COMPARATIVE ANALYSIS OF PATIENTS’ AND NURSES’ PERCEPTIONS OF NURSE CARING BEHAVIOURS IN TWO TERTIARY HOSPITALS IN JOS

ABSTRACT
The purpose of this study was to comparatively assess patients’ and nurses’ perceptions of nurse caring behaviours in Jos University Teaching hospital (JUTH) and Plateau State Specialist Hospital (PSSH) Jos. A cross-sectional descriptive survey design was employed to study 332 patients and nurses.  No sampling was done as all the subjects who met the inclusion criteria were included in the study. Data were collected using a modified Caring Behavior Assessment questionnaire (CBA-Q) (37 items), a 5-point likert-type scale and arranged in 7-subscales. Data were analyzed using descriptive and inferential statistics. The result indicated that all the caring behaviours statements except item 17  (“Visiting patient if patient moves to another hospital units” with item mean of 2.63; SD = 1.33 and t-value of 1.24 which is below the mean criterion value of 2.50) were accepted as indicators of care by patients. The findings that “using soft gentle voice with patients”, “being kind and considerate to patients”, “answering patients’ questions clearly”, and “giving patients’ treatments and medications on time” were the four highest (most important) scored items by patients. The findings that “visiting patient if patient moves to another hospital unit” “preparing patient for death when it is inevitable”, “Praying with and or for patient” and “checks his or her perception of the patient with the patient before initiating any action” were the four lowest (least important) scored items by patients. The result is indicative that all the caring behaviour statements except item 17 (“visiting patient if patient moves to another hospital unit”, with item mean of 2.62, SD = 0.90, and t-observed value of 1.69 which is below the mean criterion of 2.50) were accepted as indicators of care by nurses.  The findings that “giving patients treatments and medications on time”, “treating patients information confidentially”, “using soft gentle voice with patient” and “showing patient love”, were the four highest (most important) scored items by nurses. The findings that “visiting patient if patient moves to another hospital unit, “is calm” and  “preparing patient for death when it is  inevitable” were the three lowest (least important) scored items by nurses.  Comparison of mean scores and standard deviation of patients and nurses on CBAQ subscale showed that patients and nurses perceived humanism/faith hope sensitivity”, “helping/trusting” and “human needs assistant as the most important and  “existential phenomenological/spiritual forces” as the least important subscale. The mean scores showed that nurses gave higher mean values than did patients to all the seven subscales. A comparison of the top 10 CBAQ items between patients’ and nurses’ perception revealed similarities as well as differences. Patients and nurses agreed on 6 out of the 10 most important items and do not agree on the remaining 4 top 10 caring behaviour statements. The result also indicated that nurses more than patients value the subscale “humanism faith hope sensitivity” while patients valued the subscale; “human needs assistant” more than nurses. In total, nurses scored higher in 31(83.7%) items than patients who scored higher than nurses in only 5 (13.5%) items. A comparison of the 10 least important CBAQ items showed  that patients and nurses agree on 5 out of 10 of the 10 least important items. Items 17 and 23 on the CBAQ (visiting patients when patient moves to another hospital unit”, and “check his or her perception of the patient with the patient before initiating any action” were ranked same by both patients and nurses. There is a significant difference in the perceptions of CBAQ statements as indicators of care between patients and nurses (F=7.456, P < 0.05) P = 007. It was recommended that the result of the study be communicated to nursing staff of the two hospitals. In order to help nurses meet caring expectations of clients and enhance patients’ positive health outcomes. The result from this study therefore provide improvement implications for the care of patients, like concrete information on what behaviours the patient would like to experience.
 
CHAPTER ONE
 INTRODUCTION
Background of the Study
Caring is when a loving and kind gesture is demonstrated by a person as he or she functions to promote wellness, well being, maintain health, alleviate sufferings, rehabilitate the disabled individuals, family, group, community, or population. “Nurse caring” is the process by which the nurse becomes responsive to another person as a unique individual, perceives the other’s feelings, and sets that person apart from the ordinary” (Watson 1998 in Batsdusdottir and Jonsdettir, 2002). Nurse caring behaviour on the other hand, refers to “those things that a nurse says or does that communicate caring to the patients (Batsdusdottir and Jorsdottir, 2002). Caring is the service the nurse renders while caring behaviours are those attitude, competencies and skills the nurse exhibits while rendering the services (Ehiemere, 2011).
 
Caring which has been identified as the essence of nursing, the dominant, distinctive and underlying feature of nursing practice (Leininger, 1979in Erb and Kozier, 2008), has traditionally been at the core of nursing (Larrabee, Putman and Wu, 2006). Nursing as a profession places the greatest demands specific to the development and refinement of the caring component of nursing (Azimzadeh, Rahmani, Valizadeh and Zamanzadeh, 2010). Thus, the study of human caring as an essential characteristic of nursing practice has gradually expanded from early definitional, philosophical and cultural writings on the meaning of caring to evidence-based care (Boykin and Schoenhofer, 2000). To be meaningful, Azimzadeh, Rahmani, Valinzaadeh and Zamanzadeh (2010), maintained that nurse caring must be based upon mutual agreement between nurses and patients as to what constitutes nurse caring behaviours. Nurses cannot be certain that their behaviour is consistent with patients’ perception and expectations of their care.  Nurses cannot therefore assume that patients perceive their caring efforts as they are intended. To avoid this problem, it is imperative that nurses validate with the patients that their care needs are being met (Azimzadeh, Rahmani, Valizadeh and Zamanzadeh, 2010).
 
There is currently considerable emphasis on the provision of patient-centred care in all aspects of health care (Greenhalgh, 1998 in Azimzadeh, Rahmani, Valizadeh and Zamazadeh, 2010). What is most important here is to make clear or ascertain factors that influence patients’ satisfaction to enable nurses improve quality of nursing care.  Kimble (2003) observed that the degree of congruence between patients’ expectations of nurse caring behaviour and their perception of the care they really get forms their satisfaction with nursing care. Hence, Azimzadeh, Rahmani, Valizadeh and Zamanzadeh, (2010) concluded that there could be a relationship between nurses’ caring behaviours and patients’ satisfaction.
 
Previous studies on caring (David, Ozawa, Puangrat and Takeo, 2002; Watson, 2002) focused on nurses’ perceptions of what constitutes caring for the patient, patients’ perception of what is important in making them feel cared for, and comparisms of patients’ and nurses’ perceptions of what constitutes important nurse caring behaviours (Azimzadeh, Rahmani, Valizadeh and Zamanzadeh, 2010). Many of these studies have generally demonstrated significant discrepancies (differences) in patients’ and nurses’ perceptions of nurse caring behaviours, (Chang, 2005). This discrepancies may result in patients’ needs being unmet and patients’ dissatisfaction with the care received.
 
Kimble (2003) opined that the perception of an uncaring nurses’ behaviours can lead to increased anxiety and diminished coping abilities for patients and litigation for nurses and health institutions. Although human caring has been perceived as a universal phenomenon, the expressions, processes and patterns vary among cultures (Leininger, 1998 in Azimzadeh, Rahmani, Valizadeh and Zamanzadeh, 2010). This means that culture and values affect our understanding of the concept of caring (Evans, Mizuno, Okada, Ozawa and Taked, 2005). Since nurse caring behaivour is central and crucial in hospital for achieving, effective, efficient, minimal risk to patients, satisfaction of patients, and overall physical, psychological and sociological patients’ positive health outcomes, there is therefore a need to ascertain nurses’ and patients’ perceptions of nurse caring behaviours in different settings. This is a practical approach to the caring concept and the basis for this study in a Nigerian setting where there is a dearth of literature on comparative analysis of patients’ and nurses’ perceptions to nurse caring behaviour.
 
Statement of Problem
Although the concept of nurse caring behaviour is central to the practice of nursing, there is, discrepancies as to a single definition of nurse caring behaviour. Patients and nurses differ in their perceptions of what they consider to be caring behaviour (Patistea, Siamanta, 1999). Major sources of information regarding patient’s perception of nurse caring behaviour are hospital satisfaction surveys conducted in United States of America. However, there may be some relationship between patients’ satisfaction and a patients’ perception of “very good care”, but they do not necessarily mean the same thing (Sossony and Poirier, 2007). Also surveying nurses’ satisfaction equally does not address nurses’ perceptions of what constitutes caring behaviour. Further comparism of what constitutes caring from both the patients’ and nurses’ perspectives will help patients, nurses and organizations as they continually seek to improve patient care.
 
In Nigeria care of patients has encountered several serious challenges that suggest a large disparity with international standards which must be filled. The perception of nurses’ caring behaviours varies from culture to culture as well as the setting of their practice.  Complaints of poor attitude of nurses towards patients are rife and appear to be increasing. In Jos such complaints were observed on daily basis but escalated since the incessant civil unrest, emanating from the Boko Haram mayhem, with unprecedented casualties and subsequent increase in hospital admissions. This has led to the perception that nurses are increasingly distancing themselves from patients, and giving care that is not meeting patients’ expectations.
 
The researcher having stayed in the wards for not less than fifteen years of his clinical practice been in frequent contact with professional nurses and patients have observed that there are discrepancies in nurses’ and patients’ perception of the nurse caring behaviours from certain incidents. The nurse intends communicating caring, but the patients views the nurses action as uncaring  (not indicative of caring). For instance, increase in workload which makes nurses prioritize care to the most seriously ill-patients with the tendency of leaving some patients unattended to is regarded as neglect by patients. Inattention or neglect however is unacceptable to both nurses and patients (Baldusdotti and Jonsdottier, 2002). A night nurse may order all patients to go to bed and sleep and consequently put off the bright light. The patients and her relatives may view the nurse’s action as doing that to pave way for her to go and sleep herself, and not purely having the interest of patients at heart etc.
In these instances, the nurse caring behaviours that the nurse perceived as indicative of caring is not perceived as such by the patient. These discrepancies may result in patients’ needs not being met leading to patients’ unsatisfaction with the care being rendered by the nurses. In the midst of these discrepancies, one therefore wonders whether there are congruencies in the nurses’ and patients’ perception of nurse caring behaviours as much as there are differences. The understanding is that emphasizing on nurse caring behaviours identified by both patients and nurses, may enhance patients’ positive response to care and hence win their cooperation in ensuring compliance to prescribed regimen or procedures of management.  Based on the foregoing, the present study is designed to have a comparative analysis of patients’ and nurses perceptions of nurse caring behaviours in two tertiary hospitals in Jos.
 
Purpose of the Study
The purpose of the study was to have comparative analysis of patients and nurses’ perceptions of nurse caring behaviours in two tertiary hospitals in Jos, North-central Nigeria.
The following specific objectives were set for the study.

1. To determine nurse caring behaviour statements that patients perceived as indicators of care.
2. To determine the most and least important nurse caring behaviours as perceived by patients.
3. To determine nurse caring behaviour statements that nurses perceive as indicators of care.
4. To determine the most and least important nurse caring behaviours as perceived by nurses.
5. To determine if differences exist in the nurse caring behaviours statements that patients and nurses perceived as indicators of care.

 
Research Questions  
The followings are the questions this research study addressed:

1. Which of the nurse caring behaviour statements are perceived by patients as indicators of care?
2. Which of the nurse caring behaviour indicators are perceived as most and least important by patients?
3. Which of the nurse caring behaviour statements are perceived by nurses as indicators of care?
4. Which of the nurse caring behaviour indicators are perceived as most and least important by nurses?
5. Do differences exist in the nurse caring behaviours that patients and nurses perceived as indicators of care?

 
Research Hypotheis

1. There will be no significant difference in the perceptions of nurse caring behaviours of patients and nurses.

 
Significance of the Study
The findings of the present study revealed what patients and nurses perceived as indicators of care. Based on the findings, health institutions and nursing services may utilize the corresponding suggestions to map out strategies to improve nursing care. It could contribute to benchmark to measure the nurses performance and as foundation for development of guideline for practice. The findings of this study might allow nurse clinicians to be sensitive to their caring behaviours by increasing their realization of how behaviours are perceived by patients. Could provides information to new nurses thereby leading to improve performance and better meet patients needs. The result could enhance research in the concept of caring as well as the patients’ expectations of the nursing staff. It could also harmonise the nurses behaviours/cares in line with expectations of patients leading to satisfactions of patients. It could help to evaluate, define and set up standards of nursing care.
 
Patients care needs being met as a result of knowledge gained from this study would lead to decrease in patients’ anxiety that usually lead to diminished coping abilities, litigation and financial loss on the part of the nurse and institution. It will also increase patients’ patronage of the institution, because nursing care is the “single most significant factor in the patient’s perception of high quality hospital care”. (Buldursdottir, Jonsdottir, 2002). It could go a long way in improving the public image of nurses and nursing that “creates a framework by which others approach nursing as a profession, as well as each nurse, individually. It has been proven that image influences patients’ safety, resource allocation, public policy, recruitment into the profession and other issues that have far reaching consequences” (Kearns, 2009). It could assist the nurse to achieve a better pedestal in their relationship with the patients and appropriate job satisfaction and by extension establish the reputation of the health institutions as valuable healthcare providers in the ambience of competitive standing. The result of this study and corresponding suggestions if implemented could reveal the contribution of nursing to patients’ recovery which might contribute to appropriate budget for nursing.
Scope of the Study
The study was delimited to the comparative analysis of patients and nurses perceptions of nurse caring behaviours in two tertiary hospitals in Jos. It  looked at nurse caring behaviours that are indicators of caring, most and least important nurse caring behaviour indicators, and then compared patients and nurses indicators of caring. The two hospitals were chosen, because of the large patient population and various cadres of nurses.
 
Operational Definitions
Caring Behaviour: Nurse caring behaviour refers to action by nurses taken towards their patients to show empathy and this entails things they do or say to patients, or how they do or say them to positively influence their  patient’s faith, trust, feelings, learning, needs, support and spirit as measured by the Caring  Behaviour Assessment Questionnaire (CBAQ) designed by Cronin and Harrison.
Perceptions of Nurse Caring Behaviour: Refers to patients’ and nurses’ responses or reactions to selected caring behaviour statements in the CBA measuring instrument for this study. In other words, perceptions of nurse caring behaviour refers to patients’ or nurses’ feeling towards caring behaviour statements in CBA and was measured by numerical quantification of the magnitude of that feeling such that the strongest positive perceptions as of a nurse caring behaviour are truly reflective perceptions of of care by the patients or nurses is rated 4 suggesting a strongly agreed by the respondent to that effect. Similarly, the next is 3 suggesting agreed, 2 suggesting disagreed, 1 suggesting strongly disagree and 0 suggesting undecided.
Patient: Male or female, aged 18 years and above, sick, admitted for not less than five (5) days of date of data collection in either Jos University Teaching Hospital or Plateau State Specialist Hospital Medical or Surgical Unit.
Tertiary Hospitals in Jos: These are Jos University Teaching Hospital and Plateau State Specialist Hospital.