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Nurse Caring Behaviors as perceived by Nurses and Patients: A

Scoping Review


Society as of today has a broad understanding of care, but

there is no single definition of care that is applicable to all

situations. In nursing, many theorists has its own definition on

caring. Here are some of the definition given by nursing

theorists: Caring is the fundamental structure of many nursing

theories (Henderson, 2007); Human Caring is seen as the origin

and essence of nursing (Leininger, 1986); and according to Watson

(1988), it maintains human dignity in healthcare systems as moral

principle and measure of intervention and treatment. Therefore,

to become an effective and efficient nurse one has to develop

caring behaviors that are not only being perceived by the caring

nurse but also the one receiving the care.

Caring as an essential element of nursing is widely accepted

among nurses. Nurses' caring approach enhances patient's health

and well-being and facilitates health promotion. Nurses' caring

behaviors were highly valued as important in providing quality

patient care (Bermudez, 2011). Caring to be an interpersonal

relationship indicates that it is a mutual endeavor of the nurse

and the patient, encompassing both the feelings and the behaviors

that occur between them.

Many studies have concluded that changes in the health care

system have strengthened nurses workload and responsibilities.

Caring nurses must find ways on how to preserve their caring

behaviors in such changes because of the increased perception of

patients with regards to the care that they receive from nurses

especially when one`s condition is difficult.

Knowledge, attitude and skills of nurses are the basis of

nurse caring behaviours as three most important factors in

evaluating the quality of nursing care behaviours. The quality of

nursing care can be evaluated by measuring knowledge, attitudes

and skills of nurses. However, some patients may not understand

properly caring behaviours (Chang et al., 2003).

To be meaningful, the caring of nursing must be based upon

mutual agreement between nurses and patients as what constitutes

nurse caring behaviors. Nurses cannot be certain that their

behavior is consistent with patients' perceptions of their care

and also, nurses cannot assume that patients perceive caring

efforts as they are intended. Hence, nurses should see that

patients themselves are the recipients of care and their

perception of the delivered caring is important; in addition, the

variation in the patient and nurse perceptions of caring

behaviours may cause dissatisfaction among patients. Therefore,

assessment of nurse caring behaviours from patient and nurse

perspective can provide better feedback for nurses and nursing

administrators as well as patients.

Objective and Review Questions:

The objective of this study is to assess and determine Nurse

Caring behaviors based on the nurses and patients perception.

Specifically, it aims to answer the following questions:

1. What are the determinants of the caring behaviors of nurses

in the hospital setting?

2. What is the level of nurse caring behavior as perceived by

3. What is the level of nurse caring behavior as perceived by

patients according to their age group (Pediatric/Elderly)

and their cases (oncology,trauma,DM)?

Inclusion criteria:

Studies were included in the final synthesis if they sampled

patients and nurses. Studies with non-clinical populations (e.g.,

community, companies) were excluded. We were interested in

studies that had a primary aim to explore the perception of

nurses and patients on nurse caring behavior. Studies that uses

Caring Behavior Inventory tool and quantitative research design

were also included. Broad categories of evaluating the quality of

nursing care behaviours were explored in this review: knowledge,

skills and attitude.

Type of Participants

Studies that were included focused on patients who are

admitted and were receiving healthcare service. Those that

focused on registered nurses who were involved in the delivery of

healthcare services were also included.


Nurse caring behavior was the key concept of this review.

Studies were considered the level of programs and activities

implemented to improve caring behavior of nurses.


Hospital setting was the context for this review.


The scoping review, a methodology described by Arksey and

OMalley and that was later systematized, was adopted for this

study. The scoping reviews six methodological steps were

followed: (1) identify the research question; (2) and relevant

studies (search for relevant studies); (3) select studies; (4)

extract data; (5) separate, summarize and list the results; (6)

report results.

To properly answer the studys question, we opted to search

primary studies describing the contexts of the Nurse Caring

behaviors in general. The search included studies published from

2007 to 2017. In order to be comprehensive, various sources were

consulted, including the databases of ProQuest and Google

Scholar. The search terms were related to components of nurses

caring behavior, and perceptions of nurses and patients.

Excluded studies were those addressing subjects other than

nurses, such as students, studies conducted in contexts different

from that of hospital care setting such as primary health care

and/or teaching facilities. Two researchers independently

conducted the search between February to March 2017.

Disagreements were discussed with a third and fourth researcher

and resolved by consensus that is, results from the independent

search conducted in the databases were compared and differences

were verified in order to comprise the highest number of studies

addressing the topic.

The mapping of data with the use of a structured instrument

enabled the identification of the studies essential elements,

which allowed the synthesizing and interpretation of data and the

generation of a basic numerical analysis of the extension, nature

and distribution of studies included in the review. Finally, the

results were compiled to present an overview of the overall

content through an organized thematic construction in accordance

with the nurses' and patients perception of nurse caring



From an initial database search of 1,728 papers, 1,693

papers were excluded after reading the article title, then there

were 19 papers excluded after reading the abstract, and finally 5

papers were excluded after they were read fully (Figure 1).

Eleven papers were selected for inclusion in this review.

Majority of the papers were descriptive studies, 3 of which are

descriptive correlation and 3 are descriptive comparative studies

and the rest were considered descriptive studies in general.

Meanwhile, one paper was a literature review, and another paper

is a metasynthesis. Some of the papers have use various tools

like the Caring Behavior Inventory (CBI), Nurse Caring Patient

Scale (NCPS, Care Assessment Questionnaire (Care- Q) by Larson,

and a Modified Caring Behavior Assessment Tool.


Determinants of Nurse Caring Behaviors

Two of the papers reviewed used the Caring-Behavior

Inventory (CBI) which is a 42-item questionnaire and used a 6-

point Likert Rating for each item. The items were group into 4

subscales namely: Assurance, Knowledge and Skill, Respectfullness

and Connectedness.

Also, the Nurse Caring Patient Scale (NCPS) which was

developed through the metasynthesis of 90 published qualitative

studies emphasized 3 attributes: (1) Presence and Concern for the

other, (2) Knowledgeable and Competent Care, (3) Respect for the


Furthermore, one study showed that spending time with

patients was a predictor of the nurses ability to express Caring

Behaviors and that listening is reflective of caring.

Nurse Caring Behavior as Perceived by Nurses

One study showed that Nurses demonstrated self efficacy and

believe that they have the ability to establish Caring relations

with patience. Nurses perceive caring behaviors being related to

a nurse's ability to anticipate the needs of the patients. Nurses

also put a higher value on caring behaviors which demonstrated

technical competence, the altruistic and emotional aspects of

Another study showed that a nurses feeling of ease and

acquaintance may influence the amount of caring behaviors

rendered. Nurses do know their patients well enough to judge what

aspects of caring the latter consider important in order to feel

well cared for.

The clinical nurses who participated in a study which aimed

to describe nurse's perceptions in their own caring behaviors six

month after an implementation of a new Relationship Centered Care

Professional Practice Model, rated all aspects of caring very

high. The result of the study were consistent with prior

researches that used the CBI.

Nurse Caring Behavior as Perceived by Patients

Elderly Patients

Two studies that were reviewed focused on elderly patients

perception of Nurse Caring behaviors. According to the results of

the studies, elderly patients responded that nurses were actively

applying caring skills and caring knowledge. According to them,

active caring includes knowing, having a presence, doing for,

advocating and supporting, which demonstrates interpersonal care

that elder patients desire. Elderly patients also defined a good

nurse as a nurse who have the necessary technical and

psychosocial skills to care for patients.

Pediatric Patients

A study that was aimed at identifying the nursing actions

that are important in constituting a feeling of being cared for

by pediatric patients. The study showed that the Nurse Caring

Behavior mostly perceived by the pediatric patients was being

cheerful and gentle with me. The ranking of the most important

nurse caring behaviours by the PPs revealed that be "cheerful and

gentle with me" "treat me as individual", "be kind to me" "be

considerate" were considered very important. These items are on

Jean Watson's subscale of humanistic/ faith-hope/ sensitivity.

Watson(2007), stated that this subscale which include kindness,

empathy, concern, and love for self and others provides the basis

of human caring thereby promote the best professional care.

Therefore it constitutes the first and most basic factor for

science and ethic of caring. Other items identified in this study

includes; "help me feel good about myself", "listen when I talk",

"give me their full attention when with me", and "answer quickly

when I call for them"),' 'help me with my care until am able to

do it myself" and "should not expose my body". These finding

supports that of Schmidt , Bernaix , Koski , Weese , Chiappetta,

and Sandrik (2007), who conducted a qualitative study to assess

the perception of nurse caring behaviours among paediatric

patients. They reported that children appreciated nurses who

smiled and used kind words, provided age-appropriate diversion

and light-hearted conversation, promoted positive well-being and

a sense of security, interacted with them as an individual and

provided comfort and support.

Trauma Patients

Patients receiving care through trauma services expressed an

overall positive perception of caring from the nursing staff. The

study which used the CBI highlighted the need to spend time with

the trauma patient and to respond quickly.

Oncology Patients

The study that was aimed at determining the caring behaviors

perceived by oncology patients and oncology nurses used the

Caring Assessment Questionnaire p (Care-Q) by Larson. The

original questionnaire consisted of 50 caring behaviors that were

categorized into the following 6 subscales. "Being accessible" (6

items), "Explains and facilitates" (6 items), "Comforts" (9

items), "Anticipates" (5 items), "Trusting relationship" (16

items), "Monitors and follows through" (8 items). In the study

however, have converted the Care-Q forced response format to a

Likert-type free rating scale.

The results showed patients and nurses perceived "Monitors

and follows through", "Being accessible" as the most important

and "Comforts", "Trusting relationship" as the least important

subscale. Indeed, there are the same ranking for patients and

nurses. Also these mean scores showed that patients gave higher

mean values than did nurses to a large number of subscales. This

indicates that patients, to a greater extent than nurses,

consider several Care-Q dimensions to be of a very high


Diabetic Patients

The study aimed to examine the perceptions of caring

behaviors that influence the patient experience in acute care

nurses to hospitalized patients with Diabetes. Patients with DM

identified that keeping them informed of their response to

treatment or procedures for the day as reflective of more caring.


This scoping review provides an overview of how nurses and

patients perceive nurse Caring Behaviors. While some of the

articles reviewed pertained to specific target populations, the

frameworks and concept all pertains to Nurse Caring behaviors.

The results show that elderly patients desire actions and/or

behaviors which demonstrates interpersonal care. Some of the

interpersonal skills identified are: expressed concern of the

patient's physical and emotional status, self-disclosure of

feeling, and non-verbal caring behaviors to include sitting at

the bedside and sustaining eye contact.

Watson(2007) stated that sub scale which include kindness,

empathy, concern and love for self and others provides the basis

of human caring thereby promote the best professional care. An

analysis of the relative importance of identified behavior

revealed that nursing actions that focused on the physical care

and monitoring of patients were seen as most indicative of

caring. Teaching activities were also perceived as significant

whereas extra, individualized aspects of care were viewed as less

important in the critical care setting. Furthermore, patients

tend to focus on how a nurse does versus what a nurse does when

asked about their perception of caring behaviors.

Increasingly high extent agreement between patients and

nurses as to the importance of caring behaviors could have great

potential for improving the quality of nursing care. Furthermore,

the "Being accessible" and "Explains and facilitates" subscales

or the likes were more value by patients than nurses, so it is

needed that nurses notice this issue in clinical work. Also, both

the oncology patients and nurses perceived highly physical

aspects of caring. However, for delivering holistic care,

oncology nurses must value affective/emotional aspect of caring,


However, one study comparing the patients and nurses

perception, shows an incongruence between nurses and patients

perceptions on the frequency of provided/received nursing care.

Nurses constantly reported providing caring behaviors more

frequently than patients receiving them. This reflects therefore

that how nurses perceive nurse Caring behaviors does not

necessarily equal to how patients perceive them.


This reviews results show that nurses' and patients'

perception of Nurse Caring Behaviors varies and therefore

unpredictable. This review presents some limitations. The initial

purpose was to assess most of the existing literature. The

possibility of accomplishing this, however, is limited, as there

may be studies published in other languages and in index

databases not included in this study.

The results show that how a nurse performs nursing, how a

nurse administers care and how a nurse demonstrates caring

behaviors correlates with patients' perception of caring.

Furthermore, the determinants identified are almost alike with

other studies, that which constitute to Knowledge, skills and

attitude.The challenges presented require that nurses should be

aware of the fact that the nurse Caring Behavior they are

providing to patients may not be perceived by patients as they

were intended.

The conclusion is that this reviews results are useful for

future studies addressing the practice and education of nurses.

There is a need to more fully understand the dimensions of nurse

caring. Further study is recommended to determine the meaning

that the individual caring behaviors have for nurses. Also, it is

important to ascertain if there are variations in the perceived

importance of caring behaviors dependent on the patients

receiving care. Also, continued study comparing nurses and

patient perceptions of caring behaviors of nurses is recommended

as are studies linking nurse caring behaviors to patient


Hence, educational reinforcement on caring to nurses and

more studies is also recommended. Nursing is quickly moving

towards the forefront of our health care system but it must not

forget caring as its foundation.