Caring Behaviour of Nurses in Orthopaedic Wards of Selected Health Institutions as Perceived by Patients

Nurses are trained to provide hands-on care to patients in a variety of settings, which include physical care which can range from total care to helping a patient prevent illness. The health of a patient can significantly improve when they (patients) perceive caring nursing behaviours and are satisfied with the quality of care been received from their care giver. The aim of this study was to determine the caring behaviour of nurses as perceived by patients admitted to orthopaedic ward in some selected hospitals in Osogbo, Osun state, Nigeria. A descriptive comparative design was used. Convenient sample technique was used to select 616 respondents consisting of male and female patients admitted to orthopaedic wards of selected hospitals. The questionnaire on Caring Behaviour Assessment scale was adapted from CBI. The most highly ranked perceived nurses’ behaviour by patients rated “satisfactory” was the general perception of the patients and rendering of basic needs. The findings also revealed that patients rated nurses behaviour (care-giving) with respect to human needs assistance, the provision of safe environment, assisting in psychological care and giving physical comfort as average. Lastly, findings also revealed that patients rated perceived nurses behaviour (care-giving) as “not satisfactory” with regards to meeting their communication needs, nutritional needs and individualized care. In conclusion, care giving is an important branch of nursing and it depicts the quality of care received by a patient which in turn is capable of aiding speedy recovery.


Introduction
Nursing has always been synonymous with the concept of care and caring [1].Majority of individuals choose nursing as a profession because of their desire to care for other individuals.Caring is a science which encompasses a humanitarian, human science orientation, human caring processes.It can simply be defined as the act giving someone attention of providing treatment [1].Caring behaviours are defined as behaviours evidenced by nurses in caring for patients [2].The top ten caring behaviours, derived from nursing literature are: attentive listening, comforting, honesty, patience, responsibility, providing information so the patient can make an informed decision, touch, sensitivity, respect, calling the patient by name [3].
Patients that receive good care or support during illness are more likely to trust the nursing staff and cope better with their anxieties and grief."Care" as a concept has led to the development of theories such as Leininger's theory of cultural care and Jean Watson's theory of human caring [4].Care as a science that encompasses a humanitarian, human science orientation, human caring processes, phenomena and experiences whose goals are centred on helping the patient gain higher degree of harmony within the mind, body and soul [5].Madeleine Leininger explains that care is the essence of nursing and the central dominant and unifying focus of nursing [6].Clukey states that nurses show a caring behaviour through the tone of voice and words they say [7].Most patients judge the quality of care by the support and communication they receive from nurses.Patient will remember nurses by the behaviours the nurses demonstrated during illness.Clukey further states that caring takes time i.e., you must be present and fully engaged; not acting in a hurry and you must know your patient as individuals [7].Giving physical comfort is very important which includes being attentive, anticipating patients' needs and providing assistance for the patients and family [4].The caring behaviours evidenced by nurses in caring for patients include attentive listening, comforting, honesty, patience, responsibility, providing information so that the patient can make an informed decision, touch, sensitivity, respect, calling patient by name.Mrs Shofunlayo, a mother of quintuplets narrates the caring attitude of nurses in the Lagos University Teaching Hospital as kind and not weary of assisting [8].
Majority of the accident victims that come into the hospital end up in orthopaedic wards [9].This fact signifies the need for improved health care for patients in the orthopaedic wards.Nurses are at the forefront of caring for all patients, and most of these patients present complex challenges for health care professionals [10].It is important nurses adapt to the challenges and care of orthopaedic patients because they stay in bed for a long period and hence nurses are in more regular and prolonged contact with orthopaedic than is the case in other working environments.Inadequate care will not only affect the patient, but it has the capacity to adversely affect the nursing profession.Nurses particularly in critical care environments, are often the most vulnerable to stress and in need of much support [11].They further discuss that lack of motivation at work, and a desire to leave the critical care environment as soon as possible as a major determinant of the caring behaviour of nurses [11].Caring behaviours are identified as behaviours evidenced by nurses in caring for patients.This study tend to reveal the caring behaviour of nurses as perceived by patients admitted to orthopaedic wards of some selected hospitals in Osogbo, Osun state.

Statement of Problem
Nursing education in Nigeria has been reviewed to propel nurses towards client care.Nursing care for hospitalized adults entails primarily curative and restorative health and it is expected that approaches to the delivery of care including attitude of nurses has changed positively.However, what is perceived by the society as the caring behaviour of nurses remains questionable.Hence, this study will reveal the caring behaviour of nurses as perceived by patients admitted to orthopaedic ward in some selected hospitals in Osogbo, Osun state.

Objective
To identify nurses perceived behaviour as caring by patients during hospitalization.

Significance of Study
The role of nurses has been revolutionized, in addition to providing direct care for individuals, it is expected that nurses should assume other roles such as health appraisals, advocates, teachers and counsellors.The total effectiveness of nursing care given to hospitalized patients needs to be researched upon because the voice of society which is increasingly knowledgeable and sophisticated regarding their expectation of health care will continue to demand high quality services rendered by nurses.This study will identify nurses behaviours perceived as caring and will help nurses working in the orthopaedic ward where time are spent with patient to improve their relationships with their patients.It will also assist nurses to be aware of assessment of their caring activities and demonstration of professional competence as viewed by patients, which are significant expressions of caring.

Methodology
Design: Descriptive research design was employed with the aid of a structured questionnaire.Settings: Selected health institutions in Osun state, Nigeria (Lautech teaching hospital, State hospital, Ashubiaro and Jolayemi mission hospital, Osogbo).
Participants: A convenient sample consisting of male and female patients admitted to orthopaedic wards.Instruments: Patients' perceptive of caring behaviours used by nurses were measured via the Caring Behaviour Assessment adapted from CBI (Caring Behaviours Scale).The instrument consist of two sections, section A is the demographic data, while section B consists of lists with 65 nursing behaviours in eleven subscales and is congruent with Milliken and Campbelle (1985) caring factors [12].Patients were asked to rate behaviours of their nurses.It is a self-developed structured closed ended questionnaire.The questionnaire was first prepared in English and then translated into the Yoruba language.
The questionnaire was pilot-tested in areas other than the study areas, and the necessary revisions were made.The questionnaire was guided by review of literature for consistency and construct validity.The reliability test was carried out using test re-test method using Pearson Product Moment Correlation coefficient and this yielded 0.86.After completing the questionnaires, the answered questions on nursing behaviours were scored.
Data collection: Ten research assistants were recruited for data collection.Participants who gave their consents to participate in the study received elaborated explanation on the purpose of the study, the type of questions and how to answer by trained facilitators.Furthermore, to ensure privacy and enhance honest and frank responses, male and female participants were treated separately.
Study period: Study period was between July 2014 and June 2015.Ethical consideration: Approval was sought from the ethics committee of Ministry of Health, Lautech Teaching Hospital and Jolayemi Hospital, Osogbo, Nigeria.Further permission and written consent was obtained from all participants in this study.Anonymity of the participants was maintained throughout the study.

Hypothesis One
There was no significant difference between the perception of patients towards 'nurses meeting their self-esteem needs and patients' satisfaction.The independent variables in this hypothesis are patients' perception and it was categorised into two (negative and positive).Those who scored below the mean were categorised as having negative perception while those with a score above the mean were categorised as having positive perception.The dependent variable is patients' satisfaction.Independent t-test statistic was employed to test this hypothesis at 0.05 level of significance and reported in Table 1.
Independent t-test analysis was employed to investigate the difference between patients perception and patients satisfaction.As presented in Table 1 the calculated t-value of 25.022 is greater than the critical t-value of 0.196 with 614 degree of freedom, this result therefore implies that, the null hypothesis which states that, there is no significant difference between the perception of patients towards nurses meeting their self-esteem needs and patients satisfaction is rejected while the alternate hypothesis is upheld.A cursory look at the mean values of the two groups when compared revealed that patients with positive perception are more and have a higher mean value (N = 336; M = 21.11;SD = 1.36) than patients with negative perception toward nurses (N = 280; M = 17.60;SD = 1.36) with the mean difference (MD = 2.51).It therefore means that, there is statistical significant mean difference between patients with positive and negative perception towards nurses, thus affecting their satisfaction.

Hypothesis Two
There is no significant relationship between 'patients perception towards nurses meeting their communication needs and patients satisfaction'.Pearson product moment correlation was employed at 0.05 level of significance and reported in Table 2.
Pearson product moment correlation analysis was conducted to investigate the relationship between patients perception of nurses meeting their communication needs and patients satisfaction.As presented in Table 2 the calculated r-value of 0.298 is greater than the critical r-value of 0.138 with 614 degree of freedom, this result therefore implies that the null hypothesis which states that, there is no significant relationship between patients perception towards nurses meeting their communication needs and patients satisfaction is rejected.It therefore means that, there is a statistical significant relationship between patients perception towards nurses meeting their communication needs and patients satisfaction.

Hypothesis Three
There is no significant relationship between patients' perception towards nurses meeting their 'human needs assistance and patients' satisfaction.Pearson product moment correlation was employed at 0.05 level of significance and reported in Table 3.
Pearson product moment correlation analysis was conducted to investigate the relationship between patients' perception of nurses meeting their human needs/assistance and patients' satisfaction.As presented in Table 3 the calculated r-value of 0.371 is greater than the critical r-value of 0.138 with 614 degree of freedom, this result therefore implies that the null hypothesis which states that, there is no significant relationship between patients' perception towards nurses meeting their human needs/assistance and patients' satisfaction is hereby rejected.It therefore means that averagely, patients perceive nurses to have met their medical needs and given assistance, showing that patients gain satisfaction.

Hypothesis Four
There is no significant relationship between patients' perception of nurses taking time and patients satisfaction.Pearson product moment correlation was employed at 0.05 level of significance and reported in Table 4.   Pearson product moment correlation analysis was conducted to investigate the relationship between patients' perception of nurses taking time and patients' satisfaction.As presented in Table 4 the calculated r-value of 0.059 is less than the critical r-value of 0.138 with 614 degree of freedom, this result therefore implies that the null hypothesis is retained.It therefore means that, patients perceive nurses not to have time for them therefore living them unsatisfied.

Hypothesis Five
There is no significant relationship between patients' perception of nurses giving basic needs and patients' satisfaction.Pearson product moment correlation was employed at 0.05 level of significance and reported in Table 5.
Pearson product moment correlation analysis was conducted to investigate the relationship between patients' perception of nurses giving basic needs and patients' satisfaction.As presented in Table 5, the calculated r-value of 0.371 is greater than the critical r-value of 0.138 with 614 degree of freedom, this result therefore implies that the null hypothesis is rejected.It therefore means that, patients perceive nurses to be very effective in rendering basic needs therefore giving them satisfaction.

Hypothesis Six
There is no significant relationship between patients' perception of nurses toward provision of safe environment and patients' satisfaction.Pearson product moment correlation was employed at 0.05 level of significance and reported in Table 6.
Pearson product moment correlation analysis was conducted to investigate the relationship between patients' perception of nurses providing safe environment and patients' satisfaction.As presented in Table 6, the calculated r-value of 0.178 is greater than the critical r-value of 0.138 with 614 degree of freedom, this result therefore implies that the null hypothesis is rejected.It therefore means that, though very low, patients perceive nurses positively in the provision of safe environment therefore giving the patients satisfaction.

Hypothesis Seven
There is no significant relationship between patients' perception of nurses assisting with nutritional needs and patients' satisfaction.Pearson product moment correlation was employed at 0.05 level of significance and reported in Table 7.
Pearson product moment correlation analysis was conducted to investigate the relationship between patients' perception of nurses assisting with nutritional needs and patients' satisfaction.As presented in Table 7 the calculated r-value of 0.017 is less than the critical r-value of 0.138 with 614 degree of freedom, this result therefore implies that the null hypothesis is retained.It therefore means that, though patients perceive nurses negatively in assisting with nutritional needs, it also affect their level of satisfaction.

Hypothesis Eight
There is no significant relationship between patients' perception of nurses assisting in individualized care and patients' satisfaction.Pearson product moment correlation was employed at 0.05 level of significance and reported in Table 8.
Pearson product moment correlation analysis was conducted to investigate the relationship between patients' perception of nurses assisting in individualized care and patients' satisfaction.As presented in Table 8, the calculated r-value of 0.074 is less than the critical r-value of 0.138 with 614 degree of freedom, this result therefore    implies that the null hypothesis is retained.It therefore means that, though patients perceive nurses negatively in assisting in individualized care, it also affects their level of satisfaction.

Hypothesis Nine
There is no significant relationship between patients' perception of nurses assisting in psychological support and patients' satisfaction.Pearson product moment correlation was employed at 0.05 level of significance and reported in Table 9.
Pearson product moment correlation analysis was conducted to investigate the relationship between patients' perception of nurses assisting in psychological care and patients' satisfaction.As presented in Table 9, the calculated r-value of 0.367 was greater than the critical r-value of 0.138 with 614 degree of freedom, this result therefore implies that the null hypothesis is rejected.It therefore means that, patients' perceive nurses moderately positively in assisting in psychological care and this affect their level of satisfaction.

Hypothesis Ten
There is no significant relationship between patients' perception of nurses providing therapeutic milieu and patients' satisfaction.Pearson product moment correlation was employed at 0.05 level of significance and reported in Table 10.Pearson product moment correlation analysis was conducted to investigate the relationship between patients' perception of nurses providing therapeutic milieu and patients' satisfaction.As presented in Table 10, the calculated r-value of 0.021 is less than the critical r-value of 0.138 with 614 degree of freedom, this result therefore implies that the null hypothesis is retained.It therefore means that, though patients perceive nurses negatively in providing therapeutic milieu, it also affects their level of satisfaction.

Hypothesis Eleven
There is no significant relationship between patients' perception of nurses giving physical comfort to patients and patients' satisfaction.Pearson product moment correlation was employed at .05 level of significance and reported in Table 11.
Pearson product moment correlation analysis was conducted to investigate the relationship between patients' perception of nurses giving physical comfort to patients and patients' satisfaction.As presented in Table 11, the calculated r-value of 1.36 is greater than the critical r-value of 0.138 with 614 degree of freedom, this result therefore implies that the null hypothesis is rejected.It therefore means that, patients' have positive but low perception toward nurses towards giving physical comfort to patients and this affect their level of satisfaction.

Discussion
The results of this study provide some concrete information on nurses behaviour (care) patient experience in the orthopaedic units of selected hospitals.A total no of six hundred and sixteen (616) respondents consisting of male and female patients admitted to Orthopaedic wards from Lautech Teaching Hospital, State Hospital Ashubiaro and Jelayemi Mission Hospital, Osogbo participated in this study.Patients completed the Caring Behavior assessment scale and rated behaviours of their nurses under eleven subscales of caring factors.Our study revealed patients ratings were in three different categories (i.e.effective and thus gaining satisfaction, average and those perceived as not satisfactory).
Our study revealed that the most highly ranked perceived nurses behaviour by patients as satisfactory include the general perception of the patients and rendering of basic needs.This study supports the findings of Kimble (2003) that revealed Human Needs Assistance as the most important subscale [13].
Another result of our findings that revealed that perceived nurses behaviour by patients is considered averagely satisfactory as regards to human needs/assistance, the provision of safe environment, assisting in psychological care and giving physical comfort.This result does not correlate with the findings of Ferdous et al. (2013) where patients in critical care units perceived physical and technical behaviours as the most important caring behaviours [14].
Further findings revealed that patients perceive nurses behaviour as not satisfactory as regards meeting their communication needs, creating time for them, assisting with nutritional needs and assisting in individualized care.This isn't in tune with the findings of Kimble (2003) in which "Answer my questions clearly" was listed as the subsequent order of importance the caring behaviours perceived by the patient [13].

Conclusion
Care is viewed as the central focus of nursing and it is fundamental in clinical practice.This research shows that nurses struggle to provide quality care as shown by the patients' perception of caring which in turn affects many areas of patient's satisfaction.

Recommendations
It is important for nurses to be knowledgeable about the caring behaviours as perceived by patients.
There is need for well-trained and clinically competent nurses to meet the caring needs of patients so as to improve the caring behaviour in the nursing practice.

Table 1 .
Independent t-test of patients' perception towards nurses and patients satisfaction.

Table 2 .
Pearson product moment correlation of patients' perception towards nurses meeting their communication needs and patients satisfaction.

Table 3 .
Pearson product moment correlation of patients' perception towards nurses meeting their human needs assistance and patients' satisfaction.

Table 4 .
Pearson product moment correlation of patients' perception of nurses taking time and patients' satisfaction.

Table 5 .
Pearson product moment correlation of patients' perception of nurses giving basic needs and patients' satisfaction.

Table 6 .
Pearson product moment correlation of patients' perception of nurses towards provision of safe environment and patients' satisfaction.

Table 7 .
Pearson product moment correlation of patients' perception of nurses towards assisting with nutritional needs and patients' satisfaction.

Table 8 .
Pearson product moment correlation of patients' perception of nurses towards assisting in individualized care and patients' satisfaction.

Table 9 .
Pearson product moment correlation of patients' perception of nurses assisting in psychological care and patients' satisfaction.

Table 10 .
Pearson product moment correlation of patients' perception of nurses towards providing therapeutic milieu and patients' satisfaction.

Table 11 .
Pearson product moment correlation of patients' perception of nurses giving physical comfort to patients and patients' satisfaction.