Comparing Nurses and Patients’ Views About Caring Behaviors and its Dimensions in Nurses

Care is considered as a fundamental concept and one of the underlying components of the nursing profession. It is also one of the most important components for achieving human development, self-actualization, and survival (1, 2, 3). In addition, patient care is an important concept and, in fact, the art of nursing, which requires the individual, social, moral, and spiritual ability of the nurse (4). Moreover, it has biological, physical, psychological, cultural, social, and environmental dimensions in addition to including the elements of emotional support, providing comfort and convenience, and establishing proper communication (5). The basis of nurses’ caring behaviors is their knowledge, attitude, and skills, which are also important factors in evaluating the quality of nurses’ caring behaviors (6). These caring behaviors includes all functions, cognition, emotions, thoughts, ideas, movements, gestures, views, and actions by which the client is cared for, and this behavior should be based on ethics (3). Additionally, nurses are morally responsible and must be accountable for their behaviors (7). Similarly, nursing care is an interactive and interpersonal process that occurs during the moments of care between the nurse and the patient (8). All patients have rights that considering such cases, especially by health care providers, create a greater sense of satisfaction and security in them (5). In other words, high satisfaction is directly related to accelerating the patient’s physical and mental recovery and reduces longterm hospitalizations and costs (9). Many experts believe that patients’ satisfaction with hospital care is one of the most important indicators of the effectiveness of care provided in different departments and its quality (10). In Comparing Nurses and Patients’ Views About Caring Behaviors and its Dimensions in Nurses Milad Jafari1 ID , Vahideh Aghamohammadi2 ID , Tahmineh Moradi3 ID , Mehdi Piri1 ID , Javad Ebadi1 ID , Khadijeh Nasiri4 ID

Int Electron J Med. Vol 9, No 3, 2020 106 iejm.hums.ac.ir http addition, care should be client-centered and according to the biographical characteristics, interests, cultural, social, and physiological characteristics of each patient (11). In most studies conducted in developed countries where patient independence and rights are highly considered, nurses evaluated cares related to the emotional or psychosocial needs of patients more important (12,13) while Khademian et al found that nurses in Iran pay more attention to the physical aspects of care (14). The results of a study by Hajinezhad et al showed that the average score of caring behavior from patients' views was higher than that of nurses' views and there was a significant difference between the caring behaviors from patients' and nurses' views (15). In another study, Papastavrou et al claimed that there is no compatibility between patients' and nurses' caring views (16). According to the dissatisfaction of patients with the caring behavior of nursing staff as the main recipients of nursing services (17) and the opinion of nurses on having the desirable caring behavior (18), it seems necessary to conduct further studies in this field. Further, adapting nurses' and patients' perceptions of caring behaviors will lead to changes in nurses' behaviors and as a result, increase patients' satisfaction and a sense of job satisfaction in nurses. Therefore, the present study was conducted to compare the views of nurses and hospitalized patients on the caring behaviors of nursing staff in Khalkhal.

Materials and Methods
The present comparative-descriptive study was conducted after its approval in the Student Research Committee of Khalkhal University of Medical Sciences (the code of ethics: IR.KHALUMS.REC.1397.009) in the second half of 2018 in Imam Khomeini hospital in Khalkhal. This medical center is the only hospital in Khalkhal and has internal departments, surgery, pediatrics, neonatal, obstetrics, emergency, and intensive care units. The statistical population of the present study included employed nurses and hospitalized patients in the departments of Imam Khomeini hospital in Khalkhal. After obtaining a license from Khalkhal University of Medical Sciences, the research team referred to Imam Khomeini hospital in Khalkhal and obtained permission from hospital management. After explaining the objectives of the research and obtaining written consent from patients and nurses, the questionnaire was given to the subjects. Using Cohen's formula with a 95% confidence interval and considering a 10% dropout in samples, as well as using the mean and standard deviation of the results of a study by Hajinezhad et al(0.98 ± 4.89), a total of 200 patients comprised the sample patient group. In addition, 70 individuals (5.16 ± 0.52) were included in the nursing group (15). In the patient group, 200 questionnaires were distributed and all 200 completed questionnaires by patients were analyzed, but in the nursing group, 10 out of 70 distributed questionnaires were excluded due to non-return or incomplete completion. Multistage sampling was performed as well. According to the number of employed nurses and hospitalized patients in each ward of the hospital, sampling was performed by the relative method during the first stage. In the next stage, the sampling of each ward was conducted by the simple random sampling technique using a table of random numbers. According to the patients' situation, especially in special wards, the completion of the questionnaires in the patients' group was done through the researcher's interview with patients. However, in the nursing group, questionnaires were distributed among nurses at the beginning of the shift and delivered at the end of the shift. It should be noted that sampling took 6 months. Further, the inclusion criteria included nurses with more than one year of work experience working at Imam Khomeini hospital in Khalkhal and patients hospitalized in Imam Khomeini hospital in Khalkhal for 3 to 7 days. The other criteria were the ability to answer questions in patients and the lack of suffering from Alzheimer's disease based on the history of the case recorded by the physician and patients' full awareness. A two-part questionnaire was used to collect data. The first part included personalsocial information of nurses and patients such as age, gender, marital status, educational status, name of the service department, work experience, job position, second job, hospitalization history, previous experience from hospitalization, the period of hospitalization, type of employment, number of children, and overtime hours, and the second part was Caring Behavior Inventory (CBI-42). The questionnaire was first designed by Wolf et al in order to investigate nurses' caring behaviors. The questionnaire had 42 questions with 5 subscales encompassing respecting others (n = 12), ensuring human presence (12), having communication and positive orientation (9), having knowledge and professional skill (5), and paying attention to the experiences of others (4). Each question was assigned a score of 1 to 6 according to the individual's answer.
Moreover, the scores of 1 to 6 were considered for 'never' , 'rarely' , 'little times' , 'sometimes' , 'often' , and 'always' options, respectively (19). The highest and lowest scores were 252 and 42, respectively. However, according to different numbers of items in each subscale and the impossibility of comparison, the obtained scores from each sub-scale and the whole caring behavior were divided by the number of items, and the gained average score was within the range of 1-6. The average higher score indicated better care behavior. It should be noted that the questions for patients and nurses were provided in third-and firstperson tenses, respectively, and obtaining a higher score demonstrated better caring behavior. The validity and reliability of the questionnaire (CBI-42) in both groups of nurses and patients in the study of Wolf et al (19) were confirmed and considered in this study. Hajinezhad et al used this questionnaire in Iran. They confirmed its iejm.hums.ac.ir http validity and calculated its reliability as 0.98 and 0.93 for patients and nurses using the Cronbach's alpha method, respectively (15). Finally, the obtained data were analyzed using SPSS software, version 13. First, the normality of the data was confirmed using the Kolmogorov-Smirnov test, and then, the standard deviation of the caring behavior score was obtained using average descriptive indicators. Eventually, an independent t test was used to compare the mean score of caring behavior from the perspective of nurses and patients, and P<0.05 was considered as the significant level for these tests.

Results
Overall, the findings of the present study demonstrated that the average age of the nurses and patients was 29.22 ± 5.80 and 39.22 ± 15.80, respectively. Most nurses were females (85%), had a bachelor's degree (100%), and worked in the emergency department (30%). Most patients were also females (56.5%) with a moderate economic status (74%) and a history of previous hospitalization (51%) and hospitalization in the emergency department (45.5). Overall, 69% of patients reported a previous hospitalization experience (Tables 1 and 2).
Based on the results related to the analysis of the questionnaire of caring behavior inventory, the means and standard deviations of caring behavior from the patients and nurses' view was 5.42 ± 0.94 and 5.30 ± 0.59, respectively. In addition, "professional knowledge and skills" had the highest score while "positive communication and orientation" obtained the lowest score in terms of caring behaviors in both groups. The results revealed no significant statistical difference between the mean scores of nurses and patients' views regarding any of the subscales (P > 0.05). However, there was a statistically significant difference between the total score of nurses and patients' caring behavior (P > 0.05), the details of which are presented in Table 3.

Discussion
The findings of the present study represented that patients have a more favorable view to nurses' caring behaviors compared to nurses themselves, which is consistent with the findings of Rasti et al (20) In their review study regarding examining nurses' and patients' perceptions from nurses' caring behaviors, Papastavrou et al found that patients considered more importance for nurses' technical and instrumental skills compared to other caring behaviors, and their level of qualification regarding performing nursing activities was essential as well (16). Pool et al reported similar results as well (24). It seems that the main factor in the high appearance and scoring of patients to the subscale of "knowledge and professional skills" was the objective and tangible nature of this subscale compared to others. In addition, patients' views on nurses and the nursing profession were limited to performing care procedures, and this factor caused patients to be neglected from other caring aspects of nurses such as communication, education, coordination, and management. Further, in the present study, the lowest score was related to the "positive relationship and orientation" dimension, which is consistent with the findings of Rasti et al (20), Sadeghian et al (18), and Hajinezhad et al (15). Similar results were obtained regarding the other part of the study, which examined nurses' views on caring behaviors. For example, "professional knowledge and skills" allocated the most important dimension of caring behavior while "positive communication and orientation" received the lowest scores of the dimensions of care according to nurses, which matches the findings of Hajinezhad et al (15), Sadeghian et al (18), and Hosseinzadeh et al (21) while it is inconsistent with the results of Salimi et al (25) and Hajinezhad et al (15). In this study, having the competence and ability to perform clinical procedures was considered as the most important caring behavior from the nurses' views. In the study conducted by Hosseinzadeh et al (21) in Ardabil, similar results were obtained as well.
Other findings of the study showed that there was no significant statistical difference between the nurses and patients' views in any of the subscales of caring behavior. However, Hajinezhad et al (15) found a significant statistical relationship between nurses' and patients' views in two subscales of "ensuring human presence" and "attention to other experiences", which is inconsistent with the findings of the present study. It seems that nurses' and patients' views about the caring behaviors of nurses in the present study have a high overlap. Additionally, a statistically significant relationship was observed between the total score of nurses and patients' views about caring behaviors in the present study. This shows that despite the overlap of nurses' and patients' views in the sub-scales of caring behavior, there was a difference in their viewpoints between the two groups, which is in line with the findings of other studies conducted in Iran (15,18,26). This statistically significant difference indicates that despite the positive view of patients about nurses caring behaviors, nurses do not have a positive attitude toward their caring behaviors. Although the findings of the present study confirm those of previous studies, it is important to note that the present study was conducted in a small environment with fewer hospitalization beds. Given that even less workload has not led to better caring behaviors from nurses' working in the public hospitals of Iran and not met patients' expectations, it is recommended that further studies be performed using checklists and with a different statistical population (private hospitals). One of the limitations of the present study is the collection of data by the self-reporting method. In addition, the other weakness of the study is the low sample size due to the small statistical population in Khalkhal. On the other hand, one of the strengths of the present study is the study and comparison of nurses' views as care providers against those of patients as care recipients. To the best of our knowledge, few studies have examined both groups in Iran.

Conclusion
In general, the findings of the present study showed that nurses paid less attention to the human aspects of caring from patients' viewpoints. Therefore, focusing