European Online Journal of Natural and Social Sciences 2014; www.european-science.

com
Vol.3, No.4 pp. 1010-1017
ISSN 1805-3602

Nurse Caring Behaviors from Patients’ and Nurses’ Perspective:

A Comparative Study
Mohammad Esmaiel Hajinezhad, Parviz Azodi*
Department of Anesthesiology, Faculty of Paramedicine, Bushehr University of Medical Sciences,
Bushehr, Iran.
*
E-mail: p.azodi@outlook.com

Received for publication: 04 July 2014.

Accepted for publication: 28 October 2014.

Abstract
Caring is a complex concept but nevertheless with many definitions of it, unfortunately there
is not agreement among researchers about the definitions of caring. As patients are the recipients of
care, it is important to identify their perceptions of caring. Accordingly, the aim of this study was to
compare nurse caring behaviors from patient's and nurse's perspective. The sample consisted of 150
patients hospitalized in Boushehr hospitals and 50 nurses caring for their patients. Data were
collected using a quota sampling method and Caring Behaviors Inventory (CBI). Findings showed
that, there were significant differences between patients and nurses perspective in subscales
including Assurance of human presence and Attentiveness to other's experience. Moreover, there
was a significant difference in total scale of nurse caring behaviors between patient's and nurse's
perspective (t=2.559, P=0.011). Significant difference in nurse caring behaviors between nurse and
patient satisfaction implies, howbeit nurses believe that they care for patients but can't to make an
estimate of their expectations. To reduce this Gap, nurses should attend to human caring and inform
patients to real caring.
Keywords: nurse caring, caring behaviors, CBI, patient perspective

Introduction
Caring is a complex and highly subjective concept; despite many definitions, there is no
consensus among scholars about the definition (Edwards, 2001). Caring is the fundamental structure
of many nursing theories (Henderson, 2007). Human Caring is seen as the origin and essence of
nursing (Leininger, 1986); according to Watson, it maintains human dignity in health care systems
as a moral principle and measure of intervention and treatment (Watson, 1988). Liu, Mac and Wong
(2006) wrote: ‘The most important task of nursing is caring and nurses continuously use the word,
caring; however, caring, its components and processes of caring are still poorly defined’. To meet
Individual needs of the patient is the centre of nursing cares (Williams, 1998) and the ultimate goal
of nurse is quality caring of the patient (Mander, 1988). In other words, a high quality caring is the
right of all patients and a responsibility of all caregiver nurses (dfern and Norman, 1990). Nurse
caring is an Interactive and interpersonal process occurring in moments of caring between nurse and
patient. This process involves nurses and patients, and it can be measured through a study (Beck,
1999). Basically, there can be no cure without care, while there is caring without cure.
Green and Davis showed a positive correlation between patient perceptions of nurse caring
behaviours and patient satisfaction (Green and Davis, 2005). Wolf, Miller and Hajynezhad and
colleagues also showed a significant correlation between patient reports of nurse caring and their
satisfaction with nurse curing (Hajinezhad et al., 2007; Wolf et al., 2003).

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Certainly, patient satisfaction is achieved when there is agreement between patient

expectations and received caring; the complete caring is provided with respect to the physical,
mental and social needs of patients (Williams, 1998). It is estimated that more than half of health
care services represent caring and the remaining represents treatment; thus, more emphasis should
be placed on caring (Holm et al., 1986). Disorders in providing health care services to clients are
undeniable in many countries (Watson, 1985); therefore, to identify and evaluate the quality nursing
care through research projects is necessary, in line with satisfied health needs.
Knowledge, attitude and skills of nurses are the basis of nurse caring behaviours as three
most important factors in evaluating the quality of nursing care behaviours. The quality of nursing
care can be evaluated by measuring knowledge, attitudes and skills of nurses. However, some
patients may not understand properly caring behaviours (Chang et al., 2003). The patients
themselves receive care and their perception of the provided caring is important; in addition, the
difference in the patient and nurse perceptions of caring behaviours may cause dissatisfaction among
patients. Therefore, evaluation of nurse caring behaviours from patient and nurse perspective and
comparison can provide better feedback for nurses and nursing administrators. Accordingly, the
present study aimed to compare the views of patients and nursing staff on caring behaviours of
nurses in surgical and internal wards to raise the quality of nursing care.

Materials and Methods

The present Study is a cross sectional descriptive-comparative study in which nurse caring
behaviours were compared in the views of patients and nursing staff. Participants included all
Persian-speaking patients admitted to the general medical, general surgery, general cardiology,
neurology, women surgery, and other wards of hospitals of Bushehr with at least 18 years old in the
third day of hospital stay. Given the small number of nurses working in the wards listed, 150
patients admitted in general and surgical wards and 50 nurses working in those wards were selected
as samples. In the listed wards, 85 nurses were working of which 50 nurses who were willing to
participate in the study and completed the questionnaire were selected by convenient sampling
method. Data collection was conducted from August 2009 until November 2009.
Data collection materials included a questionnaire and a form of personal characteristics
including age, sex, marital status, education level, type of illness, type of ward, economic status,
occupation, length of hospitalization, number of hospitalizations, hospital experience, surgery and
awaiting for surgery. The second part used caring behaviours Inventory [CBI] to evaluate the nurse
caring behaviours. This section contained 42 items and 5 subscales, including respectful deference
to others (12 items), human presence (12 items), positive connectness (9 items), knowledge and
skills (5 items), and other’s experiences (4 items). Items were based on the 6-point Likert scale,
ranging from 1=never to 6=always. Respectful deference to others refers to behaving politely and
respectfully by nurses, at the time of giving care to patient. For example, items of respectful
deference to others include listening attentively to patients, teaching patients, giving their time to
patients. Human presence refers to caring behaviours which encourage confidence in the patient by
the nurse to make the patient have less worry and anxiety; for example, nurses are sensitive to the
patient and his problems, they help patients, they talk to the patient. positive connectness refers to a
sense of connection, sympathy and solidarity between patients and nurses who show them while
caring for their patients; For example, they show caring about the patient, they touch him, they give
the patient hope, they courage trust in patient. knowledge and skills refer to professional knowledge
and expertise in performing nursing care by supplies, medicines, bandages and other items; for
example, they know how to perform injections, intravenous drugs and other items for the patient,
they show their professional knowledge and skills, they use equipment professionally. Other’s
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experience refers to give attention and care a patient through listening to the patient or observing the
patient to satisfy patient's needs and demands. For example, they eliminate unpleasant symptoms in
patients; they give priority to patient and provide a good health care. Minimum and maximum
scores CBI were 42 and 252, respectively. First-person and third-person verbs were used for nurses
and patients, respectively. This material does not belong to nurses or patients and both nurses and
patients can complete it (Beck, 1999).
Validity was already assessed by the investigator through validity content. To do this, the
text was translated into simple Persian; to assess the translated inventory, it was sent for ten
members of faculty of Nursing, Tehran University of Medical Sciences and Health Services. Then,
the final inventory was prepared and last reviewed by Faculty Council. After validating the
inventory, it was allowed to use. This inventory is the translated form of caring behaviours
inventory. Furthermore, internal consistency was used to determine the reliability of CBI; therefore,
Cronbach's alpha coefficient was calculated for this purpose. Thus, inventories were completed by
20 patients of surgical ward and 10 nurses of medical ward. Then, alpha coefficient was calculated
(for patients, r=0.98; for nurses, r=0.93). It should be noted that these samples were excluded.
Convenient sampling method was used to sample. After accessing to samples, the researcher
first explained the study objectives to convince them to agree to participate in the study. Then a brief
explanation was provided about the questionnaires; after obtaining informed consents, data were
collected on the same day from samples of each ward. Items were read for illiterate people and
answers were marked on the questionnaire. Deaf, blind and mute Patients and patients known to
have mental disorders or physical disability to complete the interview were excluded.
Data were analysed using SPSS (version 15). To achieve the study objectives, descriptive
statistics were used. T-independent t-test was used to compare the nurse caring behaviours by
nursing staff and patients.

Results
Average age was 36.43 with a range of 16-80. Most patients were married. Most patients had
diploma education (37.3%) and 49.3% of the patients were housewives. 74% of patients had
moderate economic status. 50.7% of patients had been hospitalized in the past five years. More than
half of the patients had a previous good experience of hospitalization, about 41% underwent a
surgery during current stay, and 17% were awaiting surgery. The average age of nurses was 32.18
with a range of 23-51. Most nurses were married and most of them (90%) were BS. 61.2% of nurses
had an average economic status. 38 percent had less than 5 years of experience. Table 1 shows the
personal information of the subjects.
Total mean and standard deviation of CBI in patients’ perspective were 4.89 and 0.97,
respectively (maximum mean 6); total mean and standard deviation of CBI in nurses’ perspective
were 5.16 and 0.52, respectively (Table 2). The mean and standard deviation of subscales are shown
in the same table. There was a significant difference between patients’ and nurses’ perspectives
(t=2.559, P=0.011).

Discussion and Conclusion

Results of this study identified the difference between nurses’ and patients’ perceptions
about nurse caring behaviours.
Patients more experienced behaviours related to positive connectness of CBI; this finding is
consistent with Wolfe et al (2003) and inconsistent with Hajynzhad et al. According to Hajynzhad,
patients more experienced caring behaviours related to positive connectness than other subscales
(Hajinezhad et al., 2007). This can be associated with several factors, including cultural factors;
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because previous studies of Hajynzhad et al had been conducted in Tehran, while the current study
was conducted in Bushehr, which have a different cultural context, particularly in terms of
establishing connection, suggesting the different behaviours of nurses.

Table 1: personal information of the samples

Variable Patient Nurse
Number % Number %
Sex Female 98 49 40 20
Male 52 26 10 5
Marital status Single 22 11 11 5.5
Married 122 61 39 19.5
Widows and divorcees 6 3 0 0
Ward General internal 36 18.8 11 5.8
medicine
General Surgery 76 39.8 14 7.3
Internal cardiac 8 4.2 8 4.2
Neurology 12 6.3 6 3.1
Gynecology 6 3.1 9 4.7
Other wards 4 2.1 1 0.5
Economic status Bad 6 3.1 3 1.5
Middle 108 55.4 30 15.4
Good and very good 32 14.4 16 8.2
Education Illiterate 16 1.7
(patients) Elementary and junior 49 32.7
high
Diploma 56 37.3
University 29 19.3
Education (nurses) Diploma 3 6
Associate 2 4
BS 45 90
Occupation Unemployed 22 15.1
(patients) Housekeeper 72 49.3
Worker 10 6.8
Employee 24 16.4
Self-employed 18 12.3
Admission in 5 Yes 73 5.7
years (Patient) No 71 49.3
Previous Very bad 2 2.9
experience of Bad 6 8.7
hospitalization Not so good 16 23.2
(patients) Good 38 55.1
Very good 7 10.1
Duration of the Less than a week 106 75.7
recent hospital stay 1-2 weeks 26 18.6
(patients) More than 2 weeks 8 5.7

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 Mohammad Esmaiel Hajinezhad, Parviz Azodi

Table 2: mean and standard deviation of subscales of nursing care behaviours from samples’
perspective
Subscale Patient Nurse
N=150 N=150

Result
Mean Standard Mean Standard
deviation deviation
respectful deference to others 4.83 1.02 5.01 0.59 t=1.580
P=0.116
Positive connectness 4.74 1.10 4.88 0.74 t=1.030
P=0.305
Human presence 4.90 1.01 5.35 0.53 t=4.057
P=0.000
Knowledge and skill 5.22 0.94 5.38 0.53 t=1.530
P=0.128
Other’s experience 4.99 1.11 5.39 0.63 t=3.138
P=0.002
Total 4.89 0.97 5.16 0.52 t=2.559
P=0.011

The adaptations and behaviour of patient can be another factor associated with quality of
caring and connecting to patient (Teng et al., 2007). Atmosphere of the ward and interpersonal
relationships are critical factors in patient’s perception of caring. Nurses should notice that caring
exhibit itself in nursing functions by nurse-patient relationship (Liu et al., 2006). Shortage of nurses
in hospitals cause situations where nurses neglect to focus more on less important tasks to focus
more on the main task. However, the nurse-patient relationship is the basis for achieving excellence
in nursing care (Chris, 2002). The psychological-social aspects of caring, particularly proper
communication with patients will result in patient satisfaction, rather than technical aspects (Wolf,
1986).
Patients more experienced behaviours related to knowledge and skill of CBI; this finding is
consistent with Wolfe et al (1998) and Hajynzhad et al and inconsistent with Wolfe et al (2003).
According to Wolfe et al (2003), patients more experienced caring behaviours related to human
presence than other subscales. More experience of behavioural related to knowledge and skills can
be related to objective items of this subscale, because it makes it easier for patients to find this kind
of behaviour. This also could be related to the fact that patients might not be able to evaluate
technical competencies of nurses properly due to lack of knowledge (Watson, 1985). Some studies
have also shown that nurses emphasized on these caring behaviours (Chang et 1l., 2003). In
addition, nurses may only perform tasks for which they will not questioned when lacking time and
under workload conditions (Rafii, 2004).
The results of this study showed a significant difference between patients' and nurses' views
about human presence, other’s experiences, and totally, nurse caring behaviours (t=2.559, P=0.011).
This difference may be due to various reasons. One of the reasons is unavailability of nurses. When
nurses are available, patients potentially feel that nurses care for them. Most nurses consider
physical aspects while caring, while many of the patients prefer prioritization, information,
cheerfulness and listening as important caring behaviours which nurses may underestimate them
(Chris, 2002). Furthermore, patients have less information about health care professions; thus, they
measure caring quality in terms of performance quality (Teng et al., 2007). Knowledge, attitude and
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skills of nurses are the basis of nursing practices. Through caring attitudes of nurses, patients
understand their psychosocial support (Liu et al., 2006).
There was a significant differences in patients’ and nurses’ views about other’s experience
(t=3.138, P=0.002). Prioritization is a caring behaviour related to other’s experience. According to
Watson's theory of human care, prioritization is related to philanthropic-human values, development
of self-sensitivity, and a relationship of trust and assistance (lligood and Tomey, 2001). In fact,
nurses were likely to prioritize their duties. This finding can be related to labor shortages, staff
burnout and reduced quality of care. Some studies suggest that only the patient's physical needs are
met in wards in which the overall level of staff and trained nurses is lower than workload (Steffen,
1988); moreover, this can be expected in a Task-oriented nursing system.
Comparison of scores for Caring behaviour subscales of this study and results of Wolf et al.
(2003) and Wolf et al. (1998) shows that all scores are lower than in other studies. The result may be
associated with a shortage of nursing staff, inadequate facilities, heavy workload and lack of salary
for nurses followed by decreased motivation and job dissatisfaction (Griffiths, 2009; Kalisch, 2006).
Frequently discussed in the literature is that bureaucratic requirements, such as increased workload
and reduced number of employees, lead to a lack of demand forecasting by nurses; thus, patients
may not have a good attitude towards nursing care (Henderson et al., 2007).
In relation to lower Scores for positive connectness, it is suggested that nurses provide care
consciously (Chang, E., et al. 2003); studies have shown that conscious attention to the patients
leads to trust (Teng et al., 2007). Nurses have to spend more time with patients and listen to them; in
some studies, nurses have understood that listening to patients was the best caring behaviour (Chris,
2002).
Considering the significant difference between several subscales of caring behaviours from
patients’ and nurses’ perspective, nurses are recommended to consider needs and expectations of
patients, particularly in relation to other’s experience and human presence. In addition, patients have
less information about health caring systems and measure caring quality by function; therefore,
nurses are recommended to focus on objective behaviours and provide patients with necessary
information. Patient perceptions of care quality are associated with personality of nurses. Therefore,
more attention is required on behaviours reflecting personality of nurses (Chang et al., 2003).
Moving, turning, feeding, teaching, discharge planning, psychosocial support, health, and
recording intake and excretion are those which are removed, because of a severe shortage of nursing
staff, lack of time for nursing interventions and inappropriate use of staff (Kalisch, 2006). The ratio
of nurses to patients has an important relationship with patient outcomes such as mortality, reduced
hospital stay etc.; therefore, it is necessary to increase the number of nurses (Griffiths, 2009;
Kalisch, 2006). Nurses’ willingness to help patients is the second important (Henderson et al.,
2007). Atmosphere of the ward and interpersonal relationships are important factors in the
perception of caring by patient. Nurses should consider that caring manifest itself in nursing
functions by nurse-patient relationship. It is recommended that nurses pay special attention to their
relationship with patient and adjust the atmosphere of the ward and interpersonal relationships (Liu
et al., 2006).
Because nursing care and caring behaviours can best be researched using qualitative
approaches, it is recommended to use qualitative methods to measure individual differences in
patients' perceptions of care and caring behaviours (Liu et al., 2006; Raper et al., 1999). The need
for further studies of caring behaviours among patients in private hospitals, university hospitals or
specialized units is necessary. Some patients may not recognize correctly the nurse caring
behaviours [15]; hence, it is recommended to evaluate and compare nurse caring behaviours by
checklist and CBI.
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 Mohammad Esmaiel Hajinezhad, Parviz Azodi

Acknowledgement
Authors appreciate all those who have assisted in this study, particularly studied patients.
Authors are grateful of educational supervisor of training-medical centre, Bint al-Huda, Mrs Elham
Kohansal for her sincere cooperation. This paper is the result of research projects approved by
Bushehr University of Medical Sciences. Authors, also, appreciate members of Research Council,
School of Allied Health and Medical sciences, Bushehr.

References
Alligood, M.R. and A.M. Tomey, (2001).Nursing theory, Utilization & Application., Mosby: louis.
p. 106.
Beck, C.T. (1999). Quantitative measurement of caring. J Adv Nurs, 30(1), 24-32.
Chang, E., et al. (2003). The influence of demographic variables and ward type on elderly patients'
perceptions of needs and satisfaction during acute hospitalization. Int J Nurs Pract, 9(3), 191-
201.
Chris, B.(2002). Nurses' perceptions of care and caring. international journal of nursing, 8, 8-15.
Edwards, S.D.(2001). Benner and Wrubel on caring in nursing. J Adv Nurs, 33(2), 167-71.
Green, A. and S. Davis(2005). Toward a predictive model of patient satisfaction with nurse
practitioner care. J Am Acad Nurse Pract, 17(4), 139-48.
Griffiths, P.,(2009). RN+RN=better care? What do we know about the association between the
number of nurses and patient outcomes? Int J Nurs Stud, 46(10), 1289-90.
Hajinezhad, M.E., et al. (2007). Relationship between nurse caring behaviors from patients'
perspectives and their satisfaction[persian]. Iran Journal of Nursing, 20(49), 73-83.
Henderson, A., et al.(2007). Caring for behaviours that indicate to patients that nurses 'care about'
them. J Adv Nurs,. 60(2), 146-53.
Holm, K. and G.J. Lie Wellyr (1986). Nursing research for nursing practice. WB Saunders:
Philadelphia. p. 101.
Kalisch, B.J.(2006). Missed nursing care: a qualitative study. J Nurs Care Qual, 21(4), 306-13; quiz
314-5.
Leininger, M.(1986). Care facilitation and resistance factors in the culture of nursing. Top Clin
Nurs, 8(2), 1-12.
Liu, J.E., E. Mok, and T. Wong (2006). Caring in nursing: investigating the meaning of caring from
the perspective of cancer patients in Beijing, China. J Clin Nurs, 15(2), 188-96.
Mander, R.(1988) Encouraging students to be research minded. Nurse Educ Today, 8(1), 30-5.
Rafii, F. (2004). Burn: a design to grounded theory. Iran University of Medical Siences and health
services. p. 209-235.
Raper, J., B.A. Davis, and L. Scott (1999). Patient satisfaction with emergency department triage
nursing care: a multicenter study. J Nurs Care Qual, 13(6), 11-24.
Redfern, S.J. and I.J. Norman (1990). Measuring the quality of nursing care: a consideration of
different approaches. J Adv Nurs, 15(11), 1260-71.
Steffen, G.E.(1988) Quality medical care. A definition. JAMA, 260(1), 56-61.
Teng, C.I., et al.(2007). Influence of personality on care quality of hospital nurses. J Nurs Care
Qual, 22(4), 358-64.
Watson, J.(1985). Nursing the philosophy and science of caring. Colorado associated university
press: Colorado. p. 11-12.
Watson, M.J.(1988). New dimensions of human caring theory. Nurs Sci Q, 1(4), 175-81.
Williams, A.M.(1998). The delivery of quality nursing care: a grounded theory study of the nurse's
perspective. J Adv Nurs, 27(4), 808-16.
Openly accessible at http://www.european-science.com 1016
Social science section

Wolf, Z.R., M. Colahan, and A. Costello (1998). Relationship between nurse caring and patient
satisfaction. Medsurg Nurs, 7(2), 99-105.
Wolf, Z.R., P.A. Miller, and M. Devine (2003). Relationship between nurse caring and patient
satisfaction in patients undergoing invasive cardiac procedures. Medsurg Nurs, 12(6), 391-6.
Wolf, Z.R. (1986). The caring concept and nurse identified caring behaviors. Top Clin Nurs, 8(2),
84-93.

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