect the specific cognitive, emotional, and motivational mechanisms governing nurse engagement with physical healthcare.

From an applied perspective, the NATPHCPPS provides nursing administrators, health service researchers, and clinical educators with an objective diagnostic instrument. The scale identifies clinical units where nurses perceive high emotional burdens, low intrinsic motivation, or reduced role accountability regarding somatic interventions. Identifying these specific deficits enables academic healthcare centers and psychiatric facilities to design, tailor, and implement continuing professional development curricula that address technical competencies as well as the emotional and philosophical attitudes of clinical personnel. The NATPHCPPS serves as an evaluative metric to determine the longitudinal efficacy of continuing education programs, institutional policy reorganizations, and holistic nursing interventions designed to dismantle diagnostic overshadowing and eliminate systemic healthcare disparities for psychiatric cohorts.

5. Psychological Construct

The construct measured by the NATPHCPPS is defined as the multidimensional system of cognitive beliefs, affective-emotional reactions, and behavioral action orientations held by registered and specialized psychiatric nurses concerning the assessment, prevention, intervention, and management of physical medical conditions among psychiatric patients. Grounded in psychological attitude theory, attitude is operationalized as a latent predisposition exerting directive or dynamic influence over an individual’s behavioral choices. Within the context of mental health practice, a nurse’s disposition toward physical healthcare is not a simple, unidimensional continuum of positive versus negative feeling. It represents an interplay among motivational readiness, emotional distress regarding task complexity, and ethical-professional role boundary definitions. The NATPHCPPS operationalizes this construct across three empirically verified sub-dimensions:

Motivation

The Motivation sub-dimension reflects the intrinsic drive, proactive professional volition, and behavioral readiness of psychiatric nurses to actively integrate physical health assessments and interventions into their daily clinical routines. This dimension moves beyond mere passive compliance with hospital mandates; it encompasses an active clinical orientation wherein nurses proactively seek opportunities to educate patients about somatic health, independently monitor metabolic profiles, and advocate for medical consults when laboratory or physical findings indicate somatic deterioration. For instance, an item within this domain assesses the extent to which a nurse willingly takes time to conduct routine metabolic syndrome checks—such as measuring abdominal girth, assessing blood pressure, or evaluating fasting lipid and glycemic indices—even during high-workload clinical shifts. Nurses scoring high on this dimension view somatic care not as a distracting burden, but as an essential, rewarding, and synergistic facet of psychiatric therapeutic recovery.

Emotional Challenge

The Emotional Challenge sub-dimension assesses the negative affective responses, psychological distress, feelings of professional inadequacy, and anxiety experienced by mental health nurses when confronted with physical nursing tasks. Due to specialized clinical trajectories and prolonged separation from medical-surgical units, psychiatric nurses may experience considerable apprehension when managing acute physical illnesses, dressing complex wounds, evaluating neurological symptoms, or operating medical diagnostic technologies. This dimension captures subjective feelings of frustration, fear of clinical error, stress stemming from perceived professional role strain, and reluctance rooted in personal discomfort with somatic interventions. For instance, this subscale captures whether a clinician feels overwhelmed, irritated, or professionally compromised when requested to perform comprehensive physical nursing care for a medically complex patient with severe psychiatric illness. Because elevated scores on the underlying items indicate high emotional discomfort, these items are reverse-scored; higher calibrated subscale scores signify low emotional friction and heightened resilience toward providing somatic care.

Responsibility Awareness

The Responsibility Awareness sub-dimension measures the cognitive component of the attitude construct, evaluating the degree to which a nurse recognizes, conceptualizes, and internalizes physical health management as an inalienable, core constituent of the psychiatric nursing scope of practice. This dimension gauges professional role perceptions, ethical obligation, and conceptual integration. Clinicians with high responsibility awareness reject the Cartesian mind-body dualism that historically relegated physical health entirely to general medical teams. They maintain that the mental health nurse bears an ethical responsibility to monitor lifestyle risk factors, screen for pharmacological adverse reactions, and coordinate primary physical preventative services. Conversely, low scores denote professional abdication, characterized by the belief that psychiatric nursing should remain confined to psychotherapeutic communication, behavioral containment, and psychotropic medication administration. High responsibility awareness reinforces the clinical mandate that comprehensive mental health recovery cannot occur in isolation from biological, physiological stability.

6. Theoretical Framework

The theoretical architecture of the NATPHCPPS is rooted in the Tripartite Model of Attitudes, a foundational psychological framework introduced by Milton J. Rosenberg and Carl I. Hovland in 1960 within the Yale studies on communication and attitude organization. The Tripartite Model—frequently termed the ABC model of attitudes—posits that human attitudes toward any given psychological object or behavior are structured through three interactive, inter-dependent components: Affect, Behavior, and Cognition.

The Cognitive component refers to an individual’s factual knowledge, intellectual assessments, belief systems, and perceived normative values regarding the attitude object. In the context of physical care delivery within mental health environments, this component involves the nurse’s factual understanding of mortality rates among psychiatric patients, recognition of the causal pathways linking psychotropic medication to cardiometabolic disease, and conceptual beliefs regarding the nurse’s professional role. In the NATPHCPPS, this cognitive component is embodied within the Responsibility Awareness subscale, reflecting nurses’ intellectual clarity regarding their scope of practice and professional obligation to provide somatic healthcare.

The Affective component encompasses the emotional reactions, physiological arousal, visceral feelings, and subjective moods evoked by the attitude object. Exposure to physical clinical tasks may elicit positive feelings of professional competence and altruism, or negative feelings of inadequacy, revulsion, anxiety, and frustration. In the NATPHCPPS, the affective component is captured by the Emotional Challenge subscale. This subscale models how negative emotional friction and clinical anxiety function as cognitive-affective barriers that reduce a practitioner’s willingness to engage in physical healthcare tasks.

The Behavioral (or Conative) component denotes an individual’s overt behavioral intentions, action tendencies, and observable behavioral commitments toward the attitude object. In the context of the scale, this component addresses what nurses actually intend to do, how they prioritize clinical time, and their proactive commitment to somatic screening, patient education, and clinical follow-up. This component maps to the Motivation subscale of the NATPHCPPS, quantifying the proactive drive, energy, and commitment nurses dedicate to executing physical health interventions during clinical practice.

Beyond the Tripartite Model of Attitudes, the conceptual framework of the scale intersects with social cognitive theories of behavior, notably Albert Bandura’s Social Cognitive Theory and Icek Ajzen’s Theory of Planned Behavior. Under the Theory of Planned Behavior, behavioral intentions are predicted by personal attitudes toward the behavior, subjective societal and organizational norms, and perceived behavioral control (or self-efficacy). When psychiatric nurses operate within clinical climates that devalue physical health (suboptimal subjective norms), lack clinical diagnostic equipment (reduced perceived behavioral control), and possess internalized fears of somatic care (negative attitude and emotional challenge), the probability of performing physical interventions declines. The NATPHCPPS operationalizes the personal attitudinal nexus of this behavioral equation, isolating the cognitive appraisals and affective reactions that drive somatic care delivery.

7. Validity

The validation protocol for the NATPHCPPS adhered to rigorous, modern psychometric standards spanning qualitative content evaluation, construct clarification, and empirical convergent verification.

Content and Face Validity

The developers generated an initial item pool of 45 items derived from an extensive review of international literature on integrated behavioral healthcare, empirical reports on diagnostic overshadowing, and qualitative investigations into psychiatric nursing experiences. To establish content validity, this item pool was reviewed by an expert panel of university faculty members and clinical specialists in psychiatric nursing, psychometrics, and educational measurement. Content evaluation was conducted using the Davis technique, which requires experts to independently grade each item’s relevance, clarity, and representativeness using a structured four-point ordinal rating system (ranging from 1 = Not Relevant to 4 = Highly Relevant). A Content Validity Index (CVI) was computed across item (I-CVI) and scale levels (S-CVI). Items failing to meet the strict conservative threshold of 0.80 were eliminated or revised, yielding strong expert consensus regarding the linguistic clarity, theoretical fidelity, and clinical applicability of the retained items.

Construct Validity

Construct validity was demonstrated through both exploratory and confirmatory factor analyses. The exploratory factor analysis successfully distilled the 16 retained items into three distinct, non-overlapping theoretical dimensions accounting for a substantial majority of the total variance, well in excess of the traditional 50% psychometric benchmark. Subsequent confirmatory factor analysis confirmed that the hypothesized three-factor structural model matched the observed covariance matrix. Item-factor loadings across all three subscales were statistically significant, demonstrating strong convergent associations with their assigned latent factors.

Convergent and Discriminant Validity

To evaluate convergent validity, the scale developers calculated Composite Reliability (CR) and Average Variance Extracted (AVE) for each subscale, following criteria formulated by Fornell and Larcker (1981):

• Composite Reliability: All three latent dimensions yielded CR values surpassing the established 0.70 benchmark, confirming high shared variance among the constituent indicators of each construct.
• Average Variance Extracted: The AVE values across the dimensions surpassed the recommended 0.50 cutoff, confirming that each latent subscale captures more variance from its assigned indicators than variance attributable to random measurement error.
• Discriminant Validity: Discriminant validity was supported as the square root of the AVE for each latent dimension exceeded the inter-factor correlations between that dimension and the remaining subscales, indicating that Motivation, Emotional Challenge, and Responsibility Awareness represent distinct constructs rather than redundant measurements.

8. Reliability

The NATPHCPPS demonstrates high internal consistency reliability alongside proven temporal stability, satisfying criteria for use in both cross-sectional research and longitudinal clinical assessment.

Internal Consistency Reliability

Internal consistency was assessed using Cronbach’s alpha ($lpha$) coefficients across the total scale and its individual subscales. The overall 16-item scale demonstrated high internal consistency with an overall Cronbach’s alpha of 0.94. Analysis of the individual sub-dimensions revealed similarly high reliability metrics:

• Motivation Subscale: $lpha = 0.93$, reflecting high internal consistency among the items measuring proactive engagement with physical health care.
• Responsibility Awareness Subscale: $lpha = 0.91$, indicating high measurement precision in assessing professional role acceptance and cognitive boundary identification.
• Emotional Challenge Subscale: $lpha = 0.86$, demonstrating acceptable consistency across items capturing clinical anxiety, stress, and affective barriers.

Item-total correlation analyses showed that all 16 items correlated with their respective subscale and total scale scores above the conservative 0.30 psychometric threshold, with no single item removal increasing the overall scale alpha coefficient.

Temporal Stability (Test-Retest Reliability)

To establish the temporal stability of the scale scores over time, a test-retest protocol was executed with a randomly selected subsample of 100 psychiatric nurses who completed the instrument a second time after a two-week interval under standardized conditions. This two-week temporal window was selected to minimize recall bias while preventing true longitudinal shifts in professional attitudes. Intraclass Correlation Coefficients (ICC) were calculated using a two-way mixed-effects, absolute-agreement model:

• The calculated ICC values for the total instrument and individual sub-dimensions exceeded the 0.80 threshold for good stability, with multiple indices exceeding 0.90, demonstrating high test-retest reliability.
• Paired-samples $t$-tests indicated no statistically significant differences ($p > 0.05$) between baseline and follow-up measurement administrations, confirming that the scale assesses stable psychological attitudes rather than transient emotional states.

9. Factor Analysis

The structural dimensionality of the NATPHCPPS was evaluated using a sequential exploratory and confirmatory factor analytic strategy within the validation cohort (N = 225 psychiatric nurses).

Data Suitability and Exploratory Factor Analysis (EFA)

Prior to executing factor extraction, the correlation matrix of the dataset was evaluated to verify suitability for factor analysis. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy yielded an index of 0.93, well above the recommended 0.60 cutoff, confirming sampling adequacy for factor extraction. Bartlett’s Test of Sphericity was statistically significant ($\chi^2$ test, $p < 0.001$), rejecting the null hypothesis that the correlation matrix was an identity matrix and confirming sufficient inter-item correlations.

Exploratory factor analysis was performed using principal axis factoring coupled with Varimax orthogonal rotation to achieve an interpretable simple structure. Scree plot inspection alongside Kaiser’s eigenvalue-greater-than-one criterion revealed a clear three-factor configuration. The final 16 items cleanly loaded onto their respective theoretical factors without problematic cross-loadings (defined as loadings $ge 0.32$ on secondary factors). The three-factor solution explained well over 50% of the total cumulative variance in nurses’ attitudes, demonstrating stronger explanatory power than earlier instruments in the literature.

Confirmatory Factor Analysis (CFA)

To confirm the structural integrity of this three-dimensional model, Confirmatory Factor Analysis was executed using maximum likelihood estimation. The three latent constructs—Motivation, Emotional Challenge, and Responsibility Awareness—were modeled as inter-correlated latent factors. The model’s goodness-of-fit was evaluated against conventional cutoff criteria:

• Normed Chi-Square ($\chi^2 / df$): The ratio of chi-square to degrees of freedom fell below the threshold of 5.0, indicating reasonable model-data fit.
• Comparative Fit Index (CFI): Reached $ge 0.95$, demonstrating excellent fit relative to the baseline null model.
• Incremental Fit Index (IFI): Reached $ge 0.95$, providing further evidence of model fit.
• Root Mean Square Error of Approximation (RMSEA): Evaluated at $< 0.08$, with a 90% confidence interval supporting acceptable approximation error.

While the utilization of the single validation cohort for both EFA and CFA stages constitutes an acknowledged methodological limitation, the high sample adequacy, strong factor loadings, and convergence across multiple goodness-of-fit metrics support the internal validity of the three-factor structure.

10. Instrument / Measurement Tool

The Nurses’ Attitudes Towards Physical Health Care of Psychiatric Patients Scale is structured as follows:

• Test Type: Standardized psychological self-report rating scale.
• Administration Format: Paper-and-pencil or secure computer-based self-administered questionnaire.
• Item Count: 16 individual psychometric items distributed across three distinct sub-dimensions.
• Subscale Allocation:
  • Motivation: Proactive willingness and intrinsic drive to deliver somatic care.
  • Emotional Challenge: Negative affective responses, anxieties, and emotional friction (negatively keyed).
  • Responsibility Awareness: Cognitive endorsement of physical health monitoring as an essential nursing role.
• Response Scale: 5-point Likert response scale:
  • 1 = Strongly Disagree
  • 2 = Disagree
  • 3 = Undecided / Neutral
  • 4 = Agree
  • 5 = Strongly Agree
• Target Population: Registered nurses, clinical nurse specialists, nurse managers, and healthcare staff practicing within inpatient psychiatric facilities, psychiatric emergency departments, or community mental health clinics.
• Administration Time: Approximately 5 to 10 minutes.
• Scoring Protocol:
  • Direct Scoring: Items within the Motivation and Responsibility Awareness subscales are scored directly from 1 (Strongly Disagree) to 5 (Strongly Agree).
  • Reverse Scoring: All items within the Emotional Challenge subscale are negatively worded and must be reverse-scored prior to aggregation ($1 = 5, 2 = 4, 3 = 3, 4 = 2, 5 = 1$).
  • Total Score Calculation: Sum the responses across all 16 items after completing the necessary reverse scoring. Total scores range from a minimum of 16 to a maximum of 80.
  • Subscale Scores: Subscale totals may be calculated independently to isolate specific cognitive, affective, or motivational profiles.
  • Interpretation: Higher composite scores indicate more favorable, proactive, and holistic attitudes toward providing somatic healthcare to psychiatric patients. Lower scores signal prominent attitudinal barriers, clinical anxiety, or role abdication requiring targeted educational remediation.

11. Permissions & Fee and Test Year

The Nurses’ Attitudes Towards Physical Health Care of Psychiatric Patients Scale was formally published in 2026 in BMC Nursing. In accordance with open-science publishing principles and educational measurement standards:

• Academic and Clinical Research Use: The scale is available for academic, educational, non-commercial, and clinical healthcare quality improvement applications. Researchers and healthcare institutions seeking to utilize, translate, cross-culturally adapt, or electronically reproduce the instrument are requested to obtain formal authorization and secure the complete original item inventory by contacting the corresponding developer, Dr. Nurcan Düzgün, via email at [email protected].
• Fees: There are no licensing fees, purchase costs, or ongoing operational royalties required for non-commercial academic research, university dissertations, or public healthcare institutional assessments.
• Commercial Applications: Any commercial implementation, proprietary software integration, or profit-driven organizational consulting utilizing the scale must negotiate explicit licensing agreements with the primary authors and Gazi University.
• Attribution Requirement: All scientific publications, technical reports, white papers, or clinical presentations incorporating findings derived from the NATPHCPPS must cite the foundational validation paper published in BMC Nursing.

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13. Items of the Scale