الفهرس 
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Abstract
Caring is an intentional act that conveys physical and emotional security and genuine connectedness with another person. It validates the humanness of both the nurse and the patient. It is much more than a nice, vague emotion that one may or may not experience depending on the level of energy or wellness he may feel on a particular day. But, is an intentional act of the will, in which the caregiver moves beyond personal barriers, in order to connect with the other person in the space where they genuinely exist at that moment.
The need to feel being cared for is at its highest during critical illness. This need originates from the incapacitating nature of critical illness that cause the critically ill patients to experience a loss of self-worth and self-esteem, be stripped of their sense of independence and privacy; feel isolated from their family and significant others and lose autonomy, as well as control over their bodily functions.
Despite the centrality of caring in the provision of care to the critically ill patients. The invasive treatment to which critically ill patients are subjected and the frequently unstable nature of their condition may results in their physical needs to be often perceived as having greater priority than psychological needs. Thus, in order to retain the focus for nursing: the patient for whom the practice of nursing exists, it was necessary to carry out this study.
Aim of the study:
This study aimed at determining the state of caring in the intensive care units through the direct observation of nurses’ caring behaviors and nurse-patient interaction and measuring nurses’ caring ability.
Setting:
The study was conducted in two critical care units in Alexandria Main University Hospital, the casualty intensive care unit (Unit I) and the general intensive care unit (Unit III).
Subjects:
The sample of this study comprised all nurses (N=66) who were involved in providing direct patient care in the Casualty and General intensive care units at the time of data collection (27 diplomas, 7 associates, 32 interns).
Tools of the study:
Three tools were used for data collection in this study.
Tool I: Caring Behaviors Observation Sheet:
The researcher developed this tool based on current related literature to assess caring behaviors of nurses as they care for their patients. It consists of three parts:
Part one - Nurse’s profile:
It includes nurse’s demographic data such as (name, age, marital status, qualification and years of experience), type of working shift (morning, or evening), and date of observation.
Part two - Profile of the patient cared for by the nurse:
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his part included patient’s demographic data (patient’s name, age, sex, marital status, level of education), the name of the intensive care unit, hospital number, date of admission and ICU LOS, present medical history (diagnosis, state of responsiveness, receiving sedatives or muscle relaxants, state of intubation, duration of mechanical ventilation and number of weaning trial failure if on mechanical ventilation).
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art three - Caring Behavior Rating Scale (CBRS):
It consists of a set of 73 caring behaviors which were selected based on ranking as important “caring” behaviors by patients and providers in the literature review, ability to observe and measure the behavior in the intensive care setting ; and the researcher own experience in caring for critically ill patient. These 73 caring behaviors are categorized for facilitating observation into 11 main caring behaviors subscales. A scoring system was developed to calculate Caring Behavior Score for each shift and the Mean Score of the three shifts for each nurse with possible scores range from 0 to 100.
Tool II: Nurse- Patient Communication Observation chart:
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he researcher designed this tool to describe nurse-patient communication. It provides data to answer questions like who initiated each interaction, what was the content of the nurse - patient communication? was nursing and /or medical intervention/investigation occurring at the time of interaction?, how long was each interaction?, and total time spent communicating over the observation period.
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ool III: Caring Ability Inventory (CAI):
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t was developed by Nkongho (1990) to measure the degree of a person’s ability to care for others and has been found to be a reliable and valid measure of this construct. The inventory consists of 37 items, and responses are given using a 7-point Likert-type scale (1 = strongly disagree to 7 = strongly agree). Possible scores range from 37 to 259.
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he Caring Ability Inventory was translated into Arabic. Then the three tools tested for content validity by five experts in the fields of critical care, mental health nursing and statistics.
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ermission was obtained from the hospital authority where the study was undertaken. Then a pilot study was done to test the applicability of the tools and necessary modifications have been done accordingly. The reliability of Caring Behavior Rating Scale was tested statistically, The Cronbakh α reliability coefficient was 0.753 ( significant at α > 0.65)
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urses in the setting of the study were informed that the researcher will be present in the unit for the purpose of investigating the care provided to patients but didn’t informed exactly about the topic of the study or the observational nature of the research, to minimize any alteration in the nurses’ behavior due to the presence of the researcher. Data was collected
on 198 nurse observations over a period of 6 months. Each observation continued for a minimum of 5 hours. The observer assumed the role of a complete observer, adopting a passive role with no direct social interaction in the setting. The researcher sat in a place that allowed her to observe the nurses and their interactions with patients but did not interfere with the flow of patient care.
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mark was placed in the done column of the Caring Behavior Rating Scale (CBRS) next to each behavior any time it was performed by the nurse for her patient. A mark also placed in the not done column when the behavior was imminent but missed by the nurse. Caring behaviors that were not applicable during an observation were left without marking in either the done or the not done columns. For some behaviors, it was not possible to determine specific frequency in which they should occur. Therefore, a mark was placed in the done column whenever it was performed by the nurse and in the not done column when it was never done by the nurse throughout the observation period.
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he duration of each interaction was counted in seconds using a digital clock. Then the total duration of communication for each observation was calculated as the sum of the duration of all the interactions occurred over the observation period. The researcher observed each nurse for 3 times including one morning and two evening shifts. Night shifts were excluded because fewer interventions are performed; patients are almost always sleeping and less communication is used during the night. Only one nurse was observed each shift. Following each observation, the observed nurse was asked to read the statements of the Caring Ability Inventory (Tool III) and rate how well each statement reflected her thoughts and feelings about other people in general. After reverse coding the 13 negative items, the 37 items in each completed CAI instrument were summed to arrive at the total CAI score.
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ata collection took six months, from February to July 2005. Then data were statistically analyzed and expressed as percentages, frequencies, means and standard deviations. Statistical tests used in the present study were: F-test (ANOVA), Kruskal-Wallis Test (K-W-χ2) and Pearson correlation coefficient. The significance level was set at p < 0 .05
Results:
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he current study revealed that:
Nurses’ CAI Mean Score was 185.18 ± 19.78 (range, 165.4 - 204.96). There was no significant difference in caring ability score in relation to nurses’ qualification, years of experience or age. While there was a highly significant Pearson Correlation Coefficient between nurses’ Caring Ability Inventory Score and Caring Behavior Mean Score (r =.323, p =.008).
Regarding Nurses’ caring behaviors, it was observed that ”Inspiring Hope”, ”Presencing/sharing/Reassuring” and ”Fostering orientation” subscales total mean scores were the lowest among caring behaviors subscales (4.87 ± 12.62, 9.390±13.324, 7.054±5.920 respectively). While, the highest total mean scores were for ’comforting’, ’supporting the patient’s family’, ’protecting / advocating’ subscales (58.66± 31.55, 56.9119.27±, 64.45±35.68 respectively).
While, the highest total mean scores were for ’comforting’, ’patience’, ’protecting / advocating’ subscales (58.66± 31.55, 49.30±42.28, 64.45±35.68 respectively).
A significant difference was found between different nurse qualifications in relation to Caring Behavior Mean Score (χ2 =7.287, p = .026). Bachelor nurses had a relatively higher Caring Behavior Mean Score (26.26 ±12.41) than that of diploma nurses and associate nurses (17.61 ± 9.30, 23.53 ± 6.96 respectively). The Caring Behavior Mean Score differed significantly by nurses’ years of experience (χ2 =11.83, p = .003). Nurses with less than 2 years of experience had relatively higher Caring Behavior Mean Score (28.47±11.99) than nurses with more than 2 years of experience. However, no significant difference was found between different age groups (χ2 =1.293, P=.524) or different settings (t =1.600, p =.111) in relation to Caring Behavior Mean Score.
In addition, there was significant difference in nurses’ caring behavior score in relation to patient’s responsiveness (χ2 = 0.721, p =.030). Nurses cared for responsive patients demonstrated higher Caring Behavior Scores than those cared for unresponsive ones. On the other hand, no significant difference was found in Nurses’ Caring Behavior Score in relation to patient’s ICU LOS (χ2 = 2.596, p = .628 ) . Meanwhile, a high significant difference was found between different shift types in relation to Nurses’ Caring Behavior Score (χ2 =19.094, p =.000). The mean Caring Behavior Score during the long day shifts (9.81 ± 9.12) was much lower than that during morning and evening shifts (22.94 ± 15.23, 23.59 ± 14.40 respectively).
In relation to nurse-patient communication, the mean duration of communication was as short as 12.08 ± 20.31 sec. The duration of nurse-patient communication over a shift period, was less than 30 sec. in as much as 57.1% of observations, increasing to be more than 1 minute in only 2.5% of observations. 33.3% of observations were characterized by absence of nurse-patient interaction. In only 7.6% of observations, the number of interactions exceeded 10. The majority of interactions were nurse initiated (62.3%) and occurred during physical care (70.1 %).
Nurses’ verbal communication content was dominated by ”Requests or Commands” (29.5% of all content) and ”Procedural/Task Intentions” (27.9%). Whereas, ”Reassurance /Sharing /Inspiring hope” constituted only 7.1% of interactions. In addition, negative communication in the form of shouting, expression of being annoyed and bored or sarcastic communication was observed in 4.9% of interactions. Moreover, nonverbal communication in the form of eye contact and touch was absent in the majority of interactions (60.8%). Eye contact was observed in 36.4% of interactions, while touch was observed in only 0.9 % of interactions. Meanwhile, eye contact with touch was observed in 1.9% of interactions.
There was a high significant difference between nurses’ qualifications in relation to communication duration (χ2 = 20.107, p =.000) with bachelor nurses more communicating with their patients (17.64±26.36) than associate and diploma nurses (10.67±8.52, 6.20±9.35 respectively). In addition, there was an observed increase in the duration of nurse-patient interaction with the decrease in the years of experience but this increase was not statistically significant. However, the duration of nurse-patient communication did not differ significantly by nurses’ age
Furthermore, there was high significant difference in the duration of nurse-patient communication in relation to ICU LOS (χ2 = 14.692, p = .005) and patient’s responsiveness (χ2 = 94.054, p = .000). Responsive patients and those with LOS more than 20 days received relatively more communication from their nurses than other patients did (. Nurses communicated for a longer duration with intubated responsive patients (18.5 ± 17.57) than with unintubated ones (16.8 ± 28.96).
In addition, a high significant difference was found between nurses working in the casualty intensive care unit (unit I) and those working in the general intensive care unit (unit III) (t =3.012, p =.003). Nurses in unit III communicated for a relatively longer duration (16.47±19.66) than those in unit I (7.94 ±20.15).
As for shift type, communication duration during the long day shifts (5.50 ±6.35) was markedly decreased compared to that during morning and evening shifts (15.05±26.39, 11.90±17.88 respectively). However, this difference was not statistically significant