Oncology patients' and oncology nurses' perceptions of nurse caring behaviours

Oncologypatients’and oncology nurses’perceptions of nurse caringbehaviours

Kimberly A.Christopher,KathrynHegedus

Previous research on patients’andnurses’perceptions of nurse caring behaviours hasdocumentedsignificantdifferences intherankingof importantbehaviours.However, thesesamples have included avariety ofmedical-surgical patients andnurses anddifferent typesof institutional settings, allofwhichmayhave affectedtheresults.Thepresent study soughtto determine if patients andnurses fromone subspecialty area and one institutionwouldhavemore concordant perceptions of caring.Forty-fouroncology patients and 49 oncologynurses completed the Respondents Perceptions of Caring Behaviour Scale (RPCBS).Results showedthatoverallmeanpatient rankingswerehighlycorrelatedwithmeannurserankings (Spearman’s correlations coefficient 0.94, P50.0001).TheWilcoxon two-samplerank sumtest was used to test the difference in rankof the 20 items between the patientsand nurses.Therewas a significant difference in rank in only sixof the 20 items.These datasuggestthatoncologypatients andnurseshavemore concordantperceptionsofcaring thanpreviously investigated groups. Implications for practice and further research arediscussed. # 2000 Harcourt Publishers Ltd

Keywords: care, caring, caring perceptions, nursing

DieWahrnehmung von Krebspatientenund Krebspflegekraº ften der Verhaltensweise von Krebspflegekraº ften in ihrer ArbeitFruº here Studien uº ber dieWahrenehmung seitens Patienten und Pflegekraº ften in bezug auf dasVerhalten derPflegekraº fte in ihrer Arbeit hast grobe Unterschiede in der Rangordnung der wichtigenVerhaltensweinsenaufgezeigt.DieseTestgruppen umfassten jedoch unterschiedlichemedizinsch-chirurgische Patienten undPflegekraº fte und unterschiedliche Arten von Institutionen, was die Ergebnisse vielleicht beeinflusst hat.Das Zieldieser Studiewar, herauszufinden, ob Patienten und Pflegekraº fte einer spezifischen Untergruppe und aus einerInstitution uº bereinstimmendeWahrnehmungenmachten.Vierundvierzig Krebspatienten und 49Krebspflegekraº fte fuº llten einen Fragebogen Respondents Perceptions of Caring Behaviour Scale (RPCBS) aus.Das Resultat Zeigte, dass allgemein diemittleren Benotungen der Patientenweitgehendmit denen derPflegekraº fte uº bereinstimmten, (Spearmans Korrelationskoeffizient 0.94, P50.0001).Der Wilcoxon zwei Proben-Bewertungssummen-Test wurde Fuº r die unterschiedliche Benotung Zwischen Patienten und Pflegepersonal von20 Fragen angewandt.Nur bei sechs der 20 Fragenwar ein deutlicher Unterschied zu erkennen.Dies Ergebniszeigt, dass Patienten und Pflegekraº fe in dieser Studie uº bereinstimmendereWahrnehmung in bezug auf die Pflegehaben, als in fruº her untersuchten Gruppen.Die Konsequenzen fuº r die Praxis und fuº r weitere Untersuchungenwerden in diesemArtikel diskutiert.

Percepciones de las conductas de atencioŁ n de enfermer|¤a de pacientes oncolo¤ gicos y enfermeros oncolo¤ gicosLas investigaciones anteriores sobre las percepciones que tienen los pacientes y los enfermeros con respecto a laatencioŁ n han documentado diferencias significativas en la clasificatioŁ n de conductas importantes. Sin embargo,estasmuestras han incluido una variedad de pacientes y enfermerosmeŁ dicos/quiruŁ rgicos y diferentes tipos deentornos institucionales, todo lo cual puede haber afectado los resultados. Este estudio intentoŁ determinar si lospacientes y enfermeros de un a¤ rea de subespecialidad y una institucio¤ n tendr|¤an percepcionesmaŁ s concordantesde la atencioŁ n.Cuarenta y cuatro pacientes oncoloŁ gicos y 49 enfermeros oncoloŁ gicos rellenaron la Escala dePercepciones de Entrevistados sobre laConducta de laAtencioŁ n (RPCBS).Los resultados indicaron que engenerallas clasificaciones de los pacientes estabanmuy correlaciones de Spearman 0.94, P50,0001). Se utilizoŁ el test desumatoria de clasificacioŁ n de dosmuestras deWilcoxon para someter a prueba la diferencia en la classificatioŁ n delos 20 elementos entre los pacientes y los enfermeros. Se observoŁ una diferencia significativa en la clasificacioŁ nsoŁ lo en seis de los 20 elementos. Estos datos sugieren que los pacientes y enfermeros oncolo¤ gicos tienenpercepciones de la atencio¤ n ma¤ s concordantes que otros grupos previamente estudiados. Se tratan lasrepercusiones para la praŁ ctica e investigaciones posteriores.

Kimberly A.ChristopherPhD, RN,OCNAssistant Professor,College of Nursing,University ofMassachusetts,Dartmouth,OldWestport Road,North Dartmouth MA02747,USAE-mail: [email protected] HegedusDNS, RN, AssociateProfessor,University of Connecticut,Storrs,CT 06269,USACorrespondence ando¡print requests to:Kimberly A.Christopher

European Journal of Oncology Nursing 4 (4),196^204 # 2000 Harcourt Publishers Ltddoi:10.1054/ejon.2000.0108, available online at http://www.idealibrary.com on

Patients’ and nurses’ perceptions of nurse caring behaviours 197

INTRODUCTION

In an attempt to meet the ongoing challenge of

demonstrating and articulating the nature of

nursing’s contribution to health care, various

nurse scholars have argued that caring is the

central focus or ‘essence’ of nursing (Benner &

Wrubel 1989, Crowden 1994, Leininger 1984,

Watson 1985). However, if caring is the ‘central,

dominating, and unifying feature of nursing’

then this must be demonstrated in a manner

relevant to practice and the patient (Morse et al.

1990). This research study measured and de-

scribed the extent to which a sample of oncology

patients and nurses in a comprehensive cancer

center agreed on the importance of selected nurse

caring behaviours. Although concordance of

perceptions has been measured in a variety of

nurse and patient samples, no investigation has

focused specifically on cancer patients and nurses

in a comprehensive cancer center setting. Such

data increases knowledge on the caring nature of

oncology nursing, identifies the degree to which

this sample of oncology patients and nurses

agree on priority caring behaviours and facil-

itates a plan of nursing care based on priority

caring behaviours identified by oncology pa-

tients.

REVIEWOF THELITERATURE

Previous research with nurses and patients has

concluded that the concept of caring is a critical

component of high-quality nursing care (Benner

& Wrubel 1989, Gadow 1985, Watson 1985,

Williams 1997). Today’s health-care environ-

ment with its emphasis on market competition,

cost containment, shorter hospital stays and

expanding use of high technology increases the

necessity to identify nursing behaviours that

make patients feel that they are being cared

for. The literature indicates that congruency of

patient-nurse perceptions and goals is important

for the patients to profit from their care (von

Essen & Sjoden 1991a). For example, investiga-

tions have documented a positive relationship

between patients’ overall satisfaction with the

hospitalization experience and their recovery,

comfort, health behaviours and compliance

(Gardener & Wheeler 1979, Keane-McDermott

et al. 1987, Kovner 1989, Lauer et al. 1982,

Valentine 1989, Williams 1997). More specifi-

cally, research has concluded that recovery

outcomes are enhanced when patients encounter

satisfying ‘nurse caring experiences’ (Valentine

1989).

Professional interest in nurse caring beha-

viours has existed since the Nightingale era

(Donahue 1995). However, over the last 25 years

an increasing number of nurse scholars have

focused on the phenomenon of caring and

systematic inquiries into the philosophical (Grif-

fin 1983, Leininger 1980, 1988, Roach 1987),

ethical (Fry 1988, Gadow 1985, Watson 1985),

professional (Benner & Wrubel 1989, Knowlden

1988, Weiss 1988) and clinical relevance (Larson

1984, Orem 1985) of caring have ensued. The

overall goal of nursing research on caring is to

identify and measure the impact that caring has

on patient health outcomes. More specifically,

the aims are to measure the extent to which

nursing care contributes to patient well-being,

quality of life, the recovery process and length of

hospitalization. However, research to date has

focused on identifying specific caring behaviours

from the perspective of patients and nurses,

developing a systematic classification of caring

behaviours and measuring the extent to which

patients and nurses agree on the importance of

nurse caring behaviours.

Classification of caring behaviours

Based on a review of the research literature,

‘affective’ and ‘instrumental’ categories of caring

behaviour are most frequently identified (Benner

1984, Clifford 1995, Komorita et al. 1991,

Larson 1984, Lea et al. 1998, Mayer 1986, von

Essen & Sjoden 1991a, 1991b, Watson 1985).

Both categories include two types of activities.

Affective caring behaviours include 1) those

activites which establish a relationship with the

patient based on qualities such as trust, sensitiv-

ity and empathy and 2) activities that offer

support, for example, surveillance, comfort and

privacy (Watson et al. 1979). Instrumental caring

behaviours include 1) physical activities or tasks

such as medication administration, hygiene care

and equipment management and 2) cognitive-

oriented activities such as teaching programmes,

advising and problem solving (Watson et al.

1979). To date, research findings have generally

demonstrated significant differences in patient

and nurse perceptions of nurse caring behaviour

(Kyle 1995, Larson 1984, Mayer 1986, von Essen

& Sjoden 1991a, Widmark-Petersson et al. 1998,

White 1972) This dichotomy requires further

investigation if nurse clinicians are to consider

such perceptual differences as they plan and

implement their nursing care.

Patient perceptions of caring

Research with medical, surgical, rehabilitation,

home-care and elderly patients has consistently

demonstrated that patients are most concerned

with instrumental caring behaviours (task-

oriented). Rehabilitation patients perceived

clinical expertise, for example knowing how to

administer an injection, how to manage the

equipment and when to call the doctor as the

European Journal of Oncology Nursing 4 (4),196^204

198 European Journalof Oncology Nursing

most important nurse caring behaviours (Keane-

McDermott et al. 1987). Caring by ‘doing extra

things’ was the most frequent response of a

sample of home-care patients receiving home-

visiting nurse services (Henry 1975). White

(1972) evaluated the responses of 300 hospita-

lized patients on the importance of 50 nursing

activities and concluded that patients were

primarily concerned with their physical care.

Brown (1986) asked a sample of 80 hospitalized

medical-surgical patients which nursing beha-

viours were perceived as indicators of care by the

nurse. Two response categories were identified:

what the nurse does (for example, assessment

and nursing procedures) and the nurses’ personal

and professional qualities. Brown concluded

that the affective and instrumental dimensions

of caring were equally important in this sample.

Using the Caring Assessment Instrument

(CARE-Q Instrument), which employs a Q-sort

methodology, Larson (1984) had 57 adult cancer

patients who were hospitalized in three acute

care hospitals prioritize 50 nurse-caring beha-

viours on a seven-point scale. The 10 most

important behaviours identified were again con-

cerned with the instrumental or task-oriented

aspects of care and included knowing how to

give injections, manage equipment and giving

medications on time. Mayer (1986) replicated

Larson’s study (1984) with a group of 54

oncology patients and found that patients again

selected instrumental behaviours as most indica-

tive of caring.

Scandinavian investigators (von Essen &

Sjoden 1991a, 1991b) used a Swedish version of

the CARE-Q Instrument to determine how

medical-surgical patients and nurses ranked

caring behaviours. Both studies identified sig-

nificant differences in perceptions of caring.

Again patients consistently ranked competent

clinical expertise as most important. Some

investigators have assumed that the differences

in patient and nurse perceptions resulted from

differences in the content of patients’ and nurses’

cognitive associations with caring behaviour

(von Essen & Sjoden 1991a, 1991b, Larson

1984, Mayer 1987). Recenly, Widmark-Petersson

et al. (1998) explored this possibility with a group

of cancer patients and cancer nurses. Subjects

were asked open-ended questions about their

cognitive associations with nine preselected

CARE-Q behaviours. Content analysis revealed

similar representations of the nine caring beha-

viours. However, patients described physical,

medical and technical aspects of caring to a

greater extent than nursing staff (Widmark-

Petersson et al. 1998).

Focusing on a maternity clinical population,

a sample of antepartum and postpartum patients

rated the importance of 65 caring behaviours

identified on the Caring Behaviour Assessment


instrument (CBA) (Schultz et al. 1998). Investi-

gators hypothesized that uncomplicated mater-

nity patients would focus less on the clinical

aspects of care and more on the teaching and

emotional support aspects of care. However, this

was not the case. Again, all subjects indicated

that the most important aspects of caring were

continuous monitoring of their condition and

demonstrable clinical competency.

Nurse perceptions of caring

Nurses select caring behaviours from the affec-

tive category (emotional) as the most important.

Nurses reported satisfying psychosocial

needs rather than physical care as the priority

(White 1972). Gardner and Wheelers’ (1979)

sample of 74 nurses identified three behaviours

as most caring: interest in the patient, creating an

environment where the patient is free to express

feelings and listening to the patient. Nurses

identified ‘listening’ as the single most important

caring behaviour in several studies (Ford

1981, Gardener & Wheeler 1979, Larson 1986,

Mayer 1987). Using the Care-Q Instrument

with oncology nurses, Larson (1986, 1987) and

Mayer (1986) determined that the most impor-

tant nurse caring behaviours were listening to the

patient, touching the patient in order to comfort,

allowing patients to express their feelings, being

perceptive of patients’ needs and planning for

such needs and realizing that patients know

themselves best. Swedish investigators (von

Essen & Sjoden 1991a, 1991b, Widmark-Peters-

son et al. 1998) administered a Swedish version

of the Care-Q Instrument and obtained results

similar to Larson and Mayer. As an exception to

this pattern, the Keane-McDermott et al. (1987)

study also using the Care-Q Instrument, reported

that rehabilitation nurses identified competent

clinical expertise as the most important nurse

caring behaviour. Prioritizing physical needs

before affective needs is, according to Keane-

McDermott et al. (1987), congruent with reha-

bilitative nursing philosophy. Lea et al. (1998)

conducted a large postal survey of nurses and

student nurses (n¼1452) in order to examine the

potential existence of an underlying structure of

caring. Factor analysis of data from the Caring

Dimensions Inventory resulted in the first factor

focusing on the psychosocial aspects of care and

the second on the technical. Again, this nurse

sample’s priority was the affective aspects of

care.

These studies clearly demonstrate differences

in perceptions of caring by patients and nurses.

Patients valued activities associated with being

‘cared for’. When considered in light of the fact

that patients enter the hospital to have a problem

eliminated or improved, it is not surprising

that they focus on interventions related to the


problem (Komorita et al. 1991). Nurses, on the

other hand, emphasize behaviours indicative of

the cognitive process of ‘caring about’ (Komorita

et al. 1991). When ranking behaviours, nurses

may assume a level of technical competence

as fundamental to their practice (Mayer 1986).

However, previous research that measured

nurses’ assessment of the extent to which patients

were experiencing stress, discomfort, anxiety and

depression demonstrated that nurses’ misper-

ceived and overrated patients’ emotional distress

(Farrell 1991, Holmes & Eburn 1989, Johnston

1976, Mason & Muhlenkamp 1976). Therefore,

nurses cannot assume that patients perceive

caring efforts as they are intended. To avoid

poor communication and dissatisfied patients it

is imperative that nurses validate with patients

that their care needs are being met.

Limitations of previous research

Differences in patient-nurse perceptions may be

attributable to methodological limitations; for

example, the study sample and size, the setting in

which the nurse–patient interaction takes place

and the data collection instruments. Sample sizes

in the previously described studies are generally

small. With one exception (Lea et al. 1998) all

samples had less than 110 participants

(range¼ 30–105). Perceptions of caring are

influenced by the setting in which the nurse and

patient interact (Fealy 1995, Larson 1987, Mayer

1987). Therefore, studies that drew samples from

a variety of settings (Larson 1984, 1986, von

Essen & Sjoden 1991b) may not consider the

importance of the context of the nurse–patient

interaction and the extent to which this influ-

ences perception. Moreover, combining multiple

types of patients (for example, medical, surgical

and oncology (Brown 1986, von Essen & Sjoden

1991b)) and different types of institutions (for

example, university and community hospitals

(Larson 1987, von Essen & Sjoden, 1991b)) may

contribute to perceptual differences.

In addition, data collection instruments may

limit the application of findings. Specifically,

those studies using the forced choice Q-technique

(Larson 1986, 1987, Lea & Watson 1996, Mayer

1987, von Essen & Sjoden 1991a, 1991b) may

inadvertently bias results because the technique

limits the number of responses per category

(Polit & Hungler 1995, von Essen & Sjoden

1991a, Widmark-Petersson 1998). Also those

data collected with the CBA instrument may

not distinguish between more caring and less

caring behaviour because responses tend to be

positively skewed (Schultz 1998). Finally, instru-

ments that merely request the ranking of specific

items do not provide any information on the

meaning of caring for patients (Kyle 1995, Morse

et al. 1990).

Previous research that combined multiple

types of patients, nurses and institutions demon-

strated a lack of agreement with important

caring behaviours. The current study was de-

signed to determine if patients’ and nurses’

perceptions of caring behaviours were more

concordant when the sample was selected from

one subspecialty area and one institution.

PURPOSEOF THESTUDY

This descriptive exploratory study focused on the

caring perceptions of oncology patients and

oncology nurses in a comprehensive cancer

center in northeast USA.

Specific objectives were:

1. To measure the oncology patients’ and

oncology nurses’ perceptions of nurse caring

behaviours.

2. To describe the extent to which oncology

patients and oncology nurses agree on their

perceptions of nurse caring behaviours.

3. To identify those caring behaviours on

which patients and nurses disagree.

METHODOLOGY

Design

This was a descriptive exploratory study. All

subjects completed a brief demographic form

and the self-administered Respondents Percep-

tions of Caring Scale (RPCS) that rank ordered

20 caring behaviours (Hegedus 1999, Hegedus &

Neuberg 1994).

Setting

Comprehensive cancer center in northeast USA.

Recruitment

Approval to conduct the study was obtained

from the Institutional Review Board at the

comprehensive cancer center. Participation was

voluntary and subjects were assured of confiden-

tiality. English-speaking oncology patients who

were hospitalized for cancer therapy including

chemotherapy, bone marrow transplantation,

febrile neutropenia, spinal cord compression,

dehydration and pain control were potentially

eligible to participate in this study. Each patient

was determined by their primary medical and

nursing staff to be through the acute phase of

their admission, to be clinically stable and

psychologically appropriate to participate in the

study. Patients were not receiving pharmacolo-

gical therapies in doses that impaired cognition.


200 European Journal of Oncology Nursing

In addition, patients must have had a least one

prior admission to the institution. This criteria

was included because the facility was a tertiary

cancer center and many patients, newly referred

to the institution, were unfamiliar with the daily

hospitalization routine. The investigators felt

that as a common minimum among the study

subjects, two hospitalizations would provide the

subjects with an adequate frame of reference and

interactions with the nursing staff to successfully

evaluate caring behaviours.

All English-speaking registered nurses em-

ployed on the in-patient clinical units who

worked at least 20 hours per week were eligible

to participate in the study.

Three times per week the nurse researcher

reviewed the in-patient admission list and

identified potential study subjects. Once it was

determined that the patient met the eligibility

requirements, the nurse researcher approached

the patient with an explanation of the study. The

instrument packet materials were reviewed and

written consent to participate in the research was

obtained from each patient who agreed to

complete the instrument.

Nurses were informed of the study at a staff

meeting and through a letter sent to each eligible

nurse. The letter explained the study and also

included a postcard which the nurse returned if

she/he was interested in participating. The nurse

researcher met with each interested nurse,

explained the purpose of the study and the

instrument packet materials, and obtained

written informed consent to participate in the

study.

Respondents Perceptions of CaringScale (RPCS)

Based on the literature, clinical observations and

discussions with nurses, 45 items representing

a wide range of nurse caring behaviours were

initially selected (Hegedus 1999). Ten nurses with

expertise in either the substantive area of caring

or instrument development evaluated the 45

items (Davis 1992). The content experts were

asked to assign each item to one of Benner’s

(1984) seven domains of nursing practice and

to indicate how strongly they felt this was the

appropriate domain using Gable’s (1986) scoring

procedure, 1¼ not very sure, 2¼ strongly agree,

3¼ no question about agreement.

Two criteria were used to retain items: a

minimum of 80% agreement of assignment of

items to a domain and a minimum comfort level

of 2. The final scale had 20 items that reflected

two of Benner’s domains, the helping role and

the teaching-coaching function (Hegedus 1999).

Results of the instrument pilot test are reported

separately (Hegedus 1999).


Procedure

The study packet included the following materi-

als: instructions for completing the RPCS, the 20

caring items typed on individual self-adhering

labels and three sheets of paper – one each titled

‘Most Caring’, ‘Average Caring’ and ‘Least

Caring’. The papers were divided into 20

consecutively numbered lines on which the

caring labels were placed. Information on

how to contact the nurse researcher was pro-

vided.

Previous research experiences at the facility

that required study subjects to rank order

preselected items were not successful. Investiga-

tors noted that once the first few items were

prioritized, subjects were unable to discriminate

between the remaining items. The investigators

determined that providing the subjects with a

more structured process, for example sorting

into specific subgroups then ranking within the

subgroups, was easier for the subjects to

complete (D.S. Neuberg, personal communica-

tion, September 14 1995). Pilot testing of the

RPCBS also determined that subjects had

difficulty with sorting and ranking the items

(Hegedus 1999). Based on these experiences, the

RPCS was revised to a two-step process.

First the subjects sorted the 20 items into one

of three subgroups – ‘Most Caring’, ‘Average

Caring’ and ‘Least Caring’. Then in the second

step, subjects rank ordered the items from most

to least within each subgroup. To further

facilitate the ranking process, the caring item

‘The nurse treats me as an individual’ was

selected as the starting point. During the item

selection phase of developing the instrument, the

content reviewers concurred that ‘The nurse

treats me as an individual’ was a very caring

behaviour and would serve as an appropriate

anchor against which the other caring items

could be compared (Hegedus 1999). Subjects

began by determining which of the three

subgroups they would place the item ‘The nurse

treats me as an individual’. The remaining 19

items were then sorted into the subgroups by

comparing the specific item to ‘The nurse treats

me as an individual’ and deciding if the item

was more caring, less caring, or equally as caring

as this.

After the items were sorted into the subgroups,

the subject took each subgroup and ranked the

items from most caring to least caring within that

subgroup. Once the ranking was completed the

self-adhering labels were attached to the appro-

priately designated paper so that the ‘most

caring’ item was placed in the space labeled #1,

the next item in space #2 and so forth.

The directions were reviewed with the study

subjects when the packets were distributed.

Questions were answered as needed. Two


patients and one nurse returned incomplete

packets that were not included in the analysis.

Data analysis

Overall correlation of mean rankings was deter-

mined by Spearman’s Rho. Mean rankings for

individual items were calculated using a Wilcox-

on rank sum test comparing two groups. No

correction for multiple comparisons was in-

cluded in the P-values reported.

RESULTS

A total of 44 patients completed the instrument

(26 female, 18 male). Of those patients recruited,

six refused to participate. The median age was 50

(range 22–71). Patients were being treated for a

variety of oncological malignancies and approxi-

mately one third were admitted for a bone

marrow or stem call transplantation. Forty-nine

nurses (48 female, 1 male) out of a possible total

of 78 completed the instrument (62% participa-

tion rate). The median age of the nurses was 36

(range 26–51). The median length of time work-

ing at the institution was 8.75 years (range of

6 months–19 years), indicating that the vast

majority of nurse participants were very experi-

enced in caring for oncology patients.

Overall patients’ mean rankings were highly

correlated with nurses’ rankings (r¼ 0.94,

P50.0001). Patients ranked several items as

significantly less caring than the nurses’ ranking

and several additional items as more caring than

the nurses. Specifically, the patients and nurses

assessment of 14 out of the 20 caring behaviours

were concordant (Table 1). Both groups selected

and ranked the same top five caring items – the

Table1 Mean Rank Score for Patients andNurses, and

Caring Behavior Item

The nurses treatme as an individualThe nurses speak tome in angry tonesThe nurses respectmy rightsThe nurses did not talk about howmy illnessmight a¡ectmy liThe nurses encourageme to expressmy frustration and angerWhen I’m sad and cry the nurses stay withmeThe nurses coachme through bad experiencesThe nurses comfortme by their silent presenceWhen I am fearful the nurses try to easemy fearsThe nurses do not individualizemy careThe nurses know how tomakeme laughThe nurses provide soothing reassurance through their touchThe nurses are always honest withmeThe nurses know when I need a smileThe nurses are in toomuch of a hurryThe nurses know when I need a hugThe nurses do not explain procedures to meThe nursesmakeme feel importantThe nurses did not tellmewhat to expectThe nurses do not listen to themembers ofmy family

nurses treat me as an individual, the nurses

respect my rights, the nurses are always honest

with me, when I am fearful the nurses try to ease

my fears, and the nurses coach me through bad

experiences. Of the three least caring behaviours,

both groups identified being in a hurry and

speaking in an angry tone of voice as uncaring.

Patients identified failing to listen to family

members and nurses identified failing to explain

procedures as the third least caring behaviour.

Six items had significantly different mean

rankings. Specifically, the nurses perceived re-

spect for patient rights, expression of anger and

fear, staying with a sad and crying patient, and

providing soothing reassurance through touch as

more caring behaviours than patients. Patients

did not consider the absence of a discussion of

how illness might affect their life and failure to

individualize care to be as uncaring as the nurses

reported.

Interestingly, the last seven items were the

same for both groups; however, they were not

ranked in the same order. In the nurse group 6 of

the 7 items had just about the same rank score

(range¼ 16.2–16.7), suggesting that the nurses

had a clear sense of what were not considered to

be caring behaviours. In the patient group the

rank scores were spread out. This lack of

uniformity in the patients’ scores suggested that

patients were able to discriminate between caring

items and determine that certain behaviours were

less caring than other behaviours. This lack of

uniformity may also indicate that cancer patients

and nurses have different perceptions of caring.

However, out of the seven least caring items only

two (the nurses did not talk about how my illness

might affect my life and the nurses did not

individualize my care) actually had statistically

significant different mean rankings.

P-value less than 0.05 by theWilcoxon test

Patients Nurses P-value

3.3 2.517.0 19.05.2 3.6 0.01

fe 13.9 16.2 0.0111.1 7.1 0.00019.2 6.7 0.0036.9 6.610.6 9.55.6 6.314.2 16.6 0.029.0 10.39.2 7.1 0.025.2 4.59.4 10.315.5 16.711.1 10.215.2 17.07.3 6.914.9 16.616.0 16.5


202 European Journalof Oncology Nursing

Limitations of the current study

Findings from the current study must be

considered in light of several methodological

limitations. A small convenience sample (n¼ 93)

was used. Therefore, the findings cannot be

extrapolated to other cancer patients, nurses or

cancer institutions. Also, because the sample was

small, the investigator provided each subject with

an individual explanation of the study instru-

ment directions. It must be determined whether

or not the sorting and ranking procedure can be

successfully completed without a verbal explana-

tion. Otherwise, this scale will not be feasible for

use with large samples.

DISCUSSION

The ultimate goal of nursing research on caring

is to identify and measure the impact that caring

has on patient health outcomes. The first step

towards achieving this goal is to systematically

determine the extent to which patients and

nurses agree on important nurse caring beha-

viours. The lack of perceptual agreement in

previous studies has been attributed to samples

that combined different types of patients and

different types of hospital settings and thereby

disregarded the possibility that perceptions of

caring were influenced by the context in which

the interaction occurred. Previous studies that

included some oncology patients and nurses

determined that there was no perceptual agree-

ment on caring behaviours (Larson 1987, Mayer

1986, Widmark-Petersson et al. 1998). The

current study comprising oncology patients and

nurses from one cancer institute determined that

perceptions of caring were very highly correlated

in this sample. It supports the position that

perceptions are influenced by the context of the

interaction (Fealy 1995, Larson 1984, 1987, von

Esson & Sjoden 1991b). Therefore, future caring

research must carefully select the study sample

and setting if the best measures of perceptual

agreement are to be determined.

Although there was concordance between

oncology patients’ and nurses’ views of most of

the nurse caring behaviour items, there were

some differences between the two groups. It is

important for oncology nurses to recognize that

differences exist and not to assume that nursing

efforts are always perceived as caring. For

example, in this sample, nurses and patients did

not agree on the extent to which touch as

a form of reassurance was a caring behaviour.

Nurses ranked touch as more caring than

patients. Perhaps patients do not want to be

touched or perhaps touching was merely not a

reassuring action. However, this is an interesting

patient–nurse discrepancy in light of the current


emphasis on alternative/complementary thera-

pies, many of which involve some form of touch

healing. Based on study findings, alternative

ways of providing patients with reassurance

should be identified. Oncology nurses must ask

their patients about the values they associate

with caring. Results from this study demon-

strated that these oncology patients were capable

of distinguishing between caring items and

assigning a priority ranking to the individual

items. Patients were actually more discriminating

than nurses when assigning importance to the

least caring behaviours. Of note, von Essen and

Sjoden (1991b) also found that patients were

more discriminating in their evaluation of items.

Clearly patients have beliefs and expectations

about caring which nurses need to identify.

These beliefs influence patients’ attitudes toward

nursing care and the potential benefits or out-

comes from such care. Nurses want to use their

time to best benefit the patient (Schultz et al.

1998). Clear communication will identify desired

behaviors, facilitate appropriate plans of care

and increase the likelihood that ‘patients feel

cared for’ (Widmark-Petersson et al. 1998)

Moreover, identifying agreement and disagree-

ment with specific caring behaviours provides

nurses with information on specific aspects of

their practice that should be reinforced and those

that need to be changed.

Although measuring caring behaviours can be

a challenge, it is possible. The present study

adds to our knowledge of the caring nature of

oncology nursing practice by specifically identi-

fying the most important caring behaviours. This

sample of oncology patients and nurses were in

strong agreement on priority behaviours and this

information should be incorporated into plans of

nursing care. Further evaluation of the instru-

ment using larger samples and other oncology

settings will add to our understanding of priority

caring behaviours in this particular group of

patients and nurses.

ACKNOWLEDGEMENT

Thank you to Susan M. Grant MS, RN, OCN for

supporting this research.

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Oncology patients' and oncology nurses' perceptions of nurse caring behaviours