Introduction
Caring is an intricate interpersonal process that takes place between a nurse and a patient [1‐3]. It is demonstrated through nurse caring behaviors, which are actions and conducts that professional nurses exhibit when establishing a relationship of respect, concern, and support with their patients [4]. The impact of caring extends to benefit nurses and patients in terms of fulfillment of needs, such as physical and emotional well-being, and plays a role in future experiences. Therefore, it is essential for nurses to prioritize behaviors that convey care as a fundamental aspect of nursing practice [2, 5]. Caring behaviors enable nurses to establish connections with patients, make informed decisions that enhance patient safety and well-being, and ensure the continuity of holistic nursing [5, 6].
Nurses and patients often perceive caring behaviors differently [7‐9], with nurses reporting more frequent instances of specific caring behaviors than patients acknowledge [10, 11]. Studies suggest that patients place greater importance on physical-based care, while nurses view expressive caring as more significant [11, 12]. This discrepancy in perception can have important implications for patient care and outcomes. It highlights the need for effective communication and understanding between nurses and patients to ensure quality healthcare delivery [11]. The caring behaviors inventory (CBI) has yielded varying mean scores in studies, ranging from 3.37 [13] to 5.28 [7]. High-quality nursing care is thought to be customized to meet the unique needs, beliefs, expectations, and individuality of each patient [9]. To achieve this customized care, nurses must cultivate emotional capacity [14].
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Nurses’ perceptions and expressions of caring behaviors are shaped by a complex interaction of factors, influenced by the specific cultural and organizational contexts in which they work. This highlights the complex nature of nursing practice and underscores the significance of caring behaviors within the profession. Understanding how nurses perceive and exhibit caring, along with the factors that influence these views, is crucial for enhancing patient care and achieving positive outcomes [9, 15].
Several factors contribute to nurses’ perceptions of caring, including their relationships with patients, doctors, and colleagues [6, 16, 17], the quality of the work environment [2], and issues related to staffing, workload, and working hours [16, 18‐20]. Resource availability, job satisfaction, and support from management also play significant roles [16, 17, 21, 22]. Additionally, personal characteristics such as sex, age, experience [9, 18, 19], and work-related stress [2, 23] can impact how nurses perceive and enact caring behaviors. When nurses feel limited in their ability to demonstrate caring behaviors, it can lead to feelings of inefficiency and inadequacy in providing care [24]. However, to deliver truly holistic care that addresses patients’ physical, emotional, social, and spiritual needs, nurses must possess a high level of professionalism and moral integrity [25].
In Ethiopia, the caring culture has traditionally been influenced by a task-oriented approach, where caring is viewed as simply completing a task. Emphasizing authentic care over mere task completion is crucial for improving patient satisfaction, safety, and health outcomes [2]. Studies have shown that work-related factors can impact the provision of patient-centered care [17, 22]. Despite this, our understanding of nurses’ perceptions of caring behaviors and the factors that shape these perceptions is limited, particularly in low-income countries such as Ethiopia. Investigating medical-surgical nurses’ perceptions of caring behaviors using quantitative and qualitative methods could provide valuable insights into how nurses recognize patients’ care needs and improve the provision of care and the overall patient experience [26, 27]. Medical-surgical units typically comprise a combination of experienced and novice nurses, along with a large number of patients who have diverse needs and conditions. This creates a favorable setting for observing and analyzing a wide range of caring behaviors in practice. Therefore, this study aims to examine medical-surgical nurses’ perceptions of caring behaviors and achieve a more comprehensive understanding of the factors influencing these perceptions within the study context using a mixed-methods design. The qualitative data were utilized to complement and explain the quantitative findings.
Methods and materials
Study design and setting
A sequential explanatory mixed-methods study [28] was carried out at three referral hospitals in the Amhara Regional State, Ethiopia, including the University of Gondar Comprehensive Specialized Hospital (UOGCSH), Debre Markos Referral Hospital, and Debre Birhan Referral Hospital. Initially, we collected self-reported data using the Amharic version of the Caring Behaviors Inventory-16 (CBI-16) [29]. Subsequently, we conducted qualitative interviews aimed at complementing and explaining the quantitative findings, integrating the data through a connecting approach [30, 31]. The qualitative findings were used to explain and provide further insight on the quantitative results. Data were collected over three months from January to March 2022. The results are reported in accordance with the Good Reporting of a Mixed Methods Study (GRAMMS) checklist [32].
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Study participants
The quantitative component of the study involved surveying nurses with a Bachelor of Science (BSc) degree or higher, working in the internal medicine and surgical departments of the referral hospitals (N = 148). A census approach was employed, ensuring that all eligible nurses in these departments are included.
In the qualitative phase, fifteen nurses were initially selected from the survey respondents, with five nurses selected from each hospital. However, three of the selected nurses were unable to attend the interviews due to a high workload, resulting in a final qualitative sample size of twelve nurses. Demographic data from the quantitative phase were used to purposively select a diverse group of nurses, ensuring the inclusion of both male and female nurses with various educational backgrounds and different levels of experience in nursing, through maximum variation purposive sampling [33].
Data collection tools and procedure
Data collection tools
A structured self-administered survey package was used to collect sociodemographic data (such as age, sex, marital status, level of education, and years of experience in nursing), the CBI-16, and study-specific items that pertained to perceived management support, nurse-to-nurse relationships, nurse-doctor relationships, work-related stress, and job satisfaction (see Supplementary Material 1).
Caring behaviors Inventory-16
The CBI-16 is one of the most frequently used instruments designed to assess nurses’ perceptions of caring behaviors [6]. This 16-item, six-point Likert-type scale is grounded in Watson’s theory of human caring, which emphasizes the importance of the nurse-patient relationship and the role of compassion, empathy, and presence in delivering quality care [26, 34]. Respondents rate their agreement with statements related to caring behaviors. A higher mean score on the CBI-16 indicates a higher level of perceived caring behaviors among nurses. This suggests that nurses with higher CBI-16 scores are more likely to perceive themselves as engaging in caring behaviors, such as providing emotional support, demonstrating empathy, and fostering a sense of connection with their patients. The CBI-16 has proven to be a reliable and valid tool for measuring nurses’ perceptions of caring behaviors, making it valuable for research and practice settings [26].
Nurse-to-nurse relationship and management support
The study assessed the nurses’ perceptions of their professional relationships with colleagues and their satisfaction with hospital management through a single question that offered binary response options: Good/Not good and Yes/No, respectively.
Nurse-doctor relationship
The professional relationship between nurses and doctors was assessed using the six-item Nurse-Doctor Relationship Scale (NDRS). The scale employs a four-point Likert-type scale (1 = never to 4 = very frequently) and scores above the mean suggest that nurses experience a high frequency of conflict [35].
Work-related stress
Work-related stress occurs when individuals encounter work demands and pressures that do not align with their knowledge and abilities, thereby challenging their coping abilities. In this context, perceived work-related stress was assessed using the 15-item Occupational Stress Scale (OSS). This scale employs a three-point Likert-type ranging from low stress [1] to extreme stress [4]. Response scores between 1 and 1.99 indicate low stress, scores between 2 and 2.99 indicate moderate stress, and a score of 3 signifies high stress [36].
Job satisfaction
Job satisfaction refers to the level of contentment experienced in work. Nurses’ job satisfaction was assessed using the Job Satisfaction Scale (JSS), which employs a four-point Likert-type scale ranging from 1 (completely disagree) to 4 (completely agree). To determine job satisfaction, the mean score of the eight items was calculated. A score equal to or above the mean indicates satisfaction, while a score below the mean signifies dissatisfaction [37, 38].
Interviews
Semi-structured open-ended questions derived from the literature [39‐41], taking into account the findings from the quantitative analysis, were used to collect qualitative data. These questions were used in conjunction with follow-up questions during face-to-face interviews (see Additional file 1). To evaluate adequacy, appropriateness, and to further refine the interview questions, a pilot interview was conducted with a nurse [42]. Interviews were conducted in Amharic language and recorded with the participants’ permission using a digital voice recorder. Data collection ceased after the twelfth interview, as the information gathered was deemed sufficient to answer the research questions (information power) [43].
Data collection procedure
Initially, quantitative data were collected through a structured, self-administered survey package. After analyzing this data, the findings guided the collection of the qualitative data. The qualitative insights were then used to explain or expand upon the quantitative results, providing a deeper and more detailed understanding of nurses’ perceptions of caring behaviors [30, 31].
Data quality control
To ensure data quality, a pretest was conducted among 15 nurses (10% of the sample). The questionnaires were coded prior to data collection, and cross-checking was performed to verify consistency and completeness of the returned questionnaires. Internal consistency reliability of the instruments was assessed using Cronbach’s α, with values between 0.70 and 0.90 considered good [44]. The Cronbach’s alpha values were α = 0.89 for the CBI–16, α = 0.82 for the OSS, and α = 0.77 for the NDR. Additionally, the variance inflation factor (VIF) was calculated and found to be 1.18.
Trustworthiness
Trustworthiness of the study was ensured through author dialogues during the proposal, interview, and analysis phase. Themes were shaped through close collaboration between two team researchers (AJF, MHS). These themes were then enhanced and refined through discussions with seasoned academic researchers who possess substantial expertise in both quantitative and qualitative research (KE, LW, BG, LDG). Additionally, the study incorporates direct quotes from interviews with nurses, which are relevant to the findings.
Data management and analysis
Stata-16 was used to conduct the statistical analysis [45]. Descriptive statistics were computed to summarize socio-demographic characteristics, including frequencies, percentages, means, standard deviations (SDs), medians, and ranges. Additionally, we assessed assumptions for parametric testing, such as linearity, normality, homoscedasticity, multicollinearity, and undue influence of outliers. Subsequently, we employed a multiple linear regression model to explore the relationship between nurses’ perceptions of caring behaviors and associated factors. Furthermore, we conducted a two-sample t-test to compare perception scores related to resource availability for provision of care. The significance level was set at p < 0.05, and model fitness indices were calculated along with a 95% confidence interval (CI).
Following the transcription of the interviews, the verbatim transcripts were cross-referenced with the audio recordings and subsequently translated into English by the principal investigator. To ensure consistency and accuracy, the English transcript was then blindly back-translated to Amharic by a bilingual nurse researcher [46]. The transcripts were meticulously reviewed multiple times by two investigators (AJF, MHS) to become fully immersed in the data.
A codebook thematic analysis, guided by the recommendations of Braun and Clarke, was then employed to deductively identify meaningful patterns [47]. This approach is one of several variations of thematic analysis designed to uncover patterns of meaning within a qualitative dataset, as categorized by Braun and Clarke into ‘coding reliability,’ ‘codebook,’ and ‘reflexive’ approaches.
In the quantitative analysis, factors such as sex, nurses’ age, nurse-to-patient ratio, work-related stress, job satisfaction, and perceived availability of resources were found to be associated with the overall perception scores of nurses. These quantitative findings were then utilized to create a structured coding framework for developing and documenting the qualitative analysis.
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The themes were systematically developed through a process of coding and theme refinement, which was conducted in accordance with the results of the quantitative analysis. Additionally, these evolving themes underwent further discussion and refinement in collaboration with senior academic researchers who possess extensive expertise in both quantitative and qualitative research methodologies (Table 1). Finally, the narrative was structured according to the research objectives, and the qualitative findings were triangulated with quantitative results during the interpretation phase of the mixed-methods analysis.
Table 1
Code and theme development
Codebook Development | ||||
|---|---|---|---|---|
Initial Themes | Codes | Final Themes | Theme Definitions | Quotes |
Nurses’ demographics (gender, age) | Nursing care is very important to the patient | Caring is universal and fundamental in nursing | Caring is the foundation upon which nursing actions are built. | “The most important caring behavior, I think, is being compassion; I think it is very important for the nurse to be polite, that being knowledgeable is very important.” |
I think the nurse-patient relationship should be given priority | ||||
Caring is most important thing for me | ||||
Providing immediate response | ||||
Work-related factors (nurse-to-patient ratio, work-related stress, job satisfaction) | Overlapping tasks | Impediments to provision of comprehensive care | Any barriers that hinder nurses from providing a comprehensive and holistic array of services to patients. | “Working without gloves increase contamination, hospital being uncomfortable and as a result I do not think the right care is provided.” |
Resource scarcity | ||||
Management decisions | ||||
Insufficient resources | ||||
I provided proper care only once | ||||
Imbalanced nurse-to-patient ratio | ||||
Relationship with colleagues | ||||
Conflict with doctors | ||||
Resources (perceived availability of resources) | Work-related stress | Perceptions of the work conditions | Views and experience of nurses on their workplace. | “There is shortage of the necessary supplies, for example, screen for keeping patient’s privacy. This can help you do better.” |
Communication | ||||
Collaboration | ||||
Job satisfaction | ||||
Recognition | ||||
Results
The initial presentation focuses on quantitative results, obtained from the multiple linear regression analysis. Subsequently, we delve into the qualitative findings in detail, followed by an explanation of the mixed methods employed.
Quantitative findings
Demographic characteristics of study participants
In this study, 156 questionnaires were distributed to nurse respondents, of which 148 were completed and returned, resulting in a response rate of 94.9%. More than half (51.4%) of the respondents were male, and the mean (± SD) age was 31.6 years (± 5.8). 67.6% of the respondents were married, 91.9% held a bachelor’s degree in nursing. The median salary reported was 7071 Ethiopian Birr. 96.0% were staff nurses and 71.0% provided care for 6–8 patients. 73.7% reported having a good relationship with colleagues, 54.0% experienced lower frequency of conflict with doctors, and 56.1% expressed satisfaction with their jobs (Table 2).
Table 2
Characteristics of the study participants
Characteristics | Quantitative sample (N = 148) | Qualitative sample (N = 12) |
|---|---|---|
n(%) | n | |
Sex | ||
Male | 76 (51.4) | 6 |
Female | 72 (48.6) | 6 |
Age in years | ||
≤ 29 | Mean 31.6 (SD = 5.8) | 5 |
30–39 | (Min = 24, Max = 58) | 5 |
≥ 40 | 2 | |
Marital status | ||
Married | 100 (67.6) | 7 |
Single | 48 (32.4) | 5 |
Level of education | ||
BSc | 136 (91.9) | 7 |
MSc | 12 (8.1) | 5 |
Working unit | ||
Internal medicine | 65 (43.9) | 6 |
Surgery | 83 (56.1) | 6 |
Work experience in years | ||
≤ 5 | Median 6.5 (2–36) | 3 |
6–10 | 6 | |
≥ 10 | 3 | |
Shift nurse usually works | ||
All shift | 120 (81.1) | |
Day | 28 (18.9) | |
Extra work hour per month | Median 30 (10–80) | |
Nurse staffing | ||
≤ 5 | 29 (19.6) | |
6–8 | 105 (70.9) | |
≥ 10 | 14 (9.5) | |
Resource availability | ||
Yes | 39 (26.4) | |
No | 109 (73.6) | |
Management support | ||
Yes | 49 (33.1) | |
No | 99 (66.9) | |
Nurse-nurse relationship | ||
Good | 109 (73.6) | |
Not good | 39 (26.4) | |
Nurse-doctor relationship | ||
Low conflict | 80 (54.1) | |
High conflict | 68 (45.9) | |
Work-related stress | ||
Low stress | 79 (53.4) | |
Moderate stress | 69 (46.6) | |
Job satisfaction | ||
Satisfied | 83 (56.1) | |
Dissatisfied | 65 (43.9) |
Nurses’ perceptions of caring behaviors and associated factors
The overall mean (95% CI) score for nurses’ perceptions of caring behaviors was 4.75 (ranging from 4.65 to 4.86). The multiple linear regression analysis revealed that sex, age, nurse staffing, work-related stress, and job satisfaction were associated with nurses’ perceptions of caring behaviors. Furthermore, the multiple linear regression model explained 30% of the variability in nurses’ perceptions of caring behaviors; F(10, 137) = 5.92 P < 0.001 (as shown in Table 3).
Table 3
Estimated coefficients, confidence interval, and p-value for multiple linear regression analysis (n = 148)
Caring Behaviors Inventory-16 | Unstandardized Coefficients | 95% CI | P-value |
|---|---|---|---|
Sex Male Female | 1.00 0.300 | 0.098, 0.501 | 0.004* |
Age | 0.028 | 0.011, 0.045 | 0.001* |
Marital status Married Single | 1.00 0.211 | –0.003, 0.425 | 0.053 |
Extra work hour per month | 0.006 | –0.001, 0.013 | 0.075 |
Nurse to patient ratio | –0.115 | –0.184, − 0.047 | 0.001* |
Management support No Yes | 1.00 0.104 | –0.100, 0.308 | 0.315 |
Nurse-nurse relationship Good Not good | 1.00 –0.192 | –0.427, 0.042 | 0.107 |
Nurse-doctor relationship Low conflict High conflict | 1.00 0.174 | –0.021, 0.370 | 0.081 |
Work-related stress Low stress Moderate stress | 1.00 0.298 | 0.100, 0.495 | 0.003* |
Job satisfaction Satisfied Dissatisfied | 1.00 –0.254 | –0.460, − 0.048 | 0.016* |
Female nurses scored 0.30 units higher on the CBI-16 scores compared to male nurses. Additionally, for every unit increase in nurses’ age, the mean score of nurses’ perceptions of caring behaviors increased by 0.03 units. Furthermore, nurses’ perceptions of caring behaviors varied based on the number of patients they cared for. Specifically, for each unit increase in the number of patients, there was a predicted decrease of -0.12 units in the mean score of nurses’ perceptions of caring behaviors. Interestingly, work-related stress was correlated with nurses’ total perception scores; nurses experiencing moderate stress were more likely to yield higher scores. Nurses who reported job satisfaction were predicted to score 0.25 units higher on mean score than those who were not satisfied with their jobs.
A two-sample t-test was performed to compare perception scores between nurses who believed that resources were available in hospitals for holistic care and those who perceived resources as unavailable. The results revealed a significant difference in perceptions of caring behaviors between nurses who perceived resources to be available (M = 4.93, SD = 0.58) and those who perceived them as unavailable (M = 4.69, SD = 0.66); (t = -2.19, p = 0.03).
Qualitative findings
Twelve nurses participated in semi-structured interviews to explore their perceptions of caring behaviors. Seven participants held a bachelor’s degree in nursing, with experience ranging from two to 31 years (Table 2). The codebook thematic analysis of the transcribed data revealed three themes: caring is universal and fundamental in nursing, impediments to provision of comprehensive care, and perceptions of the work conditions.
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Caring is universal and fundamental in nursing
Participants characterized nursing as a profession deeply rooted in the core principle of caring for others. They emphasized that caring lies at the heart of the nursing discipline, serving as a fundamental and universal guiding force. The nurses spoke passionately about their role as caregivers, highlighting the central focus on providing patient-centered care and ensuring patient safety as the primary objectives of their practice.
“Nursing involves caring for others. Nurses provide comprehensive care to patients, which encompasses multi-faceted nursing care such as administering medications, positioning, feeding, educating, counselling, and bathing.” (Participant 1).
The participants emphasized the critical importance of delivering comprehensive, individualized care tailored to each patient’s unique needs. They described nursing as a holistic endeavor aimed at addressing the multifaceted physical, emotional, and psychosocial needs of patients. Through their care-oriented interventions, the nurses sought to provide comfort, alleviate suffering, and enhance the overall health and well-being of those in their care. Additionally, the interviewed nurses highlighted that caring is integral to nursing practice and extends to other fields prioritizing human welfare.
“Caring is a concept that plays a central role in nursing, although it is also embraced by other professions that focus on human welfare.” (Participant 10).
The nurses demonstrated a strong commitment to their caring roles, expressing a deep belief that caring should drive every aspect of nursing practice. This sentiment was consistently articulated across the participants’ narratives, highlighting its centrality within the profession. The most important caring behaviors, as perceived by participating nurses, encompass respect, compassion, effective communication, empathy, prompt responses to patient needs, attentiveness to patients’ feelings, and the provision of counseling and psychological support.
“I think it is crucial for nurses to demonstrate compassion while delivering care.” (Participant 11).“I believe that when we demonstrate respect for patients and prioritize transparency, it positively influences their response.” (Participant 4).“Numerous essential nurse caring behaviors exist. However, the foremost among them is effective communication between the nurse and the patient. When this communication is strong, patients feel encouraged to share their concerns openly. Sometimes patients refrain from discussing even their pain management needs.” (Participant 7).
Impediments to provision of comprehensive care
Participants acknowledged that various factors could impact the quality of care. They recognized that care delivery may vary among nurses due to several reasons, such as the lack of clear practice guidelines in the wards, time constraints, inadequate professional support and unavailability of necessary resources. Nurses highlighted that work overload, resulting from low nurse-to-patient ratios and extended working hours, can significantly compromise the quality of care they are able to provide to their patients.
“When nurses have too many patients, providing adequate attention and care becomes challenging. The lack of clear guidelines for prioritizing care exacerbates this issue, and additional support and resources are needed to maintain high-quality patient care.” (Participant 7).“Providing care for three patients is distinct from caring for eight or nine patients. Particularly during nighttime, the nurse-to-patient ratio does not align proportionally. Crafting a nursing care plan typically takes 40 minutes to an hour. Consequently, the current nurse-to-patient ratio falls short of ensuring optimal care.” (Participant 12).
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Participants believed that implementing practice guidelines in hospital wards would enhance nurses’ ability to provide consistently standardized, evidence-based patient care. They emphasized that applying these guidelines uniformly across the nursing staff would foster greater teamwork and collective accountability.
“Due to several factors, I perceive that our patient care falls short of being adequate. I do not attribute this to a knowledge deficit. Instead, I believe that that implementing practice guidelines within the wards would enhance nurses’ ability to consistently deliver care in a standardized manner.” (Participant 9).“Implementing practice guidelines ensures that the care we provide is consistent with the most current evidence-based best practices.” (Participant 12).
Some participants emphasized the critical role of timely access to resources in enabling them to provide high-quality patient care. They highlighted that the availability of necessary equipment, supplies, and support services is essential for nurses to effectively carry out their duties and meet the diverse needs of their patients. They expressed the belief that with adequate resources and support, there should be no obstacles preventing them from providing the high-quality, patient-centered care they aspire to deliver.
“Consistently encountering moral dilemmas is a common experience. When I provide excellent patient care, it brings me satisfaction. Consequently, I perceive no barriers to fully expressing caring behavior to the extent I desire.” (Participant 2).“Efficiently utilizing available resources is crucial for providing care. However, there are instances when resource scarcity leads to nurse dissatisfaction and emotional exhaustion. These factors can impact nurses’ caring behaviors, potentially affecting patient outcomes.” (Participant 6).
Perception of the work conditions
The work environment of nurses plays a crucial role in shaping the quality of care they provide. Participants emphasized that various factors within this environment, such as workplace stress, interactions with colleagues, unit dynamics, gaps in timely care delivery, patient communication, and overall job satisfaction, significantly influence nurses’ perceptions of caring behaviors and the quality of care they are able to deliver. Interactions with colleagues also play a vital role in the work environment.
“Collaboration in patient care involves a team effort, where nurses and doctors work together. It is essential to foster a positive relationship between nurses and doctors. Additionally, we regularly communicate with residents and intern doctors, providing guidance on treatment protocols.” (Participant 8).“Occasionally, conflicts arise due to errors in intern doctors’ orders, especially considering they are newly assigned to the job.” (Participant 5).“For me, working in the internal medicine units can be stressful. The demands of caring for patients in these units, such as providing timely care and handling complex cases, can take a toll on nurses. However, it is essential to recognize the challenges and find ways to mitigate stress while maintaining high-quality patient care.” (Participant 1).“Work-related stress negatively impacts both on job satisfaction and the quality of care that we provide. As nurses, we encounter stress due to patient health, care responsibilities, excessive workloads, and resource demands. When we experience stress, it can affect the care we provide to patients; the care may not be complete. Therefore, it is crucial to maintain a balanced workload for nurses, addressing both physical and emotional demands, to mitigate the impact of workplace stress.” (Participant 3).
Mixed-methods findings
The qualitative findings closely aligned with the quantitative results, providing a complementary perspective on nurses’ perceptions of caring behaviors. Through interviews, nurses shared personal experiences, providing valuable insights into the associations observed in the quantitative data. The qualitative data revealed the impact of work-related challenges, such as high workloads, inadequate resources, and poor management support, on nurses’ ability to deliver patient-centered care. The integration of both approaches has provided a rich understanding of this complex phenomenon, enhancing the comprehension of how organizational factors influence nurses’ capacity to uphold core caring principles.
Discussion
Caring lies at the heart of nursing practice. Effective care promotes healing, well-being, and a sense of wholeness that goes beyond illness, trauma, or life-altering events [48]. Nurses’ perceptions of caring behaviors profoundly influence service quality. The triangulation of quantitative and qualitative findings revealed a clear and coherent association between nurses’ perceptions of caring behaviors and factors such as female sex, age, nurse staffing, work-related stress, and job satisfaction, with the qualitative findings complementing the quantitative results.
Nurses in this study showed high perceptions of the care they provide, which is in line with studies conducted in Europe [9, 49] but higher than those in Indonesia [13], Greece [9] and Ethiopia [50]. However, the perceptions were lower than studies in Europe [7, 9] and Asia [8, 51]. These differences may be explained by differences in organizational structures, healthcare delivery systems, aspects of nursing education and training, and cultural contexts [52, 53]. The prevailing caring culture in Ethiopia, where the traditional task-oriented approach of medicine dominates the healthcare system, appears to influence nurses’ perceptions of caring behaviors [6].
Nurses’ perceptions of caring behaviors are influenced by socio-demographic characteristics, such as age and sex [9]. Our analysis revealed that female nurses tend to perceive higher levels of caring behaviors compared to male nurses, which aligns with research findings demonstrating stereotypical expectations regarding caring behaviors among female and male nurses [9]. A study showed that female nurses had higher average scores for caring behaviors, although the difference was not statistically significant [54]. If caring is stereotypically associated with femininity, male nurses may be less inclined to exhibit caring behaviors, potentially resulting in lower perception scores than their female counterparts [9]. Additionally, the nurturing aspect often associated with motherhood in female nurses may impact their perceptions of caring.
The influence of nurses’ age on their perceptions of caring behaviors has been studied, with varying results. Some studies have shown that senior nurses have higher perceptions than younger nurses [18, 19], while others found no significant impact [20]. However, one interview participant suggested that nurses should maintain a consistent personal disposition when caring for their patients, regardless of their age or sex.
The work environment significantly influences nurses’ perceptions of caring behaviors, stress levels, job satisfaction, quality of care, and patient experiences [2, 11]. Therefore, creating a caring environment is essential for effective nursing practice. When nurses perceive lower levels of caring behaviors, it can result in feelings of inefficiency in care delivery [24]. Nurse staffing is a critical factor in shaping these perceptions and the overall quality of care provided. In this study, nurses responsible for ten or more patients reported lower scores on the CBI-16 compared to those caring for five or fewer patients. This finding is consistent with studies conducted in Malaysia [19] and Ethiopia [16, 18, 20].
High workloads contribute to increased stress and exhaustion among nurses, often forcing them to prioritize tasks and focus their attention on patients. As a result, they may concentrate on delivering basic, physically oriented care [24] and perform tasks that are less likely to be questioned during periods of increased workload. Such practices can adversely affect the overall quality of care and patient outcomes [51, 55]. Interviewed nurses noted that work overload leads to time constraints, hindering optimal care provision. They suggested that improving work environments could enhance patient safety and the quality of care. Therefore, to advance nursing practice in Ethiopia, health institutions should implement policies that enable nurses to assess their perceptions of caring behaviors and the working environment.
Nurses are a fundamental component of the healthcare system, serving as coordinators of multidisciplinary care in various aspects of patient care [56]. However, certain workplace situations may provoke stress and dissatisfaction, which can negatively impact nurses’ caring behaviors [35]. Interviewed nurses cited work overload, lack of time, poor professional support, resource scarcity, and inadequate management support as common sources of work-related stress. Similarly, high levels of work-related stress have been linked to suboptimal care and low perceptions of caring behaviors [15, 21]. To mitigate the impact of stress and enhance working conditions, it is essential to provide support for nurses after stressful events and address the factors that contribute to stress [57, 58]. Addressing the sources of work-related stress and supporting nurses in coping with these challenges can help maintain their ability to provide compassionate, high-quality care to patients.
Job satisfaction is a subjective sense of fulfillment derived from one’s work. Studies have consistently shown that nurses who reported job satisfaction were more likely to observe elevated levels of caring behaviors compared to their dissatisfied colleagues [17, 22, 59]. When nurses feel valued and fulfilled in their roles, they are more inclined to demonstrate caring behaviors and deliver high-quality care. A plausible explanation for this phenomenon is that job satisfaction positively influences nurses’ motivation, which in turn affects their perceptions of caring behaviors [18]. During interviews, nurses emphasized that effective work performance hinges on job satisfaction and a positive attitude. However, factors such as low nurse-to-patient ratios, high workload, resource unavailability, inadequate management support, and policy priorities can significantly impact nurses’ job satisfaction and their ability to provide patient-centered-care [17, 22, 59]. Creating a conducive working environment that minimizes work-related stress is essential. The workplace should be comfortable for nurses and aligned with their job requirements [57]. By addressing the factors that contribute to job dissatisfaction, organizations can help foster a positive work environment and enable nurses to deliver the high-quality, compassionate care that they aspire to provide.
Resource availability plays a significant role in nurses’ ability to provide high-quality care. In our study, nurses who perceived that resources were readily available in the hospitals tended to have higher perceptions of their own caring behaviors. Conversely, resource unavailability has been associated with lower perceptions of caring behaviors, uncertainty regarding care fulfilment, and the delivery of suboptimal care [16, 17, 24]. Therefore, ensuring the availability of both material resources and staffing is essential for enhancing the provision of comprehensive nursing care [2, 60]. During interviews, participants emphasized the importance of efficiently utilizing available resources to optimize care delivery. The literature also advocates for maximizing resource efficiency to improve overall quality of care [17]. By addressing resource constraints and optimizing the utilization of available resources, healthcare organizations can create an environment that enables nurses to deliver the high-quality, compassionate care that patients deserve.
Strength and limitations
The strength of this study lies in its mixed-methods design, which enhances our understanding of the factors associated with nurses’ perceptions of caring behaviors, yielding comprehensive results. The combination of quantitative and qualitative approaches allows for a more thorough exploration of the phenomenon, providing both statistical insights and in-depth contextual understanding. While the quantitative sample size was relatively small, it encompasses nurses from geographically distant hospitals and included all medical-surgical unit staff. This diversity in the sample helps to improve the generalizability of the findings beyond a single healthcare setting. Additionally, the inclusion of nurses from various units and locations enhances the representativeness of the data, capturing a broader range of perspectives.
However, a limitation of the quantitative portion is that the assessment of nurse-to-nurse relationships and management support relied on a single item, providing a global measure rather than a more detailed examination of these factors. This approach may have limited the ability to uncover the nuances and complexities underlying these important aspects of the nursing work environment. Future research could benefit from utilizing more comprehensive and multi-dimensional measures to gain a deeper understanding of these influential factors.
Conclusion
The study’s findings shed important light on the multifaceted factors influencing nurses’ perceptions of caring behaviors in the Ethiopian healthcare context. It is important to understand both the individual and contextual factors, such as nurses’ personal values and organizational cultures, in determining their orientation toward caring. When there are discrepancies between nurses’ expectations and the actual working environment, it can significantly impact their physical and emotional well-being, leading to uncertainty in care provision. Therefore, understanding individual and contextual factors that shape nurses’ caring behaviors is crucial. Systems-level approaches to supporting and empowering nurses in their caring roles and creating a conducive environment that shape nurses’ perceptions and experiences are essential steps toward enhancing the quality-of-care delivery. Healthcare policy makers should consider the importance of these factors to foster a culture that better enables nurses to actualize their caring potential.
Acknowledgements
The authors would like to express their deepest and heartfelt appreciation to nurses who participated in the study, and nurses who collected the data.The authors would also like to thank the University of Gondar for supporting the research work.
Declarations
Ethical approval and consent to participate
The ethical principles outlined by the Council for International Organizations of Medical Sciences (CIOMS) and the World Health Organization [61] were strictly followed. Approval was obtained from the Institutional Review Board of the University of Gondar (Ref. No. V/P/RCS/05/7L/2020) and then permission was obtained from each respective referral hospital. Each questionnaire had an information sheet and a consent form; hence, written consent was obtained before participating in the interviews.
Participant confidentiality was maintained by coding the questionnaires and making the data only accessible to the principal investigator. The participants were informed that the collected data were to be used only for the intended research and the results of the study would be published in a reputable journal, with no identifiable information linked to the study participants.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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