Factors Influencing Caring Behaviors from Nursing Students’ perspectives

Background: Caring behaviors ensure the well-being of patients and maintain their motivational stability which makes them of great importance in nursing. However, n ursing education is under great pressure to prepare students to work with vulnerable populations, so nursing educators need to be well-prepared during the educational process and need to refocus attention on caring behaviors and factors affecting them. Objective: Assessing caring behaviors and the factors influencing them from nursing students’ perspectives. Settings: The study was conducted at the Technical Nursing Police Institute in Alexandria. Subjects: Comprised of nursing students enrolled in the fourth and fifth academic year during the second semester of 2019-2020. Tools: two tools were used. Tool one: “Caring Behavior Assessment Scale (CBAS) ". Tool two: “Factors Influencing Caring Behaviors from Nursing Students’ perspectives ". Results: 66.0% of the nursing students thought that caring behaviors are highly important and 96.7% of them acknowledged the factors influencing caring behaviors. Conclusion: There is no doubt that caring behaviors are very important in the nursing profession since they are highly effective in maintaining patients' motivational balance throughout their recovery journey. However, there are numerous factors affecting them, whether positively or negatively. These factors can be hospital-related, personal, institutional, professional or patient-related and some are more influential than others. Recommendations : A study about patients’ satisfaction regarding nursing students’ caring behaviors and a workshop to educate nursing students about caring behaviors should be conducted and the present study should be replicated from patients' perspective.


Introduction
Nursing education is under great pressure to prepare students to work with vulnerable populations that face unpredictable situations.So, nurse educators need to be well prepared during the educational process to be professionals and need to re-focus attention on caring behaviors in both the classroom, clinical environment by educating students on the foundational caring behaviors in nursing by role-modeling, mentoring students to foster caring and professional behaviors in practice (Li, et al., 2016).
According to Watson (2009) theory shows that caring as the disciplinary foundation for nursing and caring science as an advanced view of nursing and human sciences.The aim of a caring sciencecentered curriculum is to give nursing students an overall view of caring science, so that nursing students will be able to care individual's health as professional nurses .On the other hand, nursing students should be able to create an atmosphere that supports the patients' sense of well-being and conveys to patients a feeling of being cared for (Bergen, & Barber, 2019).Thus, the main goal of nursing education is to nurture nursing students with the knowledge and skills required to care for patient (Li, et al., 2016).
Caring has been described as the moral ideal of nursing and the heart of nursing.Moreover, caring is the major intellectual, theoretical, heuristic, and core to the practice of the nursing profession.Despite the lack of a universal definition for caring, it is known that in consist of two major elements of instrumental and expressive behaviors (Shalaby, Janbi, Mohammed,& Al-harthi, 2018).The instrumental caring behaviors consist of the technical and physical behaviors, and the expressive caring behaviors include the psychosocial and emotional behaviors (Nursalam, Wijaya, Bakar, & Efendi, 2015).
The caring behaviors include a wide variety of features and actions and these may be words, thoughts, feelings, looks, actions, movement, body language, touch, procedures and/or information.Caring behaviors is not so much to cure the patient as to maintain his motivational balance while nurse is undergoing the technical procedures necessary to get him well.It is not something that nurses do when they have a few extra minutes but rather is a consistent commitment to a holistic approach to patient care (Udomluck, et al. 2012).Therefore, nurses who learn to integrate these components into an intuitive whole and meet both the physical and psychological needs of their patients are the expert nurses who exemplify the goal, values, and beliefs of the profession.In order to achieve professional excellence in nursing; affective objectives should receive more attention educationally to help nursing students to receive not only training on many technical skills, but also on empathy or being sensitive to patient's feeling (Mostafa, 2014).Also, the clinical training exposes students to real life situation related to patients care besides a nurse who may be a good role model for nursing caring behaviors or a nurse who disrupts these caring behaviors.Subsequently, nursing students may find themselves still effort with which caring behaviors to rank in their practice and how to apply these caring behaviors in the nursing practice (Labrague, et al., 2017 ;Kiblasan, 2020).In addition, the information obtained from the nursing students' perception of care and caring behaviors will help to enhance the knowledge and understanding of the phenomenon of caring in the educational settings.(Zamanzadeh, et al., 2014).On the other hand, knowing the factors that may affect nursing students caring behaviors are very important to inform nursing educators and nursing managers about the areas of improvement, these factors are; education, culture and achieving clinical experiences (Oluma, & Abadiga, 2020).
In Egypt, there is a few research done about the nursing caring behaviors and the factors affecting its.Taking it into consideration, and adding to it the importance of assessing nursing students' perspective about the importance of nursing caring behaviors, and how this caring affect behavior is a critical component of humanistic nursing care.Also, the enhancement of these caring behaviors in nursing students and using them in nursing practice will lead to the improvement in the quality of patients care.Hence in nursing education, a better understanding of undergraduate nursing students' perspective about the importance of nursing caring behaviors and the factors influencing its will be important to inform nursing educators about areas of improvement.

Aims of the Study
This study aims to assess caring behaviors and the factors influencing them from nursing students' perspectives.

Method
Permission to conduct the study was obtained from the Research Ethics Committee at the Faculty of Nursing, Alexandria University, dean of the Faculty of Nursing, Alexandria University, and head of Police Technical Nursing Institute.Content validity for the tools was tested by 5 experts in the field of Nursing Education and Critical Care Nursing then the necessary modifications were accordingly made.The reliability of the tools was tested using Cronbach's Alpha.The Tool I and tool II were reliable and the coefficient values were (0. 939, 0. 940s) respectively.A pilot study was carried out on 10% of the sample size of nursing students to test the clarity, feasibility and applicability of the study tools.Those students were excluded from the study.Data was collected over a period of two months starting from the end of March, 2020 till the end of July, 2020.The researchers interviewed the study subjects to collect the necessary data and distributed the study tools at the clinical areas and classrooms after explaining the aim of the study.All the nursing students were given the same instructions by the researchers about how to fill the questionnaire.Each study subject needed about 15-20 minutes to complete the study tools.

Ethical considerations:
Written informed consent was obtained from nursing students after giving an explanation about the aim of the study.Participants' confidentiality of the collected data was ensured.The researchers emphasized that participation in the study is entirely voluntary as well as withdrawal from the study at any time.

Statistical Analysis
The collected data were coded and entered in special format to be suitable for computer feeding.Following data entry, checking and verification process were carried out in order to avoid any errors.Data were analyzed using the statistical package for social science SPSS (version 20).Statistical analysis tests, which included: Chi square, student T test and paired T test.Graphical presentation included: Bar graphs were done for data visualization.

Results
Table 1 shows the distribution of the nursing students according to their demographic characteristics.It can be observed that 84.0 % of the nursing students were more than19 years-old.As regards to sex, it can be noticed that more than two thirds of nursing students were females.In regards to the academic year, there was equal percentile distribution of the nursing students for fourth and fifth level.According to average success rate in the past academic year, it was found that almost all nursing students (98.0%) achieved success rate equal or more than 80%.It was observed from this table that more than two thirds (74.0%) of the nursing students did not attend any previous courses about caring behaviors while almost all (96.7%) of nursing students received previous hospital training.Concerning duration of hospital training period, more than three quarters (80 %) of the student received a training period more than 12 months.
Table 2 illustrates the distribution of caring behaviors levels according to nursing students' perspectives.The majority of the nursing students reported that human needs assistance, expression feelings, spiritual forces, humanism and supportive environment caring behaviors were highly important as represented by (82.0%, 79.3%,75.3%,74.0%,69.3%)respectively.
Table 3 shows the distribution of factors influencing nursing students' caring behaviors from their perspectives.As regards to personal factors, it was observed that the majority of nursing students strongly agreed that the presence of professional conscience, interest and respect to nursing profession and sense of responsibility toward the patients were factors that affect nursing students caring behaviors as represented by (94.7%, 89.3%, 86.7%), respectively.In relation to professional factors, it was observed that more than two thirds of nursing students had strongly agreed that the presence of enough professional knowledge to demonstrate caring behaviors and the presence of new technical skills to apply caring behaviors were the most important factors as represented by (72.0%, 68.0%), respectively.As for institutional factors, the majority of nursing students strongly agreed that competency and qualification of nurse educators, presence of respectful relationships between students and educators and presence of enough clinical training settings were among the most vital factors that affect nursing students' caring behaviors as represented by (80.0%, 79.3% 78.7%), respectively.Concerning hospital-related factors, more than two thirds of nursing students strongly agreed that presence of resources and comfortable learning environments and support from hospital administrators were factors that affect nursing students caring behaviors as represented by (80.7%, 76.0% 72.0%), respectively.Regarding Patients-related factors, it was observed that more than two thirds of nursing students agreed that the patients' level of consciousness and their interaction, patients' reaction /response affect communication with them in caring behaviors, and presence of cultural differences of the patient were factors that affect nursing students caring behaviors as represented by (78.7%, 75.3% 74.7%) respectively.

Figure 1
demonstrates the distribution of factors influencing nursing students' caring behaviors total percentage score.The majority of the nursing students reported that hospital-related factors, personal factors, institutional factors and professional-related factors had high effect on caring behaviors as represented by (98.0%, 97.3%, 95.3%, 89.3%), respectively.
Moreover, more than half of the nursing students (62.0%) emphasized that the patient-related factors highly affected caring behaviors, while more than one third of them (36.7%) reported that it had moderate effect.
Table 4 shows the relation between caring behaviors dimensions and factors influencing them.It can be noticed that there is a high statistically significant relation between nursing students' caring behaviors levels and the professional-related factors as well as patients' related factors as represented by (0.002, 0.000), respectively.On the other hand, there is no statistically significant relation between nursing students' caring behaviors levels and personal, institutional and hospital-related factors as represented by (0.494, 0.186, 0 . 333), respectively.Generally, there is no statistically significant relation between nursing students' caring behaviors levels and the total factors influencing them (0.212).

Discussion
Caring behaviors are very important for nurses and patients and their families as they increase patient satisfaction for patients as well as nurses who meet both the physical and psychological needs of their patients (Khresheh, & Barclay, 2019).Nurse caring behaviors are the most essential part in health care services since they build up trustable and close relationships between the patients and care providers.They are very necessary in enhancing the human life and are considered as a basic key factor in the provision of healthcare facilities to the patients.Nurses' caring behaviors include showing respect for the patients, providing feelings of security, minimizing anxiety and maintaining positive and good communication (Abdullah, et al., 2017).
The main findings of the current study revealed that human needs assistance was the most important caring behavior, according to nursing students.This result may attributed to the technical aspect of nurses' tasks, since nursing students must be skillful in handling injections, drugs and infusions and must feel confident when performing their duties.These findings are consistent with Pajnkihar et al. ( 2017) who emphasized that the human needs assistance is a highly important caring behavior as perceived by nurses.As regards to expression of feelings, it was the second highest important subscale, as perceived by nursing students.This may be due to the awareness of students with the needs of patient for emotional and psychological support, because the critical nature of illnesses makes patients more susceptible to psychological distress and problems such as anxiety, depression and mood swings, which may lead to more deterioration of their health.These results are in line with Papastavrou, et al., (2011) who found that nurses perceive their psychological skills and expressive or affective caring behaviors as more important.On the other hand, Oluma, & Abadiga, (2020) found that nurses perceived concrete observable aspects of caring behaviors as more vital than expressive caring behavior.
Moreover, the spiritual forces dimension was found to be highly important to nursing students.These results may be because spirituality can help patients in the recovery process by facilitating their autonomy and assisting them to live and grow beyond the limitations imposed by their illnesses.This is consistent with Hellman, et al., (2015) Mamier, et al., (2018) who found that 80% of nurses asserted that they could attend to patients' spirituality during taking care of their physical needs.Elbahnasawy, et al., (2018) also found that nurses even perceived spiritual forces as the most important amongst caring behaviors.Regarding the humanism dimension, the majority of the nursing students emphasized that it is an essential caring behavior.
Similarly, O'Connell and Landers (2008) conducted a study in which the nursing students had the same view on the dimension.One probable cause for the similarity is that caring originates in nurse's feelings of sensitivity and empathy and that critical care nurses are committed to providing individualized and holistic care to their patients.It was also found that more than two thirds of nursing students viewed the supportive environment dimension as a necessary caring behavior.Nursing students' awareness to the vulnerable nature of the critically ill patients and the importance of maintaining patients' safety and protection in highly sophisticated, hostile and stressful ICU environment may be a justification to these results.Consistently, the study of Shalaby, et al., (2018) revealed that this dimension is highly prioritized by nurses.
The teaching/learning dimension was found to be of moderate importance to more than two thirds of the nursing students.Educating patients about their conditions can help them cope better and be more at ease and comfortable, but this might not happen sometimes.The results of this study were in disagreement with the results reached by Omari, et al., (2013) who found that the only subscales perceived as strongly important was teaching/learning.The helping/trusting dimension was also of moderate importance, according to more than two thirds of the students.Even though earning patients' trust can make their recovery smoother, relationships between nurses and patients are temporary and only for therapeutic purposes, so there is no need to build personal relations with patients.This makes the fact that this dimension is not of the top priorities more explainable.However, Crafford, (2014) found that the majority of nursing students considered helping/trusting to be strongly important.
In the present study, the students agreed that there are many factors influencing caring behaviors.It was observed that they thought the most influential factors were the hospitalrelated ones, followed by personal then institutional then professional and, lastly, patient-related factors.
Hospital-related factors were ranked as the most influencing factors: the majority of the nursing students strongly agreed that providing comfortable and safe learning environment were factors that affect nursing students caring behaviors.These results may be due to the fact that providing comfortable learning environments can improve their learning, increase their confidence and make them more eager and motivated to be part of the profession which can lead them to take better care of patients.This was in line with Parchebafieh, et al., (2020) who showed that spontaneous learning in nursing students was enhanced by providing safety and comfort to the clinical environment by instructors.
Personal factors were ranked as the second most influencing.Most of the nursing students strongly agreed that interest and respect to nursing profession is among the factors that affect nursing students' caring behaviors.The individuals' interest or respect for their jobs can heavily impact their performance, and, in nurses' case, it can affect their caring behaviors, improving the quality of care.This was supported with the study of Salimi, (2021) in which the nurses claimed that their interest and respect to their profession are major factors affecting their caring behaviors.
Institutional factors were ranked as the third most influencing factors; it was observed that more than two thirds of the nursing students had strongly agreed that the presence of respectful relationships between students and educators is a factor that can affect nursing students' caring behaviors.
Respectful relationships between students and educators help students become caring individuals, making nursing education ideal to develop, enhance and promote students' caring behaviors, increase confidence and motivation in student nurses and help them learn to care for patients.These findings were supported by Labrague et al. (2015) who found that instructors' caring behaviors had a positive impact on students' caring behaviors.
Professional-related factors were ranked as the fourth most influencing factors.It was found that more than two thirds of the nursing students had agreed that empowerment to make decisions can heavily affect their caring behaviors.Similarly, Perry, et al., (2 018) stated that students often feel appreciated, respected and trusted with permission from their educators to make independent decisions.They feel more responsible with their skills and that improves their caring behaviors as they feel the need to meet their teachers' expectations.
Patient-related factors were ranked as the fifth most influencing factors, in which more than two thirds of nursing students had agreed that the patients' level of consciousness and their interactions, patients' reaction /response affect communication with them in caring behaviors were factors that affect nursing students caring behaviors.This result may be attributed to that the way nurses behave during the interaction matters a lot in gaining patients' (and families) participation in the care process.In the same way, the manners in which patients and family respond to this interaction affect nurses' behavior.This result was consistent with Kuntarti, et al., (2018) who found nursing students stated that although the patients did not directly teach about caring, the patients' responses after the nursing students gave care made up the feedback on the students' caring.
Relation between caring behaviors dimension and factors influencing it, it can be noticed that there is a statistically significant correlation between nursing students' caring levels and their professional, patients' related factors in favor of high effect.This finding due to professional, patients' related factors are engaged in could have an impact on work outcomes.This result was consistent with Shalaby, et al., (2018) who stated that there was a statistical significant positive relationship between nurses' perception caring behaviors and their work circumstances, workload, job satisfaction, educational background and patient characteristics.Also, there is no a statistically significant correlation between nursing students' caring levels, their institutional factors, personal and hospital related factors.This result contraindicated with, Oluma, & Abadiga, (2020) who asserted that was significant correlation between caring behaviors and factors influencing such as nurse's characteristics, job satisfaction, interdisciplinary, organizational factors, and Workload and intention to leave.On the other hand, Syahridhaa, et al., (2015) who found that there is a significant relationship between individual factors, psychological factors and organizational factors with six dimensions of caring behaviors.

Conclusion
There is no doubt that caring behaviors are very important in the nursing profession since they are highly effective in maintaining patients' motivational balance throughout their recovery journey.However, there are numerous factors affecting them, whether positively or negatively.These factors can be hospital-related, personal, institutional, professional or patient-related and some are more influential than others.

Recommendations
In line with the findings of the study, the following recommendations are made:

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Conduction of a study about patients' satisfaction regarding nursing students' caring behaviors.

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Replication of the study from the patients' perspective.

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Conduction of a workshop to educate nursing students about caring behaviors.