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Chyssoula Karlou, PhD

Constantina Papadopoulou, PhD, MSc, RN

Elizabeth Papathanassoglou, PhD, MSc, RN

Chryssoula Lemonidou, PhD, MSc, RN

Fotini Vouzavali, PhD, MSc, RN

Anna Zafiropoulou-Koutroubas, MSc

Stelios Katsaragakis, PhD, MSc, RN

Elisabeth Patiraki, PhD, RN

Nurses’ Caring Behaviors Toward Patients Undergoing Chemotherapy in Greece A Mixed-Methods Study

K E Y W O R D S

Cancer

Caring behaviors

Chemotherapy

Focus group

Greece

Nursing

Mixed methods

Survey

Background: Nurses’ caring behaviors are central in the quality of care of

patients undergoing sophisticated chemotherapy protocols. However, there is a

scarcity of research regarding these behaviors in nonYAnglo-Saxon countries.

Objective: The aim of this study was to explore caring behaviors that nurses

perceive as important in caring for patients in Greece receiving chemotherapy.

Methods: We used a mixed-methods design, including a survey in 7 oncology

wards in 3 cancer hospitals in Attica, Greece, and a subsequent qualitative focus

group investigation. Caring behaviors were explored through the Caring Behavior

Inventory 24 and content analysis of 3 focus group interviews. Results: A sample of

72 nurses (response rate, 68.5%) were surveyed, and 18 nurses participated in the

focus groups. ‘‘Knowledge/skills’’ (5 [SD, 0.7]) was the most important caring

behaviors. No significant associations with nurses’ characteristics were noted, except

for higher scores in caring behaviors in participants who were married (PG.02). Six

caring-related categories emerged from the qualitative analysis: ‘‘the concept of

care,’’ ‘‘respect,’’ ‘‘nurse-patients’ connection,’’ ‘‘empathy,’’ ‘‘fear of cancer,’’ and

‘‘nurses’ professional role.’’ Moreover, they stressed barriers they faced in each

category. Conclusions: Integrated quantitative and qualitative data concur that

operational tasks are central in Greek nurses’ caring behaviors. In addition,

qualitative findings highlighted those skills equipping nurses to provide holistic

Nurses’ Behaviors Toward Chemotherapy Patients Cancer NursingA, Vol. 00, No. 0, 2018 n 1

Authors Affiliations: Oncology Nursing Department, 251 Hellenic Air Force General Hospital (Dr Karlou); School of Health, Nursing and Midwifery, University of the West of Scotland, Paisley (Dr Papadopoulou); Faculty of Nursing, University of Alberta, Edmonton, Canada (Dr Papathanassoglou); Section of Internal MedicineYNursing and Nursing Laboratory, Faculty of Nursing, National and Kapodistrian University of Athens (Dr Lemonidou and Dr Patiraki); Technological Educational Institute of Athens, Holargos (Dr Vouzavali); and Children’s Hospital ‘‘A & P Kyriakou’’ Oncology Department, Athens (Mrs Zafiropoulou-Koutroubas); and Department of Nursing, National

University of Peloponisos Faculty of Human Movement and Quality of Life Sciences in Sparta (Dr Katsaragakis), Greece.

The authors have no funding or conflicts of interest to disclose. Correspondence: Chyssoula Karlou, PhD, Oncology Nursing Department,

251 Hellenic Air Force General Hospital, P. Kanellopoulou 3, TK 11525, Athens, Greece ([email protected]).

Accepted for publication September 4, 2017. DOI: 10.1097/NCC.0000000000000562

individualized care in a hectic care environment. Implications for

Practice: Supporting nurses in attaining excellence in technical skills and in

meaningfully engaging with patients receiving chemotherapy is essential in the

realization of their caring role. These should be priorities for continuing education

and practice improvement initiatives.

N urses’ caring behaviors have been acknowledged as a core element in providing quality care.

1Y3 Histori-

cally, oncology nurses have played a pivotal role in providing care to cancer patients. In oncology nursing litera- ture, dignity, love, presence, respect, and sensitivity have been identified as the key caring behaviors.

4,5 Patients with cancer

experience the multifaceted impact of the diagnosis and chem- otherapy treatment, affecting physical, psychological, spiritual, and social domains in their everyday life.

6 Nurses have a core

role within the multidisciplinary team to provide optimal care tailored to patients’ needs and priorities.

n Review of Literature

Within cancer nursing, ‘‘caring’’ has been described as a multi- faceted phenomenon composed of specific caring behaviors, including existential aspects and nursing actions.

5 Starting from

the early study of Larson, 4

a series of studies suggest that on- cology nurses perceived having a trusting professional relation- ship between nurse and patient as the most important caring behavior.

6,8 Strong, supportive relationships foster patients’ views

of a courageous and stoic cancer experience. 9

Studies conducted in diverse cultural backgrounds and countries suggest that pro- viding emotional, informational, and practical support is central to the provision of quality care.

8,10 Chemotherapy can signify a

particularly vulnerable phase in an individual’s cancer trajectory. The onset of distressful symptoms, functional changes, and fa- tigue may make it difficult for patients to transcend the situation and embrace hope.

7,10,11 Skillful and compassionate nursing care

at this phase is essential in ensuring optimal patient outcomes. 10

Oncology nurses’ approaches to caring may be influenced by different factors, such as their personality, own philosophy of life, culture, social reality, professional identity, and the phi- losophy of their work environment.

5,12,13 Moreover, in acute

cancer treatment settings, nurses may perceive aspects such as professional knowledge and care surveillance or practical be- haviors to be essential and more ‘‘important’’ than psychoso- cial skills.

13 In a concept analysis on caring by Brilowski and

Wendler, 14

researchers pointed out that nursing care consists of actions and interactions that come from the nurses’ percep- tions of patient’s needs. Physical care, touch, presence, and com- petence were included as important attributes of what nurses believe and describe as ‘‘care.’’

n Conceptual Framework

Theories about caring vary from philosophies to grand theories to middle-range theories.

15 Watson’s Grand Theory of Human

Caring 16

has been widely used in nursing. 16

The key concept of this theory is the interpersonal nurse-patient relationship and nurse’s ability to create and sustain a healing environment. Watson has described caring through a clinical ‘‘caritas’’ process.

1 Her

theory provides the structure and the language needed to sup- port and guide nursing practice in different contexts and health- care systems.

16,17 Smith’s

2,16 reviews on research related to

Watson’s theory indicate that nurses seemed to take compe- tence and technical activities for granted, whereas interper- sonal activities were perceived as the most important caring behaviors, particularly for patients with a life-threatening illness.

Identifying nurses’ perceptions on adopting certain caring behaviors in an acute cancer treatment environment offers the potential to better understand the ways caring is offered and the factors that affect it, as well as nurses’ own awareness of caring. Currently, there is a lack of evidence on oncology nurses’ perceptions of caring behaviors within a Greek context.

n Study Purpose

The aim of the present study was to determine the caring be- haviors that oncology nurses perceived to be most important in making patients undergoing chemotherapy feel cared for. The research questions were as follows: (a) What caring behaviors do nurses consider important? (b) What demographic and other per- sonal characteristics, such as gender, age, marital status, educational background, work position, total work experience, and experience in oncology, are associated with nurses’ perceptions of caring?

n Methods

Design

Qualitative research is recognized as the most suitable to in- vestigate philosophical ideas such as ‘‘caring’’

18 and is often

used to illustrate the meaning of caring from nurses’ perspec- tives.

19 Quantitative designs are used to develop instruments

to measure aspects of caring and caring behaviors. More recently, the combination of quantitative and qualitative methods has been demonstrated.

2,3 We used a mixed-methods design, which in-

tegrated data from an exploratory, cross-sectional survey, and a subsequent qualitative investigation based on focus group inter- views with oncology nurses to explore their perceptions of caring behaviors for patients undergoing chemotherapy.

Setting and Sample

Nurses from 7 medical oncology wards in 3 metropolitan cancer hospitals in the Attica, Greece, area were recruited from January

2 n Cancer NursingA, Vol. 00, No. 0, 2018 Karlou et al

2011 to December 2011. In a previous international study with a large sample (n91100 nurses), small effect sizes of the asso- ciation between nurses’ background characteristics and responses to the Caring Behavior Inventory 24 (CBI-24) have been re- ported (r = 0.07Y0.11).20 Pooling data from different countries may have confounded actual effect sizes because of potential differences in the size and direction of associations among dif- ferent countries. Acknowledging this limitation and the fact that the aforementioned weak associations may not be clinically sig- nificant, the quantitative investigation of this study was powered to detect a medium correlation coefficient (rQ3; power = 0.80, != .05), which would explain a clinically relevant proportion (ap- proximately 1%) of the variation in CBI scores. Based on these power calculations, a sample size of at least 85 nurses was needed.

In the qualitative part of the study, 3 focus groups were conducted. Nurses with similar sociodemographic character- istics to those participating in the quantitative study were pur- posefully selected. The composition of each group was homogeneous (age, gender, family characteristics, education, and work experi- ence), but adequate variation among participants (maximum variation sampling) was sought after to encourage a greater degree of spontaneity and to present a wide range of views.

To be eligible for this study, participants had to (1) be registered nurses according to the European Directives for registration, (2) have at least 1 year working experience, (3) have worked at least 1 year in an acute oncology setting, (4) be able to speak and understand Greek, and (5) be willing to participate in the study.

Measurement In the survey phase of the study, data were collected through the use of the Greek version of the CBI-24

22 and a demo-

graphic form developed by the researchers that included gender, age, family status, education background, and years of expe- rience in nursing and in oncology. Those factors, decided upon by a panel of experts, were informed by a previous international study reporting correlates of caring behaviors in surgical nursing.

CARING BEHAVIOR INVENTORY

The CBI-24 is the latest revised version of a self-report ques- tionnaire about caring.

23 The CBI-24 has been used by more

than 132 investigators in several countries and was accepted as a simple, short, and easy to complete instrument.

3 The Greek

version of the CBI-24 22

consists of 24 items using a 6-point Likert scale (from 1 = never to 6 = always). Total scores ranged from 24 to 144. The higher scores indicated the frequency of caring behaviors practiced by nurses. The CBI-24 consists of 4 subscales: ‘‘assurance of human presence,’’ ‘‘knowledge and skill,’’ ‘‘respectful deference to others,’’ and ‘‘positive connectedness.’’ Internal consistency estimates of the Greek version of the CBI-24 include an overall Cronbach’s ! coefficient of .92, and .72 to .87 for the 4 subscales. The test-retest coefficient was 0.83; confirmatory factor analysis confirmed the 4 subscales.

FOCUS GROUPS

In the qualitative phase of the study, a focus group discussion guide was formulated, and a similar demographic form to the one used in the survey phase of the study was completed.

The focus group discussion guide consisted of 6 open-ended questions based on the CBI-24 subscales and the overall research aim (Table 1). Face validity of the questions was established by a panel of experts (2 professors of nursing with extensive ex- perience in qualitative research methodology and 2 clinical on- cology care experts).

Data Collection Procedures

Questionnaires were distributed by the primary investigator. Nurses meeting the inclusion criteria were verbally invited to participate in the study. Questionnaires with a cover letter explaining the aim and the voluntary nature of the study and guaranteeing anonymity and confidentiality were distributed. A sealed envelope and instructions were also provided. All nurses’ questionnaires were returned to a box located at the ward man- ager’s office in the sealed envelope. To increase nurses’ response rate, reminders within the following fortnight were sent.

Focus groups were organized in a neutral, easily accessible, comfortable, quiet venue familiar to all nurses in a private room within the university’s nursing department. Discussions lasted between 90 and 120 minutes and were audio recorded. A professor in nursing facilitated the focus group. A nurse spe- cialist with advanced training and experience in focus group methods was the first observer. The primary investigator served as the second observer and took written notes focusing on both verbal cues and nonverbal communication. Six nurses partici- pated in each focus group, totaling 18 participants across groups. In the beginning of each group, the facilitator introduced the aim and the process of the focus group and highlighted the overall aim of the study.

Ethical Considerations

This study was conducted according to general ethical stan- dards.

24 The Board of Directors, the Scientific Board, and the

Nursing Directors of involved hospitals approved the imple- mentation of the study. Participants in both phases of the study received written and verbal information on the purpose of the study, including its voluntary nature, the right to with- draw without any consequences, and anonymity and confiden- tiality of the data.

All focus group participants gave permission to audiotape discussion sessions. Confidentiality was maintained by assigning

Table 1 & Focus Group Question Guide 1. What does caring for patients receiving chemotherapy mean

to you? Describe your experiences.

2. What is the most important caring behavior for you personally? 3. Based on your experiences, what do you think make patients

feel that nurses guarantee their safety?

4. How do you show your respect to your patient? 5. Do you create close relationships with your patients? Please

give an example from everyday work practice?

6. Is there anything else that you would like to share with the group about nurses’ caring behaviors?

Nurses’ Behaviors Toward Chemotherapy Patients Cancer NursingA, Vol. 00, No. 0, 2018 n 3

numbers to participants, and each recording and transcription also had numerical codes. All data were secured in a locked cabinet, and only researchers who performed the content anal- ysis had access to the data.

Data Analysis

Survey data analysis was performed using the Statistical Pack- age for Social Sciences version 17.0 for Windows (SPSS Inc, Chicago, Illinois). Data were checked for normality and were transformed as appropriate. Nonparametric statistics were used where appropriate for ordinal-level data or when normality criteria were not met. Comparisons between groups of nurses were carried out using the Mann-Whitney U test and were con- firmed by t test for ease of interpretation of mean scores. De- scriptive statistics were reported.

Correlation analysis was used to test the association between nurses’ demographic and personal characteristics with CBI-24 scores (total score and subscales scores). Spearman > correlation coefficients were calculated to obtain an initial understanding of potential correlations among variables. Subsequently, multi- ple linear regression analysis with stepwise procedure was used to identify variables most strongly associated with scores in each subscale of the CBI. Bonferroni adjustment was used in case of multiple simultaneous comparisons. All P values reported are 2-tailed. The significance level was set at !G.05.

Content analysis is considered the most suitable method to analyze multifaceted and sensitive nursing phenomena such as care.

25 More specifically, the technique of deductive content

analysis was used following the phases of analysis, preparation, organization, and reporting.

25,26 Three independent experienced

researchers analyzed the data derived from field notes and ver- batim transcriptions line by line. Repeated reading, reflecting,

and searching for emerging patterns and meanings followed, and codes and categories were structured according to the CBI subscales. Furthermore, based on the purpose of the study to investigate the perceptions of nurses, an attempt was made to identify and classify all the characteristics of care. Researchers met regularly to check interpretations, validation of categories, and conclusions.

To establish trustworthiness (credibility, dependability, and applicability) of the analyzed data, collection and analysis pro- cesses were documented in detail. Research processes were based on methodological guidelines

27 ; the facilitator and observers

were experienced researchers both in the subject under dis- cussion and in focus group research.

28 Interview transcriptions

were independently analyzed by 3 investigators, who later met to discuss and reach consensus. Analyses were validated by 2 independent researchers, a psychologist and a specialist nurse, with extensive experience in qualitative research and the analysis process.

25,27 One hundred percent agreement was achieved in

the coding scheme between researchers. 28

Quotations excerpted from transcriptions were used to enhance transferability. The most representative meaningful quotations from focus group dis- cussions were used to further describe the identified categories.

27,28

n Results

For the survey phase, a total of 105 nurses were approached, and 72 nurses (response rate, 68.5%) consented to participate in the study. A purposeful sample of 18 nurses (in total) who had similar sociodemographic characteristics were invited and participated in 3 focus groups (participation rate, 100%) (Table 2).

The CBI-24 had strong internal consistency with Cronbach’s ! of .90 for the total scale and ! values of .84 to .86 for the subscales.

Table 2 & Nurses’ Demographic and Personal Characteristics Survey 3 Focus Groups

n % n %

Gender Men 9 12.5 1 5.6 Women 63 87.5 17 94.4

Age 34 (8.1) 34.8 (6.5)

Marital status Single a

40 55.6 14 77.8 Married 30 41.7 4 22.2 Divorced 2 2.8 V V

Kids No 37 53.6 14 77.8 Yes 32 46.4 4 22.2

Educational background Bachelor’s degree 4 5.6 8 44.4 Diploma 67 93 10 55.6

MSc 5 7.6 9 50 PhD 2 1.5 1 5.6 Clinical specialty

b 15 20.8 2 11.1

Work position Staff nurse 60 83.3 17 94.4 Head nurse 11 15.3 1 5.6

Total work experience, mean (SD), y 10.6 (8.6) 10.2 (6.3)

Work experience in oncology, mean (SD), y 7.7 (8.5) 9.1 (6.9)

a Single includes single, divorced, and widowed nurses.

b Clinical specialty includes medical or surgical nursing specialty.

4 n Cancer NursingA, Vol. 00, No. 0, 2018 Karlou et al

In the quantitative phase of the study (survey), the sample was predominantly female (87.5%), with a mean age of 34 (SD, 8.1) years. The mean total work experience was 10.6 (SD, 8.6) years and specifically in oncology 7.7 (SD, 8.5) years (Table 2). In the qualitative phase of the study (focus groups), the sample was also predominantly female (94.4%), with a mean age of 34 (SD, 6.5) years. The mean total work experience was 10.2 (SD, 6.3) years, and it was 9.1 (SD, 6.9) years in oncology (Table 2).

The top 3 CBI-24 caring behaviors were ‘‘knowing how to give shots, IVs, etc’’ (5.3 [SD, 0.8]), ‘‘giving the patients’ treat- ments and medications on time’’ (5.3 [SD, 0.7]), and ‘‘helping to reduce the patient’s pain’’ (5.1 [SD, 0.8]) (Table 3). Top-rated CBI-24 subscales were ‘‘knowledge and skills’’ (5 [SD, 0.7]) and ‘‘assurance of the human presence’’ (4.8 [SD, 0.7]).

No significant associations were found between CBI-24 total scores, CBI subscales, and the tested variables (age, gender, pro- fessional experience) (Table 4). Marital status was the only vari- able to correlate with higher CBI ratings (total and subscales). Participants who were married had higher CBI-24 ratings across all subscales compared with single/divorced/widowed participants (Table 5). Multiple linear regression analyses confirmed the asso- ciation between marital status and CBI scores, but indicated no other significant associations among nurses’ demographic and personal characteristics and the CBI-24 ratings. However, the models exhibited unacceptably poor fit with "’s ranging from "= .43 (PG.01) to "= .57 (PG.00).

In the focus groups, nurses’ competencies and technical skills, professional knowledge, and their perceptions of their role as health professionals were found to be the most significant caring behaviors for patients undergoing chemotherapy. Analysis of interview data revealed 6 main themes central to nurses’ caring behaviors (Table 6), the ‘‘concept of care,’’ ‘‘respect of the human being,’’ ‘‘nurse-patient connection,’’ ‘‘empathy,’’ ‘‘nurses’ personal view about the illnessVfear of cancer,’’ and ‘‘nurses’ personal perception about their role as professionals.’’

The Concept of Care

Nurses described caring as a human trait and the action of pro- viding physical and individualized care. Nurses referred to phy- sical care as a fundamental nursing intervention and their main obligation. They recognized the importance of meeting patients’ needs in providing total care and viewed the concept of care as a professional responsibility.

Care does not only mean scientific knowledgeI It is something more humane, more meaningfulI We identify their personal needsI [The patient] is basically our guide on how to provide their careI We personalize our interventionsI (N17) IIt is importantI maybe a bitI the body part at first, not to underestimate the psychological [needs]I but at first is perhaps more important to relieve the physical symptoms more. (N1)

Table 3 & Caring Behaviors Inventory (Caring Behavior Inventory 24) Subscales and Cronbach’s ! Caring Behaviors Subscales Mean (SD) Cronbach’s !

Knowledge and Skills 5 (0.7) .84

Q9 Knowing how to give shots, intravenous lines, etc 5.3 (0.8) Q10 Being confident with the patient 4.8 (0.9)

Q11 Demonstrating professional knowledge and skill 4.9 (1) Q12 Managing equipment skillfully 4.8 (0.9) Q15 Treating patient information confidentially 5 (1)

Assurance of Human Presence 4.8 (0.7) .86

Q16 Returning to the patient voluntarily 3.8 (1.1) Q17 Talking with the patient 4.3 (1.2) Q18 Encouraging the patient to call if there are problems 5 (1)

Q20 Responding quickly to the patient’s calls 4.9 (1) Q21 Helping to reduce the patient’s pain 5.1 (0.8) Q22 Showing concern for the patient 4.9 (1)

Q23 Giving the patient’s treatments and medications on time 5.3 (0.7) Q24 Relieving the patient’s symptoms 4.9 (0.8)

Respectful Deference of Others 4.5 (0.8) .86

Q1 Attentively listening to the patient 4.6 (1.1) Q3 Treating the patient as an individual 4.9 (1.1) Q5 Supporting the patient 4.4 (1.1) Q6 Being empathetic or identifying with the patient 4.5 (1.1)

Q13 Allowing the patient to express feelings about his/her disease and treatment 4.4 (1) Q19 Meeting the patient’s stated and unstated needs 4.4 (0.9)

Positive Connectedness 4.3 (0.9) .84

Q2 Giving instructions or teaching the patient 4.6 (1.1) Q4 Spending time with the patient 4.1 (1.2) Q7 Helping the patient grow 4.3 (1.3)

Q8 Being patient or tireless with the patient 4.6 (1) Q14 Including the patient in planning his/her care 3.8 (1.2)

Nurses’ Behaviors Toward Chemotherapy Patients Cancer NursingA, Vol. 00, No. 0, 2018 n 5

Nurses’ professional identity was highlighted as an essential part of the caring process, including their specialized knowledge of providing quality nursing care based on holism:

ITo do our job as best as we can in all levels, that is, when we know whyI when we have some criteria in our job to be fulfilled and which we believe to be the right ones, such as giving the right medication to the right patients, or to take care of their body properly, trying to meet their emotional needs; this is the way to provide holistic care. (N12) Ithe care provided to the patients, is by professionalsI (N7)

Respect: Respect of the Human Being

Nurses connected caring with respect of patients’ personal values, beliefs, and preferences; establishing trust and confidence; and avoiding discrimination. Nurses’ skills on vein cannulation appeared to be a contributing factor in showing respect:

INo matter who you have [lying] in the bed, you have to respect the human beingI and do the best possible for him/her as he/she is the most saint-like [person] in the world, Iand give your best possibleI treating people without discrimination. I think this is respectI (N3) I the way we handle their body, the way that we face them, our calm voice and discussionVall of these indicate respect to the patientI (N14) Respect for the patient is when we become magicians to find the right vein for cannulation. This is what it is!!!

That’s what it is!!! Here is my respect, when we find a solutionI (N1)

Nurse-Patient Connection

Nurse-patient interactions through a trusting relationship were reported by all participants to be a central part of care. This category included aspects such as a unique and dynamic bond- ing with patients. Nurses argued that personal chemistry was essential for a close relationship.

ISome patients entering the day care unit for chemotherapy, have already chosen their nurse, that is what we call rapportI We can’t separate a patient from the nurse since they (patients) made their choice, one should respect patients’ decision, since it is with them (nurse) they feel secureI. (N3) I I am a very important, very vital part of their lives, I mean that we are part of their social circleI we have a unique opportunity to stand by them in very difficult moments of their lives, and this forms our unique relationshipI is not easy I because they are between life and death. (N18)

In the day-care chemotherapy unit, the priority of care emphasized caring as ‘‘doing’’ because of staff shortage and lack of time. This included completing tasks, rather than effectively communicating and establishing a meaningful caring relation- ship. Their interpersonal relationships depended on the response in the different situations that could obstruct the formation of a more meaningful caring relationship.

Table 4 & Associations Between Nurses’ Characteristics and Caring Behavior (Caring Behavior Inventory 24 [CBI-24]) Subscales

Caring Behavior (CBI-24) Subscales

Assurance of Human Presence

Knowledge and Skill

Respectful Deference to Others

Positive Connectedness

> (P) > (P) > (P) > (P)

Nurses’ characteristics Age 0.15 (.231) 0.06 (.643) 0.09 (.454) 0.04 (.770) No. of children 0.22 (.074) 0.18 (.155) 0.20 (.116) 0.07 (.574)

Length of nursing professional experience 0.16 (.206) 0.02 (.846) 0.20 (.108) 0.12 (.327) Length of oncology nursing experience 0.12 (.364) 0.08 (.526) 0.11 (.416) 0.08 (.545)

Spearman > correlation coefficients are reported.

Table 5 & Differences in Score of Caring Behavior Inventory 24 (CBI-24) Subscales According to Nurses’ Marital Status Groups

CBI-24/Subscales

Assurance of the Human Presence

Knowledge and Skills

Respectful Deference of Others

Positive Connectedness

Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Marital status Married 5.1 (0.6) 5.2 (0.6) 4.9 (0.6) 4.6 (0.8) Single

a 4.6 (0.7) 4.8 (0.7) 4.3 (0.8) 4.1 (0.9)

P .007 .012 .001 .026

Results were confirmed by Mann-Whitney U analysis; t test results are reported to highlight differences in mean scores. a Single includes single, divorced, and widowed nurses.

6 n Cancer NursingA, Vol. 00, No. 0, 2018 Karlou et al

It is such the speed that one is required to do everything in a very short, accurate time considering the shortage of staff; thus, it is necessary to have a balance in your relationships with every patient. You have to act as a professional. (N10)

Nurses expressed their difficulty to set the boundaries in the therapeutic relationship with the patients. While they pointed out the importance of nurses’ constant presence at patients’ bedside, they recognized a need to adopt strategies to maintain their own mental and psychological well-being.

But I think we should put limits as nurses, and I have experienced this kind of challenge before. When I haven’t done it, I was less experienced; I gave a big piece of myself and it cost meI we should put in limits because there is only so much we can take inI. (N15)

Nurses also identified dealing with death and dying, as a pivotal part of caring that affected their desire to be in close contact with the patients

IWhen this man died, he affected me so much as I was affected from my father’s deathI always when I feel that this is going to happen againI I tried to stop it and

tried to stay away from a close relationship, because you will end up with the same wounds and all the related feelingsI. (N9)

Moreover, nurses stated that a trusting relationship with cancer patients gave them a sense of job satisfaction, which maintained their caring efforts

Iis the greatest benefit we get from this job, I mean that we bond with certain people Iand fortunately this interpersonal contact is what feeds us. (N12)

Empathy

Nurses stated that ‘‘being with’’ patients in the most vulnerable time of their lives was the core component of care. Nurses’ cannulation skill has been identified as a key task that involved emotion and was considered as a mode of empathy. A profound bonding connection was created between the nurse and the patient.

The oncology patient is a special patientI We should many times try to be in his/her positionI We should tell him/her that ‘‘We will stand by you through chemotherapy, you, we are here for you.’’ II think those behaviors are very importantI. (N15) II did nothing else. I just sat beside her and grabbed her hand, and I did this with calmness. (N18) When we see a patient with a great problem with his/her veins and he/she complainsI and he/she could not withstand anymore! I I have toI we have to find a solution!!! (N4)

Nurses’ Personal View About the IllnessVFear of Cancer

Nurses expressed their psychological distress facing the effect of a life-threatening disease in people’s lives. They expressed feelings of vulnerability and frustration.

ICancer is cancer. (N1) II’m afraidI I am defensive because it scares me; it scares me so much this illness (cancer)I. (N7) IPerhaps because the older I become, the most afraid I feel for this disease; above all, you are scared of cancer. (N15)

Nurses’ Personal Perceptions of Their Role as Professionals

Nurses felt that their personal characteristics and beliefs about their role also affected their perceptions of care in a chemother- apy ward environment.

It is all about patients’ care how we see, how each one of us understand itI I believe that those of us who are working, at least we try to do our best with all our mental power reservesI because neither we are gods, nor we always do everything perfectI. (N6)

Nurses mentioned that they acted as patients’ advocates within the health professional teams and highlighted the importance of a highly skilled practice and of a knowledgeable, competent nurse.

Table 6 & Focus Groups Content Analysis Provided the Following Categories

1. The concept of care as

Human trait

Patients’ physical care Individualized care Professional responsibility

2. Respect: respect of the human being 3. Nurse-patient connection

Unique relationship and very dynamic human connection;

different aspects influence nurse-patient interactions Nurses’ personal thoughts and experience that affect their

expression of connectedness with a patients Nurses’ ability and tension to delimit their connection

with patients The establishment of connectedness as a result of cancer

chronicity

The importance of nurse’s constant presence Professional development as a result of the relationship with

the patient

Nurse-patient relationship becomes transpersonal and influence nurses’ psychological and spiritual balance

The lived experience of death and dying because of the

closeness with the patient Nurse job satisfaction as a result of the close relationship with

the patient 4. Empathy

5. Nurse’s personal view about the illnessVfear of cancer 6. Nurses’ personal perception of their role as professionals

Nursing actionsVresponsibilities and clinical competence Nurse as patient advocateVand their ability for

interdisciplinary cooperation Nurses were required to be well educated and specialized in

cancer care and attend continuing education courses Nurse as role model

Nurses’ Behaviors Toward Chemotherapy Patients Cancer NursingA, Vol. 00, No. 0, 2018 n 7

INurse’s role within a team is to take care of the patient and make him not feel alone. (N1) IBut when we talk about a super nurse I when we use such an expression, we mean the nurse who covers all aspects of patients’ careI from the provision of information to communication and practical issues. (N10) When I know not only howI but why. (N1)

Continuing education and specialized knowledge were valued as very important to their identity as nurses. Moreover, nurses’ ability in venipuncture is essential element in their personal understanding of professionalism.

INowadays most hospitalized people know many thingsI If you do not know very well your subject, it is obvious immediately, how to find the right vein for cannulation; you should gain the trust from the beginning, especially in scientific issuesI We live in times that things have changed, and the patients’ demands are greater. (N17)

n Discussion

To our knowledge, this is the first study to investigate percep- tions of caring behaviors of oncology nurses in Greece. Findings showed that clinical competence and skills were considered the most important caring behaviors. Moreover, the qualitative exploration confirmed that the most valued caring behaviors are related to nurses’ professional knowledge, technical tasks, and procedures.

Oncology nurses in acute care settings are expected to be equipped with knowledge and skills to be able to gain insight into each cancer patient’s experience.

6,29,30 Nurses adminis-

tering and monitoring advanced, complex treatments require technical expertise and a high-level skill set in order to gain patients’ trust and minimize their possible sense of vulner- ability.

29Y31 Studies in Greek surgical hospitals have similarly

identified technical aspects as the most important care behaviors. 32

From the quantitative findings, behaviors related to establish- ing a close relationship between patients and nurses received the lowest priority. This was in contrast to the qualitative findings, where nurses highlighted the significance of nurse-patient con- nectedness only when specific barriers could be overcome such as staff shortage and time restrictions. Affective nursing be- haviors were judged to be most important in making patients feel cared for.

5,33

Notably, nurses in our study emphasized the barriers that prohibited them from providing their preferred standard of care. One of the most frequently mentioned barriers was the lack of time. Time pressures were further demonstrated in our survey results, ranking the behavior ‘‘spending time with the patient’’ in the 22nd position. This finding is supported by other studies that emphasize that nurses need time to be able to care

34,35

particularly in a busy oncology day-care ward. 13,30,36

Further- more, ‘‘getting the work done’’ remains a powerful underpin- ning of the work culture in most work settings.

13,35,37

In the present study, nurses felt that their venipuncture skills were the key to total care and to a close relationship with their

patients as well. This finding is supported by previous research regarding how highly technical nursing interventions can trans- mit a special feeling of compassion and self-giving to the pa- tient.

6,8,35,36,38 Studies in acute oncology settings provide evidence

that this type of highly technical, specialized care is perceived to play a pivotal role in the overall provision of nursing care. Nurses who want to prioritize patients’ emotional needs often fail to elicit patients’ concerns within their routine practice assessments. To this end, it is clear that technical skills are necessary for nurses to help them successfully meet different job requirements and guarantee effective performance.

5,39,40

Interestingly, less frequent caring behaviors in our survey, such as ‘‘including the patient in the planning of his/her care,’’ ‘‘attentively listening to the patient,’’ and ‘‘talking with the patient,’’ were shown to be major concerns for nurses during the focus groups. Arguably, acute cancer treatment settings are often very busy, with nurses feeling under constant pressure, performing multiple and complex administrative tasks, provid- ing basic care, and being left with limited time to deal with patients’ emotional needs and concerns.

13 This further stresses

the competing demands of the working environment, while research evidence supports that ‘‘being with’’ patients and families, providing personalized, holistic care, should be the ultimate goal of quality care.

41,42

Studies have emphasized the difficulties faced by nurses in maintaining a balance between person-centered, holistic care and task-oriented care in a chemotherapy administration envi- ronment.

5,10,13,35,37,42 In our study, nurses perceived their care

to include careful listening and the acknowledgment of patients’ values and perceptions. They further stressed their unique con- tribution as professionals and the importance of being knowl- edgeable, skillful, and committed to the provision of individualized care and to act as role models. This practical approach to caring and ‘‘being there’’ meets patients’ expectations of nurses.

13,32

Of note, there are a limited number of studies examining the association between nurses’ personal characteristics and caring behaviors, and these tend to have divergent findings.

21,33,43 In

our study, only marital status was correlated with nurses’ per- ception of care. Married nurses rated higher all care behaviors compared with others (single, divorced, widowed). This finding contradicts results from a study where marital status was cor- related negatively to nurses’ perceptions of care

44 and from an

international study involving surgical care settings, including Greek nurses,

21 where no associations were found between per-

sonal nurse characteristics and caring behaviors. A possible inter- pretation for this can be the special feeling of ‘‘motherhood’’ that nurses can have for patients experiencing a life-threatening illness, such as cancer, as previously reported.

45,46 Nevertheless, more

research is needed in a larger and more representative sample to further explore and explain the existence and nature, if any, of the relationship between nurses’ personal characteristics and their caring behaviors.

Limitations

The main limitation is the relatively small convenience sample that was obtained from 1 geographical area (Attica) that is not

8 n Cancer NursingA, Vol. 00, No. 0, 2018 Karlou et al

representative of Greek nurses as a whole. Moreover, despite our efforts to increase recruitment, the sample was 13 participants of the predetermined survey sample size. This may have intro- duced a type II error by failing to detect important associations between nurses’ characteristics and caring behaviors. Further- more, given the staff shortage in cancer metropolitan hospitals

in Greece, the demanding nursing workloads, and the mod- erate response rate (68.5%) in the survey phase of the study, the internal and external validity of the study may be affected. In the qualitative phase of the study, issues such as group con- sensus, dynamics, and homogeneity may have influenced the study’s findings. However, only 1 person seemed to participate in a limited way.

48 Despite the issue of limited generalization,

focus groups’ findings added depth, clarity, and better under- standing of the survey findings.

Notably, the current challenging socioeconomic circum- stances in Greece and the shortage of nurses can potentially affect the perception and expression of caring behaviors. How- ever, this study is a first attempt to investigate perceptions of caring behaviors in the field of oncology nursing in Greece.

Implications for Practice

Caring theory has the potential to guide nurses, particularly those in complex clinical settings. Furthermore, study findings may be useful to others in finding new ways to develop a quality practice environment. Healthcare policy makers need to address the shortage of staffing for nurses to have the potential and the time to enter into a caring relationship with their patients. Nurse educators’ active and continuous clinical support may be a potent tool for nurturing and fostering staff nurses to provide a work environment in which care can be practiced in a caring manner. Nurse managers should restructure work conditions, advocate, supervise, and support nurses to create an environ- ment that nurtures care as a valuable resource.

n Conclusion

This study’s findings suggest that nurses’ perceptions of caring behaviors can be focused on skills and knowledge in order to meet patients’ needs in an acute cancer treatment environment. Effective performance, professional responsibility, the provision of individualized care, and a close relationship with the patients were key concepts identified. Furthermore, all important aspects in a caring environment were affected by lack of time and staff shortage. Despite the fact that it may not always be possible for nurses to provide their perceived level of care because of these factors, this study has identified a clear need for development of services that are tailored to socioeconomic, organizational, and political conditions.

ACKNOWLEDGMENTS

The authors thank the nurses who participated in this study. This study would not have been possible without their willing- ness and help.

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