Exploring the Experiences of Oncology Nurses about the Factors Facilitating their Presence at the Bedside of Patients with Cancer: A Qualitative Study

INTRODUCTION

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.[12] It is estimated that there will be ~26 million new cancer cases and 17 million cancer deaths per year up to 2030.[23] In Iran, cancer is also the third cause of death after cardiovascular diseases and accidents.[3] Patients with cancer have many health problems and explicit needs requiring complex and individualized care.[4] Oncology nurses as providers of cancer care are view as one of the most prominent members of the health-care group.[5] 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.[6] 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.[7] 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.[8]

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.[9] The nurse presence has a positive effect on the recovery and self-care of patients.[10] Reducing the nurse presence leads to an increase in the aggression among patients and violence against employees[11] and may cause loneliness and anxiety in patients.[12] 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.[13] The presence of nurses is regarded as good quality from the patients' perspective.[14] 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.[15]

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.[16] The present study aimed to investigate nurses' experience of available facilities on their presence at patients' bedside in the oncology department.

SUBJECTS AND METHODS

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[17] 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.[18] 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.

RESULTS

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.

DISCUSSION

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.[19] Nurses' desired levels of religious beliefs can lead to improved work ethic and accountability at work.[20] Religious beliefs have positive and significant relationship with organizational commitment,[21] job motivation, and attitude toward patients and nursing caring.[22] Nurses in threatening situations use positive personal characteristics such as religious beliefs and humanitarian tendencies.[23]

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.[21] 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.[24] 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.[25] 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.[2627] 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.

CONCLUSION

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.