1. Introduction

Have you ever witnessed a health care professional pushing on the abdomen of a mother whose about to give birth in an attempt to hasten the chilbirth process? All the while another health care professional is taunting the mother, “why are you crying in pain when you had a good time in making it.” You may have seen also a health care professional doing rounds in the middle of the night to avoid talking to the patients. There are also patients who had been waiting all day for a chance to talk to their nurses. How many times have you witnessed a nurse scolding the patient and family because of stress and exhaustion? These are harsh realities but are very much common occurrences that characterize nurse-patient interaction in some hospitals in the Philippines today.

Caring Nurse-Patient Interaction (CNPI_ is essential to nursing practice. A high-quality level of nurse-patient interaction is defined as a therapeutic relationship with the patient wherein the nurses determine the client’s most relevant concerns, evaluate the client’s perceptions, provide venue for the client to express emotions, provide information and training to the client and family the needed self-care skills, identify the client’s needs, employ interventions to meet the client’s needs, and facilitate the client’s recovery (Videbeck, 2011).

In an ideal nursing care environment, nurses tend to be more caring, reliable and responsive to the patients’ needs. The nurse should possess the following attributes: compassion, humility, empathy, commitment, cheerfulness, dedication, tact, confidence, subtlety and sincerity (Gunther and Alligood, 2002).

The nurse, being the immediate influential interaction force of a patient, definitely has a great role in a patient’s total healing environment. Patients seek help from nursing staff for all kinds of reasons, such as information, reassurances, advice, or just to have a conversation (Freshwater, 2003). Nursing care means more than just giving medicines to patients. It involves so much more. Subsequently, if nurses do not have enough skills to face stressful situations or effectivelt communicate with patient and colleagues, they may lack the ability to provide outstanding patient care is at risk (Dingley, et al., 2008).

Today, finding time for a quiet interaction with patients is difficult. The fast pace of the hospital setting, presence of goal driven nurses, and hospital-limiting overtime contribute to this difficulty. In addition, the possibility of lawsuits requires nurses to document every procedure, laboratory results, and various therapies, decreasing the time for nurses to talk to their patients or to help them in eating, toileting, and self-care (Smith, 2014).

When patients were asked what they remembered in their hospital stay, the patients would remember their nurses well (Shattell, 2002). Although, nurses were mostly described by patients as nice, patients longed for nurses’ deeper connection with them. Patients felt that nurses do not care enough about them and just stayed away at the nurses’ station except for medication time. Also, they felt that hospital technologies and procedures totally disconnected them from the world they exist in and yearned for the nurses to communicate more with them (Coatsworth-Puspoky, 2006).

In the Philippines, nurses are generally underpaid, and overburdened because of the low nurse and high patient ratio, thus, further limiting the time for quality interaction between the nurse and patient. Galvez-Tan (2005) revealed that the latest nurse to patient ratio in The Philippines is 1:50. The international standard for the ideal ratio of nurses to patient in hospitals is 1:4. Even at the Philippine General Hospital (PGH), a premiere hospital in the country, the ratio of nurse to patient average from 1:15 up to 1:25. It was also reported that in many hospitals in the Philippines, the ratio would even reach 1:50 up to 1:100 (Galvez-Tan, 2005).

Many nurses in the Philippines also report of having to extend their duty hours. In an urban hospital of 100-bed capacity, nurses are only expected to be on duty for 40 hours per week. But, when no reliever is available, nurses had to be on duty for 56 hours per week, sometimes for 16 hours straight (Makilan, 2005).

Despite conducting communication technique trainings, seminars, workshops, and classes to prepare and mold nurses to interact with patients effectively such as being composed, caring, and acting professionally, effective nurse-patient interaction is still overlooked as far as nurse-patient relationship is concerned.

This study was conducted to explore the influential components affecting the CNPI in the Philippine setting. It specifically sought to answer the following determine the extent by which the nurses apply the CNPI behaviours in clinical practice and identify the most influential dimensions that characterize the CNPI?

2. Research Methods

The mixed method research which is the blending of the quantitative and qualitative research designs in one single project was used in the study to determine the influential components of CNPI from the point of view of the nurses. The quantitative part of the study used the nonexperimental, descriptive design while the qualitative part of the study used the grounded theory research design to “discover theoretical precepts about social psychological processes and social structures, grounded in data” (Polit and Beck, 2012, 268). In this study, the triangulated mixed method design was used to capture the same phenomenon, with the focus on convergence and increased validity (Polit and Beck, 2012).

2.1. Participants of the Study

All the eighteen (18) staff nurses in one tertiary hospital in Philippines participated in the study.

2.2. Research Instruments

Two major research instruments were used to gather the data:

1. Nurse–patient interaction caring scale (CNPI-Scale) by Sylvie Cossette, Chantal Cara, Nicole Ricard, Jacinthe Pepin (2005), which was originally developed to assessing nurse–patient interaction from a caring perspective. The 70-item Likert questionnaire instructed the respondents to indicate the degree or extent to which they adopt or apply the specific attitudes/behaviours in clinical practice on the scale of 1 to 5: 1 = not at all/never; 2 = not really/ rarely; 3 = undecided/every once in a while; 4 = somewhat/sometimes; 5 = extremely/ always.

2. Open-ended questionnaire

Four main questions were asked in the questionnaire:

a. What do you think are the most important factors for a nurse to apply the CNPI behaviours? Why?

b. What specific instances do you feel you are able to show CNPI behaviours to patients?

c. As a nurse, what do you think are realistic CNPI behaviours?

d. What possible programs or interventions do you think you need further as nurses to improve your CNPI behaviours?

2.3. Ethical Considerations of the Study

All the participants of the study were asked to sign the informed consent form which is included in the front matter of the survey questionnaire. They were assured of anonymity and confidentiality.

2.4. Data Analysis

To answer the first research problem which determining the degree by which the nurses apply the CNPI behaviours in clinical practice, the mean score and standard deviation of the CNPI behaviours in clinical practice were computed. Then the dense ranking of items was determined.

The mean scores obtained from each of the ten (10) components of CNPI and each of the items within each component was interpreted based on the following interpretation scale:

1.0 to 1.4 = not at all/never

1.5 to 2.4 = not really/ rarely

2.5 to 3.4 = undecided/every once in a while

3.5 to 4.4 = somewhat/sometimes

4.5 to 5.0 = extremely/ always

The qualitative data from the open-ended questionnaires were analyzed following general analytical steps suggested by Polit and Beck (2012) and he grounded theory approach described by Bernard and Ryan 92010). The result of the bottom-up method emerges from the process of data collection, coding and analysis. Constant comparative method of analysis was used to determine data saturation and identify core categories and central themes. An audit trail of the data as a form of validation was conducted by the third author.

3. Results and Discussion

3.1. Extent by which the Nurses Apply the Caring Nurse-Patient Interaction (CNPI) and Behaviours in Clinical Practice

The CNPI behaviours that pertains to “Humanism” (the behaviours that help in the formation of a humanistic-altruistic system of values) ranked highest (M = 4.56, SD = .384) indicating that this the most extremely applied component. This is followed by “Environment” (behaviours that include provision for a supportive, protective and/or corrective mental physical, societal and spiritual environment) (M = 4.47, SD = .496) (Table 1).

Three sets of behaviours ranked third, such as “Hope” (which is the instillation of faith and hope) (M = 4.42, SD =.425), “Teaching” (which refers to the promotion of transpersonal teaching-learning) (M = 4.42, SD =.380), and “Needs” (which are about assisting the patients with the gratification of human needs) (M = 4.42, SD =.445) (Table 1).

The most applied CNPI behaviours are “showing the patients with respect—as well as to those closest to them” and “encouraging them to speak their thoughts and feelings freely” (M =4.77). The next set of behaviours includes “not having a scandalized attitude,” “showing that they will be there for them if they need me,” “respecting their privacy (e.g., do not expose them needlessly)” and “helping them with the care they cannot administer themselves” (M = 4.69).

On the other hand, the CNPI behaviours which obtained the lowest mean scores indicating that these are only sometimes applied by staff nurses are the following: “asking the patients how they would like things to be done,” “helping the patients to see things from a different point of view” and “helping them to look for certain equilibrium/balance in their lives” (M = 4.08). Another set of CNPI behaviours that staff nurses only sometimes applied are: “not seem busy or otherwise occupied when I am taking care of them” and “helping them to explore the meaning that they give to their health condition” (M = 4.00). “Helping the patient to channel their difficult emotions” is also only sometimes applied (M =3.85). The CNPI behaviour which obtained the lowest mean score in terms of extent of application is “making the patients aware of the way those closest to them are experiencing their situation” (M = 3.69).

Table 1. Overall degree or extent by which nurses apply the various components of Caring Nurse-Patient Interaction (CNPI) behaviours

3.2. Dimensions of the Influential Components of Caring Nurse-Patient Interaction (CNPI)

As depicted in Figure 1-4, there are four dimensions of the influential components of CNPI: “what really affects nurse-patient interaction,” “what behaviours show caring nurse-patient interaction,” “realistic caring nurse-patient interaction behaviours,” and “how nurses can improve caring interaction with patients”. Each dimension was inferred from level I codes (or themes) which were derived from thorough analysis responses of the staff nurses in the open-ended questionnaire. Excerpts of the typical responses which were used to generate themes and categories are presented in Tables 2-5 below.

Figure 1. Collapsed level I codes into level II code of “what really affects nurse-patient interaction” based on the Grounded theory analysis of nurses’ responses in the open-ended questions

Figure 2. Collapsed level I codes into level II code of “what behaviours show caring nurse-patient interaction” based on the Grounded theory analysis of nurses’ responses in the open-ended questions

Figure 3. Collapsed level I codes into level II code of “realistic caring nurse-patient interaction behaviours” based on the Grounded theory analysis of nurses’ responses in the open-ended questions

Figure 4. Collapsed level I codes into level II code of “how nurses can improve caring interaction with patients” based on the Grounded theory analysis of nurses’ responses in the open-ended questions

Table 2. Collapsed level I codes into level II code of “what really affects nurse-patient interaction”

Table 3. Collapsed level I codes into level II code of “what behaviours show caring nurse-patient interaction”

Table 4. Collapsed level I codes into level II code of “realistic caring nurse-patient interaction behaviours”

Table 5. Collapsed level I codes into level II code of “how nurses can improve caring interaction with patients”

It is well-established that CNPI includes the humanistic, relational, and clinical attitudes and behaviours in nursing practice that promote quality nursing care (Cossette, et al., 2005). The present study showed that the staff nurses in one tertiary hospital in the Philippines believe that they as nurses could promote healing by improving interaction with patients. Findings support the claim of Robinson and Watters (2010) that nurses believe that they must not only be good with her nursing skills but able to communicate well with patients. Being involved with the patients as suggested by Lymer and Richt (2006) was also what the staff nurses consider as an essential element of CNPI Similarly, the findings of Charalambous, et al. (2010) did not differ from the results that according to staff nurses, CNPI should be characterized by shared decision-making, information giving, effective communication with the patients and their families, emotional support, and recognition of their spiritual needs.

According to Smith and Pressman (2010), nurses should be continually trained to improve their craft, especially in communicating well with patients as caregiver. Open communication between the nurse and the patients characterize also CNPI. This is probably what the trainings and seminars for the staff nurses should focus also. Like what the respondents of the present study emphasized, by being real and showing genuine self in the communication and through active listening as what Watson (2005) suggested, caring interaction between nurse and patient become more evident.

CNPI is important so that the clinical, psychological and social needs of the patient are met and treatment is maximized. Through effective patient education, treatment compliance improves (Jenkins et al., 2002). This is evident in the study since one of the themes that emerge was “Teaching” as a realistic CNPI behaviour. In fact, one respondent said that “It is through teaching the patients that a nurse can promote independence...”

It was also noted that nurses emphasized that role of emotions in nurse–patient relationships. By “showing patience and wearing a smile” by the nurse professionals to their patients, such kind gestures contribute to emotional health and therefore maintaining the emotional health of nurses in practice. Hence, it important that nurses regulate their own emotions and nurture also their own emotional health (Cecil and Glass, 2015).

Care is the essence of nursing, but caring is a complex phenomenon that remains indefinable. Literature pointed to the nature of CNPI as fundamental to the delivery of nursing care. There is no universal mechanism or dynamics on the manner by which people express and demonstrate care. We also cannot expect that a totally identical expectation of what quality of care entails. But what was very clear from the findings of the current study was that CNPI should be characterized by effective communication. This was stressed by Crawford et al. (2015) who asserted that effective communication is important to building rapport with patients. Communication cannot be underempasized as a nurse performs his or her role in when assessing the patient, conducting nursing education, as well as counselling (Crawford, et al., 2015).

Lastly, CNPI is an important set of clinical skills in nursing that help in ensuring that the patients are well-taken cared of socially, cognitively and physically. Through high-quality nurse–patient interaction, the patients’ well-being, psychological and physical health, and psycho-spiritual functioning can be optimized.