The relationship between cancer patients' perception of nursing care and nursing attitudes towards nursing profession.

OBJECTIVE: The aim of this study is to evaluate the patients' perceptions of nursing care with different types of cancer in Turkey and its relationship with nursing attitudes towards nursing profession.
METHODS: An exploratory approach utilizing cross-sectional design with a structured questionnaire, administered to patients nurses a face-to-face, with specific questions about demographic and health status and two standardized scales: Patient Perception of Hospital Experience with Nursing Care (PPHEN) and Attitude Scale for Nursing Profession (ASNP). This study was conducted at the Research and Application Hospital of Ataturk University in Erzurum, Turkey with a convenience sample of 100 patients who were discharged from medical and radiation oncology clinics and 30 nurses that give care to these patients.
RESULTS: It was found that patients' satisfaction had low levels with nursing care and similarly the nurses' attitudes from nursing profession were negative. There was a high correlation between the scales.
CONCLUSION: The nurses' attitudes towards nursing profession are affecting the nursing care of patients' perception with cancer. We suggest that the researchers must be evaluating nurse's attitudes when they determine the patient perceptions of nursing care.

Introduction

Interest in measuring satisfaction with health care has grown considerably in recent years. Patient satisfaction has been defined as the patients’ subjective evaluation of their cognitive and emotional reactions as a result of the interaction between their expectations regarding ideal nursing care and their perceptions of the actual nursing care.[1] Patient satisfaction has also been defined as the combination of experiences, expectations and needs perceived.[2] Patient satisfaction is the most important indicator of high-quality health care and is used for the general assessment and planning of health care.[3] There is a positive correlation between patient satisfaction and nursing care whereby patient satisfaction increases in an organization where giving more attention on the individuality of nursing care is given.[1]

Theories of patient satisfaction are inadequate because much research is based on an assumption that satisfaction results from the patient's perception of the care provided, or whether the service has met his or her expectations. In the literature it is emphasized that the basis of satisfaction is widely dependent on each patient's expectation and the nurse-patient relationship.[14]

Although the USA and UK studies related to the measurement of patient satisfaction with nursing care services have been conducted extensively over the years; in Turkey and in this hospital the direct measurement of patient satisfaction with nursing care is a new phenomenon. In addition, although a review of the literature in Turkey identified several tests that measured patient satisfaction with hospitalization services, there are limited studies that measured both patients’ perceptions and nurses’ attitudes towards the nursing profession. Because patient perceptions have been extremely effected by nursing attitudes and the relationship between nurses’ attitudes and patients’ perceptions of nursing care.[56789]

A human connection between an oncology nurse and a cancer patient and the patient's family is now being identified in studies as what is most memorable about treatment and what is most sustaining to families whose family member did not survive the disease.[567] Patients and families describe oncology nurses with adjectives including kind, supportive, informative, and trustworthy. What is it about the oncology nurse and the nurse's care that is so sustaining to patients or to their survivors that it is reported as a source of comfort by patients and families for years after the actual care experienced?

There is no form of mainstream cancer treatment (chemotherapy, radiotherapy, surgery, biotherapy) and no level of cancer prevention that is unaffected by the human connection between the oncology nurse and the patient or family. Cancer treatments have focused increasingly on the important elements of the human body (i.e., genes, polymorphisms), but at the same time the usefulness of these elements in cancer treatment will be also dependent on oncology nursing care and the human connection between the oncology nurse and the patient.

To be effective, treatment needs to be acceptable, understandable, and described in a way that resonates with patients’ life priorities. The acceptability of treatment relies on the ability of the oncology nurse and that of other clinicians to make a human connection with patients such that we can prepare them well for the experience of treatment in terms of what it could mean for their lives.[10]

Although nursing is an integral part of the social system in every country, its identification with the traditional role of motherhood has made it difficult to strengthen its position as a health discipline and profession. In Turkey, with the effect of technological developments in the course of time, the nursing profession has advanced substantially. Significant steps have been taken in the name of establishing a scientific and professional stand for nursing, and these developments continue.[11]

Optimal care for patients with cancer involves the provision of effective physical and psychological care. Nurses are key providers of this care; however, the effectiveness of care is dependent on the nurses’ training, skills, attitudes, and beliefs.[12]

By using scales on profession-related attitudes, it will be possible to measure the attitudes of the candidates and members of this profession as well as of the public. Besides, if there are negative attitudes towards the profession, it might be possible to plan and apply certain education targets for changing these attitudes. By this means, candidates of nursing profession might attain positive attitudes towards the profession during their education, which in turn might contribute to the increase in the number of nurses who are devoted to and fond of their profession. This research is considered to provide a contribution also to the studies on the improvement and enhancement of the profession of nursing.

Materials and methods

Study design

This study was conducted in Erzurum, Turkey. An exploratory approach utilizing a cross-sectional survey design was used to assess the patients’ perception with nursing care among cancer patients and nurses’ attitudes towards the nursing profession in Turkey. A structured questionnaire was administered to patients and nurses face-to-face, with specific questions about demographic and health status and two standardized scales: Patient Perception of Hospital Experience with Nursing Care (PPHEN) and Attitude Scale for Nursing Profession (ASNP).

PPHEN

The scale was developed by Dozier et al at 2001 in New York, and the validation and reliability studies of the scale for Turkish were carried out by Ipek Coban and Kasikci at 2006 in Turkey.[1314] This 15-item instrument, based on Swanson-Kauffman's framework, is able to detect changes in patients’ perceptions of the quality of nursing care when provided in different institutions and when care delivery changes within the same institution of caring. PPHEN has a one-factor structure, and Cronbach's α reliability coefficient was 0.92, and item total item point correlations were between 0.36 and 0.74. In addition test–retest correlation value was 0.90. ASNP is a five-point Likert scale and the cut-off point is 45. A participant can take minimum 15 maximum 75 point of the scale. The point of 45 and above shows positive perception of the nursing care.

ASNP

The scale was developed by Ipek Coban and Kasikci at 2012 in Turkey.[15] ASNP consists of 40 items across the following three domains: Properties of nursing profession, prefer for the nursing profession, general position of nursing profession. The value of the Cronbach's alpha for the total scale was 0.91. The ASNP is determined to be quite highly valid and reliable, an adequate measuring instrument to determine attitude towards the profession. ASNP is a five-point likert scale and the items 21, 23, 25, 26, 28, 30, 34 and 38 were reverse scored. If the total score is high the positive attitude is high too. Giving 3 points or above shows positive attitude towards nursing profession.

Statistical analysis

The coding and statistical analyses of the data were performed on computer using the SPSS 10.0 packed program. Analysis of variance, Pearson correlations and Student t-test were used. P-value less than 0.05 was denoted statistically significant.

Sampling procedure and settings

This study was conducted at the Research and Application Hospital of Ataturk University in Erzurum, Turkey with a convenience sample of 100 patients who were discharged from medical and radiation oncology clinics and 30 nurses that give nursing care to the patients. Data were collected between October 1 and December 30, 2012. During the research period all of the voluntarily patients and all of the nurses who work in the oncology clinics of the hospital were included in the study. The eligibility criteria for the patient participants were:

be 18 years or older (do decide with an autonomy)

have been an inpatient for 2 weeks or more (to have time to make observations about nurses)

have been discharged from the oncology clinics

no psychiatric history. (In order to make healthy decisions)

self-reported absence of pain (to answer the questions correctly)

agree to give informed consent to be interviewed (for ethical procedures)

There were 34 nurses that work the clinics but two of them were off duty and two of them did not want to participate the study. The study was completed total 30 nurses.

Results

Sample characteristics

The characteristics of thecancer patients sample (n=100) are summarized in Table 1. In the sample, 40% were aged between 60 and above years, 56% were women. Most had graduated with anhigh school education (33%), 42% had low income level. The characteristics of the nurses sample (n=30) are summarized in Table 2. In the sample, 60% were aged between 31-41 years, 28 were women. Most had graduated with a high school education (56.6%), 23 of the nurses were married and most of them were not a member of any nursing association (76.6 %). Eighty percent of nurses preferred their job for the criteria for recruitment is they felt that finding a job is easier in nursing.

Table 1

Characteristics of participating patients (n=100)

Characteristics	n	%
Gender
Female	56	56
Male	44	44
Age, yrs
19-39	23	23
40-59	37	37
≥60	40	40
Marrital status
Married	68	68
Single	32	32
Education level
Only know reading and writing	31	31
Pirmary school	19	19
High school	33	33
University	17	17
Economic status
Low income	42	42
Middle	38	38
High income	20	20
Hospitalisation experience before
Yes	48	48
No	52	52
Having any nursing association membership
Yes	68	68
No	32	32
Total	100	100

Table 2

Characteristics of participating nurses (n=30)

Characteristics	n	%
Gender
Female	28	93.3
Male	2	6.6
Age, yrs
19-30	7	23.3
31-41	18	60.0
≥42	5	16.6
Working year
1-5 year	6	20.0
6-10 year	13	43.3
≥11 year	11	36.6
Education level
High school	17	56.6
Associate degree	4	13.3
University	7	23.3
Postgraduate	2	6.6
Marital status
Married	23	76.6
Single	7	23.3
Being member of a nursing society
Yes	6	20.0
No	24	80.0
Prefer to nursing profession*
The possibility of working a large area it is a sacred profession	12	40.0
Recruitment is easy rather than other jobs	24	80.0
Possibility of academic develpoment	7	23.3
There was no other choice	9	30.0
For my family wanted	13	43.3
Total	30	100

*There were more than one answer

ASNP and PPHEN levels

The mean scores of PPHEN were (29.3±3.1). Indicating low levels of patient satisfaction with nursing care [Table 3].

Table 3

Mean values (SD) for PPHEN (n=100)

PPHEN	Mean	SD
The nurses helped my outlook become more realistic.	1.6	0.3
The nurses thought ahead about what I needed.	2.1	0.5
My requests were promptly attended to by the nursing staff	2.0	0.4
The nurses gave me their undivided attention while caring for me.	1.9	0.4
Little things were done for me without my asking.	2.1	0.5
The nurses helped make me feel at ease in the hospital.	2.1	0.5
The nurses helped me better deal with the unknowns of this hospitalization.	2.2	0.5
I was sure that the nurses alerted others to my needs and requests.	1.8	0.4
I was sure that the nurses would be there when I needed them.	1.8	0.4
I feel the nurses understood what this illness means to me.	1.7	0.3
I know that due to the nurses’ efforts some problems were avoided.	1.9	0.4
The nursing staff helped me manage the fears I had about my illness.	2.3	0.6
The nurses’ explanations helped put me at ease.	1.7	0.3
The nurses made me feel relaxed when treatments were being done.	2.0	0.4
The nurses’ actions made me feel cared for.	2.1	0.5
Total	29.3	3.1

The mean scores of ASNP were (78.29±11.06). The subscales mean scores were; properties of nursing profession was (41.59±4.01); prefer for nursing profession was (22.52±3.94) and general position of nursing profession was (41.59±4.01). The results indicate that the nurses generally had negative attitudes towards their profession [Table 4].

Table 4

Mean Scores of ASNP (n=30)

ASNP	Mean±SD	Minimum	Maximum
Properties of nursing profession	41.59±4.01	25.00	79.00
Prefer to nursing profession	22.52±3.94	21.00	49.00
General position of nursing profession	14.18±3,11	12.00	31.00
Total	78.29±11.06	58.00	159.00

A positive, statistically significant relationship was found between the nurses’ attitudes towards the nursing profession and patient perceptions of nursing care (r =0.65, P<0.001) [Table 5]. There was a significant correlation between the subscales of the PPHEN and the ASNP. The correlation of the properties of nursing profession and ASNP was 0.43, The correlation of the prefer to nursing profession and ASNP was 0.54 and the correlation of the general position of nursing profession and ASNP was 0.63 (P<0.001).

Table 5

Correlation between PPHEN and ASNP

ASNP	PPHEN
	r	P
Properties of nursing profession	0.43	0.000*
Prefer to nursing profession	0.54	0.000*
General position of nursing profession	0.63	0.000*
Total score	0.65	0.000*

*P<0.001

Discussion

It can be said that to understand patient satisfaction with care would require focusing on nursing staff who comprise the vast majority of hospital staff and who have the greatest contact with patients. Nurses, rather than physicians, are seen as responsible for the day-to-day activities on a unit. The importance of the nursing role is evidenced in a number of studies. Caregiver/Care provider can be seen as the traditional and central role of a nurse. A nurse should have responsibility not only for the patients but also for the nurse's personal and professional development. These are; Identifies own learning needs, pursues continuing education, gets involved in professional organizations and civic activities, projects a professional image of the nurse, possesses positive attitude towards change and criticism, performs function according to professional standards.[16] A great number of studies have examined cancer patients’ perceptions of nursing care.[567171819]

All studies contributed to answering cancer patients’ experiences of nurses’ behavior. The studies have shown that the patient’ perceptions are very important for care quality.[5671719]

Some cancer patients reported experiencing a feeling of confirmation when nurses understood them and took them seriously. This was regarded as an essential part of caring and facilitated the patients’ personal growth and development.[6]

Some patients described good nurses as those who were concerned and interestedin the care and well-being of their patients. They understood details of their patients’ condition that others did not comprehend. Good nurses must be sensitive and responsive to the patients’ feelings and the nurses must understand the patients’ needs. The patients described “good nurse” as a care quality and the patients’ needs. The PPHEN include 15 items in accordance with these requirements of the patients. “Patient perception” is also an indicator of satisfaction with nursing care. In our study patients with low levels of satisfaction with nursing care.[679171819]

The study has shown that the nurses heldnegative attitudes towards their profession. Similarly Kaya and Yılmaz[20] found that only 14.3% of 282 nurses were satisfied with their job. The professional levels of nurses were found to be low in professionalism studies conducted in Turkey, and these outcomes support our study.[21222324]

Hayes and Borner[25] found that important factors of job satisfaction for nurseswere the quality of relationships with co-workers, the ability to provide quality care for patients, the relationship between the nurse and patient and no night duty.

Arikan et al.[26] reported that the factors associated with and/or accompanyingjob stress, burnout and job satisfaction were age, years of work as a nurse, hospital and unit worked in, weekly work hours, number of night duties and the number of patients cared for per day.

A positive, statistically significant relationship was found between the nurses’ attitudes towards the nursing profession and patient perceptions of nursing care (r=0.65, P<0.001) Namely; the negative attitude towards nursing profession also increases as negative patients’ perception increase. This result is not surprising for the study. Kaya and Yılmaz[20] reported that communication and empathic skills of the nurses is average and receiving opinions of patients about nursing care affects patients’ perception of nursing care. It can be said that communication and empathic skills are important factors that affected from attitudes towards nursing profession.

Nurses spend the most time with patients. Patients see nurses’ interactions with others on the care team and draw conclusions about the hospital based on their observations. Also, nurses’ attitudes toward their work, their coworkers and the organization affect patient and family judgments of all the things they do not see behind the scenes. Without a positive attitude towards the nursing profession, there cannot be patient and family satisfaction.

Conclusion

It appears that oncology nurses who work in substandard staffing units often express job dissatisfaction, stress and burnout, which prompt them to seek new employment away from the oncology specialty. Their negative attitudes towards their profession affect that the cancer patients’ perceptions of nursing care. However, studies that examined the relationship between the nursing attitudes towards their profession and patients’ perceptions of nursing care have been limited. The results suggest the need to periodically review nurses’ performance in order to evaluate their attitude toward the profession and generation of internal motivation by rewarding occupational successes. Similar studies on different sample groups may be indicated.