Exploring the experiences of oncology nurses about the factors facilitating their presence at the bedside of patients with cancer: A qualitative study
Background: The presence of nurses at patients' bedside is regarded as an indication of the quality of care. There is not enough evidence on facilitators of nurses' presence at cancer patients' bedside. Aim: The present study aimed to investigate nurses' experiences of factors facilitating their presence at patients' bedside in oncology ward. Subjects and Methods: In this qualitative study, data were collected using purposeful sampling and semi-structured individual interviews with 25 oncology nurses from two teaching hospitals in Sari, Northern Iran, between 2016 and 2017. Interviews were digitally recorded, handwritten, coded, classified, and analyzed using conventional content analysis approach. Results: Data analysis led to the development of three main categories and seven subcategories. The first category, namely, “leverage spirituality” with two subcategories (motivational beliefs and religious motives). “Being with patient with compassion and commitment” is the second category with two subcategories (sense of altruism and compassionate care and adherence to the profession). The third category is “effective communication” with three subcategories (initial methods being patient, soothing communication, and intimate communication). Conclusion: The results of this study showed that nurses' spiritual beliefs, kindness, and professional commitment and establishing human-friendly relationships with the patient and family would help the nurses of the oncology unit to have a more effective presence in the patients' bed. It seems that further studies are needed to examine the facilitators of the presence of oncology nurses on patients' bedside based on severity of illness.
Keywords: Neoplasm, nursing care, oncology nursing, patients, qualitative research
Cancer is a chronic and life-threatening illness that has psychological and physical effects on patients and can greatly damage numerous dimensions of patients' life such as family relationships, sexuality, work, and self-care., It is estimated that there will be ~26 million new cancer cases and 17 million cancer deaths per year up to 2030., In Iran, cancer is also the third cause of death after cardiovascular diseases and accidents. Patients with cancer have many health problems and explicit needs requiring complex and individualized care. Oncology nurses as providers of cancer care are view as one of the most prominent members of the health-care group. Nurses are the ones who are with the patients in both their good and bad times, from diagnosis to treatment/cure, or during palliative and end-of-life care, and thus they are the ones who most closely witness what patients go through during this process. Care includes the sense of love for patients, respect for patient's rights and dignity, the protection and integrity of patients and their families, and the proper cooperation with other health professionals. In addition, the care should be based on recent evidence and have skilled nurses to ensure safe and high-quality nursing care. The art of nursing practice is not only known by technical and professional skills but also with the intention of providing a passionate presence that creates the trust and healing relationship for the best results and patient satisfaction. Caring is a fundamental nursing principle and requires the authentic presence from nurses for the oncology patients.
In caring for cancer patients, there is more emphasis on technical and therapeutic care (surgery, chemotherapy, radiotherapy, gene therapy, etc.) that is based on technical knowledge of caring for cancer patients and can be generalized to care of all cancer patients. The care should be on the basis of individual characteristics and needs or in a safe and supportive environment if necessary in such a way that patients and their families can express their physical, emotional, and spiritual needs. The nurse presence has a positive effect on the recovery and self-care of patients. Reducing the nurse presence leads to an increase in the aggression among patients and violence against employees and may cause loneliness and anxiety in patients. Nurses as members of the health-care team, which spends much time with patients, face great challenges in the care of patients with diagnosed cancers. The presence of nurses is regarded as good quality from the patients' perspective. Despite valuable studies about the presence of nurses in the practice (although limited), only one study in Iran was conducted on the development of this concept using Schwartz–Barcott and Kim's hybrid model. The presence of nurses can be identified as constructive interaction defined by intentional concentration, accountability, enlightenment, and participation. The presence of nurses requires clinical competence, self-sufficiency, reimbursement, and favorable work environment. Valuable communication, balance/recovery, and growth and excellence are the main consequences of this concept.
There is not any study on facilitators of nurses' presence at cancer patients' bedside. It is important to recognize the experiences of oncology nurses to understand and support their roles in patient care since specialized nurses are needed to meet the needs of patients and their families. The present study aimed to investigate nurses' experience of available facilities on their presence at patients' bedside in the oncology department.
This qualitative study was conducted with the conventional content analysis approach in 2017. Study participants were 25 nurses (1 matron, 3 head nurses, and 1 clinical supervisor and the rest were clinical nurses) and participants aged 26–58 years were and had 1–30 years of work experience. Three out of 25 participants were males. They purposively were recruited from clinical nurses working in the oncology department of two educational-medical centers of Golestan and Mazandaran Universities of Medical Sciences in Northern Iran. Data collection continued up to the saturation point, where the richest description of their experience was obtained. Data saturation appeared after 22 interviews; however, three more interviews were conducted to be ensured. Inclusion criteria were willingness to participate in the study, with at least a year of experience in the oncology department, tendency to participate in the study, and ability to express their experience.
Data collection was done by semi-structured individual interviews in hospitals. Interviews were started using a broad question, i.e., “Please explain a day of your work life.” Then, interviews were continued using follow-up questions such as “What factors facilitated your presence at patient's bedside? Was there any situation in which you felt your presence on the patient's bedside would increase? Can you explain more? What do you mean? and Why did you feel so?” Interviews were held in a quiet room in the study setting, lasted 40–85 min, and were recorded using a digital recorder. However, two participating nurses did not consent to sound recording but allowed us to make notes of their speeches.
The six-step conventional content analysis approach described by Graneheim and Lundman was employed to analyze the data simultaneously with data collection. Primarily, each interview was transcribed word by word and the transcript was read for several times to immerse in the data and obtain a detailed insight about them. Then, meaning units were identified and coded based on the aim of the study while taking the latent and the manifest content of the data into account. The codes were classified into broader subcategories and categories based on their similarities and differences. This process of data reduction and abstraction was continued until the categories were extracted.
To ensure that the data were authentic in all aspects, Lincoln and Guba evaluative criteria were used, including credibility, conformability, dependability, and transferability. To ascertain the credibility of the data, the researcher tried to collect valid data through prolonged engagement with the participants and immersion in their ideas and constantly summarized and repeated their statements during the interviews for clarification of their purposes. The codes and categories were shown to two of the participants for comments. An external check was also performed. For the conformability of the data, the complementary views of two faculty members with an expertise in qualitative research were also taken. The careful scrutiny of the data by the project collaborators in the course of its analysis helped ensure the dependability of the data. Maximum variation sampling and rich description of the findings and confirmation of the findings by two nonparticipating nursing helped ensure the transferability of the data.
The present study is a part of a doctoral dissertation and the outcome of a research project with the approval code of 284951217299 dated April 08, 2017 and the code of ethics of IR.GOUMS.REC.1395.305 in the session of Medical Sciences Ethics Committee in Golestan. At the beginning of the interviews, the main investigator introduced herself to the participants. Written consent was obtained from the participants. In addition, obtaining consent for recording their voice, they were assured about the confidentiality of information and voluntary participation.
Data analysis led to the development of 512 codes which were categorized into three main categories and seven subcategories. The categories were “leverage spirituality,” “being with patient with compassion and commitment,” and “effective communication.” These categories are explained with direct quotations in the following.
According to participants' experiences, spirituality was a factor that could facilitate their presence at patients' bedside in the oncology unit. Strengthening their particular beliefs and faith in Almighty God, they tried to maintain their moral to provide the effective care. This category included two subcategories of motivational beliefs and religious motives.
Findings indicated the reinforcement of a particular belief among nurses in this sector. They believed that they were chosen by the God for nursing of patients with cancer. This belief gave them a double incentive for being present at patients' bedside and providing compassionate and safe care.
“It seems that all nurses were chosen by God … during this 9-year period I am working here” (P6).
Some of them believed that their presence on patients' bedside and providing service for patients were given them the grace of God, so that they saw miracles in their lives.
“I tell them that God has chosen you to be here, so God is really looking at you. God has helped us, and I have experienced a miracle, so do not try to leave this ward” (P3).
Some nurses stated that their opinion about patient and care changed, and their care and communication with patients changed after working in this sector.
“When I came here my view was totally changed. My opinion about patients' bedside was changed. Now, I know the meaning of patient, and I feel and understand what a patient wants or what the meaning of being at patients' bedside is” (P19).
As the largest providers of health-care services, nurses have a significant potential that can affect the health-care quality. Nurses have pointed out the importance of believing in God in timely presence at patients' bedside and doing correct and precise measures, and they immediately call the department and follow-up in the case of any work neglect.
“Due to the belief in God and considering him as who sees my deeds, I do everything for patients. For instance, when I go home and remember that I forgot something for a patient,… so I spend my whole energy on patients and timely attend patients' bedside time” (P16).
Nurses stated that they often saw patients praying during their shifts. This gave them a double incentive to attend the patients' bedside despite the overcrowding sector and work fatigue.
“Patients and their attendants pray for us,…… Patients' bedside makes me tired, but their prayer is enough for me” (P20).
Prayer and religious beliefs have positive effects on reducing and confronting daily stresses in nurses. According to verse 28 of AL-RAD Surah of the Holy Qur'an, “Remembrance of God certainly brings comfort to all hearts.”
“Every time I go to work … I recite The Throne Verse, and it gives me comfort. I say that God please give me the power to work with patients” (P16).
Being with patient with compassion and commitment
Research findings indicated compassion and commitment at patients' bedside. Nurses sought to effectively attend the patients' bedside and provide their professional responsibilities using the sense of altruism and compassionate care and adherence to the profession. Compliance with ethical standards in nursing practice is another more sensitive and important care issue.
Sense of altruism and compassionate care
Nurses stated that they tried to communicate with patients, show humanistic manner, and avoid of being like a robotic nurse.
“… It is unacceptable to do anything for patients without any explanation. It should not be like robots and instruments” (P18).
Most nurses stated that they had compassionate presence at patients' bedside due to young age of most patients and severe pain.
“You see they are young and we know that cancer has no cure, we suffer from their suffering. We are human beings” (P9).
Most nurses called emotionally their patients “dear father, dear mother, my brother, my sister,…”. This type of literature and speech creates trust and patients' much cooperation with nurses.
“All of us tell patients: How are you father? Are you better today? Did you have any pain? Tell me if you had” (P1).
Almost all of the participants stated that they considered patients as their family members and tried to sympathize with them.
“…we feel that these patients are our family members, we cannot ignore them” (P4).
Most participants said that they were very patient with insults, violence, or complaints from patients and their attendants because of understanding conditions of patients and their companions. In this case, they tried to control their anger, make patients and companions calm by silence, smile, and explanation of situations.
“Once a companion of patient who died began to hit my colleague, she started running. in these cases, nurses are very patient, become silent and understand companions' mood” (P24).
Adherence to the profession
Most of the participants stated that they suffer from a lot of workloads due to the stress, difficulty of the workplace, and high patients' mortality rate, so they need a high level of job commitment, accountability, conscientiousness, and task orientation to carry out their professional responsibilities.
“I have to do treatment timely and accurately. This service is my task and I receive salary for it. The patients and companions' behaviour can affect my presence. This task is given to me and I should do it efficiently” (P20).
In fact, they consider a care satisfactory in the case that nurses are timely available for their professional responsibilities.
Effective and professional communication
Results indicated that nurses sought to provide optimal care at patients' bedside by soothing and intimate communication with patients in different ways.
Initial methods being with patient
Findings indicated that nurses communicate with patients by showing a willingness to communicate such as being happy, eye contact, smiling, introducing themselves to patients, and touching their hands and backs because they followed to build trust to be able to fulfill patients' needs. Nevertheless, the patients' willingness to have nurses' presence and communicate with them was also important in this regard.
“In the oncology unit, patients really need the attention, conversations, eye contact, being heard, and nurses' good behavior. They also need conversation with nurses at their bedside” (P 26).
“When we go at patients' bedside, we Cute their heads. They become calm when we shake hands with them, and then they start to speak to us” (P 22).
Nurses consider the self-introduction to patients as their first stages of interpersonal communication which is in fact the starting point for further and deeper communication.
“We try to establish a good relationship with patients and we first try to introduce ourselves to them, for example, I am … your nurse. Call me in the case of any need…” (P 6).
The participants seek to establish the soothing communication at patients' bedside. They spend much time for patients who have stress, anxiety, and fear to make them calm, help them in the long-term treatment and procedure, and then prevent their nonadaptive behavioral reactions.
“Speaking to patients is the most important method that gives them the comfort, and thus they will accept many things” (P 26).
Nurses stated through the strong communication, patients feel safe and trust in the treatment team. Establishing an effective communication is widely used as a key index for patient satisfaction, cooperation, and healing; and the ability to establish an effective communication with others is the heart of all patient care.
“The more nurses are at patients' bedside, the more they communicate, the patients trust in nurses, and recognize them as those who do their work intimately and can discuss their problems” (P1).
Nurses stated that they attracted more patient cooperation during nursing procedures due to more presence at patients' bedside and better communication with them.
“Most of patients do not let other nurses to take blood samples, but I do it easily because of intimate communication with them” (P 9).
According to participants' views, nurses can encourage patients to discuss their problems and ask for help by intimate communication through the presence at patients' bedside, telling jokes and using kind words. They stated that the intimacy between patients and nurses was effective in expressing their problems and ultimately affected the treatment process.
“I try to call them Mom and dad. This kind of relationship is more intimate and they can easily tell their problems” (P 12).
Nurses stated that they became intimate with patients and their families due to the chronicity of diseases and multiple hospitalizations, so that they may go to patients' homes for providing care.
“…we had a young patient with leukaemia that died. when she was in end stage of disease her mother asked me if I can provide her home care? and I did it without getting any payment” (P 6).
This study showed that spirituality, compassion and commitment, and good communication were the main facilitators of the presence of oncology nurses at the bedside of patients with cancer. Nurses' motivational beliefs and religious motives help them to be present at patients' bedside and adapt to stressful work situation despite physical and mental fatigue and organizational problems. Religious beliefs change nurses' views and valuation of their care as a stronger force and an internal control, and this force is like a shield against problems motivating nurses to continue the care and presence at patients' bedside. Religious beliefs and faith and love for God lead to mental stability and health and encourage human beings to work with selflessness. Nurses' desired levels of religious beliefs can lead to improved work ethic and accountability at work. Religious beliefs have positive and significant relationship with organizational commitment, job motivation, and attitude toward patients and nursing caring. Nurses in threatening situations use positive personal characteristics such as religious beliefs and humanitarian tendencies.
In this study, the presence of nurses on the bedside of patients with cancer, along with a sense of altruism, empathy, intimacy, and compassion due to the understanding of patients and family conditions was evident. Compassionate care is a communicative, interpersonal, and mental process through which a person communicates with other vulnerable people and works through emotional and verbal responses to reduce their pain and suffering. According to a research by Shafipour et al., patients needed caring, compassionate, kind, and committed nurses for carrying out their tasks in facing with stressful cardiac surgery to pay attention to their needs by compassion, friendliness and responsible behavior, listen to them, and express their empathy and sympathy. Patients feel calm and comfortable due to this type of nurses' behavior. Since the nursing profession aimed to help clients, the ethical development such as humanitarian desires with love to patients and enjoying to help people acted as a driving force in the present study, so that it encouraged nurses to attend and serve and put the patient health and welfare on the priority despite problems and stress of the workplace.
Findings of the present study indicated that nurses' professional growth had a significant effect on the presence at patients' bedside. Nurses' professional growth is associated with the provision of high-quality nursing service. Patients' recovery means the observance of nursing performance standards that is obvious in nurses' responding to patients' questions, accountability, task orientation, and work ethic. Responsibility for nursing has a wide range of areas, including the following: respect for the patient and his protection, patient dignity, friendship and empathy, compliance with professional commitments, accountability, accountability and conscientiousness, and justice in service. In spite of many problems, nurses of this study were committed to doing what they have taken responsibility for, or in other words, providing safe, desirable, and quality care. They felt relaxed and satisfied when worked with conscience and work ethic.
Nurses also considered the effective communication as another factor facilitating the presence at patients' bedside. They stated that nurses' communication with patients led to the emergence of caring behavior that underlay the provision of high-quality care due to the continuous assessment of patients' needs. Therefore, despite obstacles and difficulties in the process of the presence at patients' bedside, they sought to establish effective communication with patients by intimate and soothing relationships to help them cope with stress of diseases and their treatment, especially the chemotherapy. Nurses stated that in the absence of communication and inappropriate behavior with patients, some patients did not allow to be present at their bedside. A great number of studies considered nurses' higher workload and time limitations in doing tasks as disruptive factors of effective communication with patients., In the present study, some young nurses also stated that their presence at patients' bedside was as nurse-based care due to the time limit and the responsibility for taking care of several patients, and they communicated with patients during the care duration, and this could be due to the lack of communicational and technical skills and time management in these young nurses. This study has some limitations that should be point out. This study was conducted only in two educational centers with adult cancer patients. Therefore, we do not know if the experiences of nurses in nonacademic hospitals or social security and private hospitals are different or not. This study does not give us any information about the experiences of nurses in the pediatric oncology ward. We suggest research studies in the future with a variety of participants and settings.
This study revealed that the spiritual beliefs of nurses, their interest in caring the patient with cancer, empathy and compassion for the patient, and humanitarian relationships are facilitators for the presence of nurses in the patient's bed. Although nurses provided caring for the patients with cancer based of feeling mercy and religious beliefs, and in many cases, sacrificing and without financial benefits, the hospital managers need to pay attention to organizational incentives and work environment optimization. Nursing managers can use the results of this study to develop useful strategies for the presence of nurses on the patients' bedside.
This article is a part of a PhD dissertation approved by the Ethics Committee of Golestan University of Medical Sciences. The authors would like to express their sincere gratitude to the Research Deputy of Golestan University of Medical Sciences for the financial support and the participating nurses for sharing their valuable experiences.
Financial support and sponsorship
This study was financially supported by the Research Deputy of Golestan University of Medical Sciences.
Conflicts of interest
There are no conflicts of interest.