Nurses’ perceptions of caring activities in nursing

Abstract Aim This study aimed to determine nurses’ perceptions of caring activities in nursing. Design A descriptive study design. Methods A Turkish translation of the 25‐item version of the Caring Dimensions Inventory was completed by 260 nurses working in one university hospital. Data were analysed using Mokken scaling. Results Technical aspects of nursing were highly endorsed items such as “observing the effects of a medication on a patient, measuring vital signs, being technically competent with a clinical procedure, consulting with the doctor” except for the item “providing privacy for a patient” which is a psychosocial item. The range of items included in the Mokken scale with “providing privacy for a patient” (mean = 4.31) as the most endorsed, and “exploring the patient's lifestyle” (mean = 2.60) being the least endorsed item. Listening to patients and involving them in their care are not considered as caring.


| INTRODUC TI ON
Nurses are unique caregivers that make a difference in patients' lives. Nurses aim to protect, promote and optimize the health of individuals, preventing illness, facilitating healing, alleviate suffering through the diagnostic procedures and advocate in the care of individuals and families (American Nurses Association, https:// www.nursi ngwor ld.org/pract ice-polic y/scope-of-pract ice/; accessed 10 June 2020). Finkelman and Kenner (2013) underlines that caring relationship, attention to human responses, integrating assessment data, application of the scientific data, advancing professional nursing knowledge, promoting social justice, assuring safe and evidence-based practice are features of professional nursing.
Professional, personal, scientific, aesthetic and ethical human transactions are important in nursing where a patient should be a focus of practice (Kandula, 2019).

| BACKG ROU N D
Caring in the nursing profession is a challenging, universal phenomenon yet a difficult process for nurses to understand and articulate.
Nevertheless, theorists agree that caring is an essential aspect of the nursing profession (Alpar et al., 2013), and the value of nursing care on positive outcomes in patients' well-being is undeniable (Ayyub et al., 2015). Nevertheless, nurse caring is considered as a quality indicator in healthcare organizations (Burtson & Stichler, 2010). As it launched in Watson's Caring Theory, caring occurs whenever a nurse and patient come in to contact with each other's. The theory emphasizes the interactions between the caregiver and recipient; where holistic nursing care is placed in the centre of caring (Kandula, 2019).
Holistic nursing and nursing care which is in harmony with the culture are vital components of Leininger's theory of Transcultural Nursing as well (Alpar et al., 2013).
The magnitude of caring in nursing is very complex (Finkelman & Kenner, 2013); thus, studies conducted on caring in nursing reveal different dimensions of caring as well as different descriptions.
Nursing requires a range of technical and psychological dimensions and has other dimensions that are not clarified . Finkelman and Kenner (2013) emphasizes that practising as a nurse is far beyond the basic knowledge on how to do specific things or the ability to care for someone. Being able to care for someone requires attentiveness, concern and knowledge and art of caring (Finkelman & Kenner, 2013;Hudacek, 2008b).
The latest definition is caring provided by the American Association of the Critical Nurses' Synergy Model for Patient Care is: "activities performed by nurses in a compassionate, supportive and therapeutic environment to promote comfort and healing.
Nursing care also should focus on preventing unnecessary suffering as well." (American Association of Critical Care Nurses, https:// www.aacn.org/nursi ng-excel lence/ aacn-stand ards/syner gy-model ,2017; accessed 10 June 2020). According to this description, caring includes both attitudes and activities (actions) performed by nurses.
Hudacek (2008a) (Mlinar et al., 2010). Therefore, using narratives is recommended to use in nursing education to expand awareness of nursing students on caring (Hudacek, 2008a). Overall, whenever the person can meet his/ her caring needs in daily life, he/she tends to show sensitivity to the caring needs of others (Baykara & Şahinoğlu, 2014;Öztunç, 2013).
One study involving nursing students emphasizes that students who willingly choose nursing as a career and the ones' who had caring experience are more sensitive to patient needs (Birimoğlu & Ayaz, 2015). Caring perceptions of nursing students are influenced by their attitudes and experiences (Konuk & Tanyer, 2019). There is a need to support nursing students during their education using appropriate methods of teaching and role models are essential (Culha & Acaroğlu, 2019). Overall, nursing students should be taught how to care for themselves at first because being able to take care of the others is consuming a lot of energy and draining experience as well. This is also a very important practice for qualified nurses since nurses tend to ascribe different meanings to caring in nursing.
Although most of the studies involving nurses and patients show that technical aspects of nursing are an important part of their perceptions related to caring (Acaroğlu et al., 2009;Algıer et al., 2005;Ayyub et al., 2015;Geçkil et al., 2008;O'Connell & Lenders, 2008;Özdemir & Şenol Çelik, 2010), psychological dimensions of nursing care should not be underestimated (Ayyub et al., 2015), as well as providing reassurance to patients (Weyant et al., 2017) being his/ her advocate (Hudacek, 2008a) and providing culturally appropriate care (Murphy et al., 2009). Area of practice (e.g. surgical and medical) also influences nurses caring behaviours (Lea & Watson, 1999;Walsh, 1999;. Nurses who are exposed to occupational stress tend to have a low quality of life which can also influence patient outcomes (Sarafis et al., 2016). ICU nurses report that working with dying patients is a stressful, draining, depressing and heartbreaking experience. Also, supporting families is another dimension of care for ICU nurses (Kisorio & Langley, 2016).
According to critical care nurses and the relatives of critically ill patients, technical aspects of nursing are important (O'Connell & Lenders, 2008), this aspect of nursing is also valuable for nursing students as reported by different studies (Akansel et al., 2012 andWatson et al., 2001). Researchers report that gender has an influence on which caring behaviours were valued among nurses the most (Greenhalgh et al., 1998;Lea & Watson, 1999;. Differences were also found between nurses' and patients' perceptions about caring (Geçkil et al., 2008). Nurses should be famil-  (Canzan et al., 2014).
Since nurses' perceptions of caring are influenced by numerous facts, it is important to clarify the nurses' understanding of the phenomenon of caring. As far as we know of no study that determines the caring dimension of the working nurses using the Caring Dimensions Inventory Turkey (CDI-25).

| Aim
This study aimed to determine nurses' perceptions about caring activities in nursing by using CDI-25 and compare the findings with relevant literature.

| Design
Demographic variables and data on nurses working status were collected using a data collection form which consisted of 10 questions.
-Four questions were related to demographic variables of nurses.
-Five questions were related to nurses working experience, number of patients assigned, wards they work.
-One question used to determine nurses' perception of the efficiency of nursing care given to patients using the Visual Analogue Scale (0 = not efficient, 10 = completely efficient).
The Turkish translation of the CDI-25 (Akansel et al., 2012) self-administered questionnaire for measuring nurses' perceptions about caring originally developed by Watson and Lea (1997) was used for data collection. CDI-25 includes twenty-five statements of nursing actions. In the study of Lea et al. (1998), CDI-25 was categorized into five dimensions; psychosocial, technical, professional, inappropriate and unnecessary activities. There is a base question in the inventory: "Do you consider the following aspects of your nursing practice to be caring?" CDI-25 includes statements of nursing actions. Respondents answer the items included in the inventory through a 1-5 point scale (1 = disagree and 5 strongly agree).
Chronbach's alpha value of CDI-25 was calculated as 0.91 indicating that it had a high degree of internal consistency (Watson & Lea, 1997

| Sample and data collection procedure
Data were collected during September 2015-February 2016 by two of the researchers in one university hospital in the northwest region of Turkey. Four hundred fifty (N = 450) nurses were employed in the hospital during the conduction of this study. Operating room nurses and outpatient clinic nurses were excluded from the study since uninterrupted patient care is not available in those departments. Nurses who were on sick leave, annual leave or unpaid leave were also excluded making. Data were collected from 280 nurses who volunteered to participate in this study. Since 20 participants did not complete the forms properly (missing data on the data collection form and CDI-25 inventory), study was completed with 260 nurses Researchers handed the forms (data collection form and CDI-25 inventory) in envelopes to the nurses and collected completed forms after one week.

| Mokken scaling
The present study used the non-parametric item response (   Permission was obtained from the author to use the scale (CDI-25

| Ethics
Turkish Version) in this study. All of the nurses were informed about the aim of the study both verbally and in writing. They were reassured that participation is voluntary and have the right to leave the research at any time they want to.

| RE SULTS
The CDI was administered to 280 nurses and 260 completed it giving a response rate of 92.8%. Nurses' ages ranged between 20-53 years (mean = 32.34, SD 6.14). As shown in Table 1 most of the nurses were female (93.8%) and had a bachelor's degree in nursing (78.8%).
The mean working experience of nurses was 9.76 (SD 6.46) years.
According to nurses working in different wards of the hospital, the efficiency of care given to hospitalized patients was 7.14 (SD

| Concepts of Caring in Nursing
Nursing care is composed of professional understanding, knowledge and skills to practice nursing and interactions between nurses and patients (Dinç, 2010). According to Leininger's theory of Transcultural Nursing, nursing is described as a science and type of art which can be learned. Caring is an essence of nursing and basic human need.
Every single culture has some differences and similarities in terms of ethical and moral values. Thus, nurses are expected to give care to their patients in a holistic manner, suitable for their cultural structure and also be respectful to it (Alpar et al., 2013).
Being able to give sufficient, professional and culturally sensitive care to an individual is an important aspect of nursing (Murphy et al., 2009). While teaching these aspects of caring in nursing schools, there is a great emphasis on how to provide patient care properly. Thus, both teaching and learning nursing is a process that Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 1 Assisting a patient with an activity of daily living (washing, dressing, etc.    (Geçkil et al., 2008;Wysong & Driver, 2009), since they believe good technical skills reduce their discomfort and lead to less pain (Ayyub et al., 2015). although the order of the items is different. Items referring to technical aspects of nursing were found to be among the highly endorsed items. Observing the effects of a medication on a patient item was included among the second most highly endorsed items in our current study followed by measuring the vital signs, of a patient, being technically competent with the clinical procedure. According to the results of Pajnkihar et al. (2019), Slovene and Russian nurses also rated the item related to medication administration highly. While "observing the effects of a medication on a patient" was the less endorsed item in the UK study (Watson et al., 2003); the same item was not endorsed in the previous study done with Turkish nursing students (Akansel et al., 2012) as well as in Persian study done with
In Turkey because of high patient ratios per nurse in clinical environments, this may lead nurses to think about the importance of "observing the effects of medications" and "consulting the doctor" as a priority. In addition to this, physicians are the ones who are primarily arranging the treatment of the patient, notifying the doctor may have been evaluated as an important aspect of the nursing care in this study. Besides, working on rotating shifts may have influenced the nurses' perceptions. Night shifts especially exert pressure on nurses because of limited staff and having to make critical decisions in limited time may be worrisome. Concurrently, night shifts and long working hours may also have a destructive effect on nurses. Decision regret is reported to be common among nurses who work more than 12-hr shifts which link to less sleep and not being able to rest well (Scott et al., 2014). Being unable to make critical decisions is an important problem in inpatient settings that could interfere with patient safety. Different studies report that nurses who work on night shifts are more prone to sleep problems (Books et al., 2017;Ferreira et al., 2017) family stressors and mood changes (Books et al., 2017).
"Taking vital signs" which is another technical aspect of nursing has seen as an important caring activity in our study. Assessment of vital signs and evaluating the results are valuable activities in nursing that could guide the treatment of the patient. This aspect of nursing is considered a time-consuming activity because of the number of patients assigned to each nurse (mean: 10, 46 SD 7, 57) in our study. This result can be interpreted as either because nurses usually able to assess their patients during taking vital signs and evaluate the changes that may have to occur on the patient, or they perceive this activity as primary nursing care in their practice. Being technically competent was found to be in the same order in the study with Turkish nursing students (Akansel et al., 2012), and it is quite different from the results of Spanish and UK nurses (Watson et al., 2003). The results of our study are like those conducted previously where take notice of technical aspects of nursing as caring (Acaroğlu et al., 2009;Akansel et al., 2012;Ayyub et al., 2015;Geçkil et al., 2008;Karadağ & Taşçı, 2005;Karaöz, 2005;Weyant et al., 2017).
According to these studies, it can be considered that priorities in nursing care activities could change according to patients' and nurses' perspectives and expectations. Also, social, cultural and religious beliefs, the caring culture of the facilities, individual variations and willingness to practice the nursing profession may influence caring perceptions of nurses. Geçkil et al. (2008) emphasized that the protection of privacy by nurses afforded the most satisfaction to patients from the nursing care they receive. In this study "providing privacy for a patient" was the most endorsed item which is the same as a previous study with Turkish nursing students (Akansel et al., 2012).
This result could be linked to the cultural structure and the beliefs of Turkish people where privacy takes an important place. Providing privacy was the second most endorsed item in UK nurses and the fourth item in Spanish nurses (Watson et al., 2003) (Table 4).
Nurses caring behaviours have a great influence on patients' satisfaction (Azizi-Fini et al., 2012). Although patients and relatives emphasize the technical aspects of nursing; the kindness of nurses is a valuable thing that is hard for them to forget easily even after leaving the hospital, touching (Algıer et al., 2005) part of effective nursing care by patients. Having a positive attitude and smiling is worthy for patients in the evaluation of the quality of nursing care (Ayyub et al., 2015;Wysong & Driver, 2009). Patients in critical conditions and treated in ICUs are usually influenced by physical, physiological and environmental stressors (Dedeli & Akyol, 2008). Pain, tubes, not being dressed during their ICU stay, unusual noises and continual lighting are some of the stressors patients usually remember even after being discharged from the hospital. Studies reveal that not having privacy in ICU is considered an important stressor for patients (Aktaş et al., 2015;Zaybak & Çevik, 2015); however, nurses did not give this the same priority as patients (Zaybak & Çevik, 2015). Novaes et al. (1997) reported that lack of privacy is not considered a priority among all stressors especially by male patients in ICU. Emergency room (ER) patients usually experience some kind of privacy infringements according to Karro et al. (2005). This situation causes patients to withhold the information from caregivers which may lead to serious adverse effects on treatment and care of the individual. Outcomes of studies related to stressors perceived by patients could be linked to several factors such as physical environment, patient experiences and cultural disparities (Dedeli & Akyol, 2008 clinical procedure * Measuring the vital signs of a patient (e.g., pulse and blood pressure) Observing the effects of a medication on a patient Providing privacy for a patient * *Items common to mokken scales from the UK, Turkish nursing students and Turkish nurses (All of the items were listed according to their mean scores.). However, nursing care is not limited to only its' technical aspects; it is a profession that requires plenty of both technical and psychological skills which includes knowing and treating the patient as an individual. Some studies point out that nursing students usually choose nursing as a career choice because of easy employment status rather than their capability to do it (Cho et al., 2010). In Turkey, university students usually choose their careers according to their grades after university entrance examinations. So, there is no way to determine the ability of students who enter into nursing schools in current practice. Choosing a profession only because of easy employment status also could be a reason for different perceptions about nursing care besides difficulties raise by working conditions itself.

| Limitations
One of the limitations of this study was nurses who were employed in one university hospital were included. Although the results of this study cannot be generalized to all the nurses in Turkey, findings of this study are quite similar to the ones done previously with nursing students. Another limitation of the study was that there are limited studies related to perceptions of nurses about caring in Turkey.

| CON CLUS ION
In conclusion, the results of this specific study suggest that technical aspects of nursing were mostly endorsed items in CDI-25 except for the item providing privacy for the patient. It has been perceived that although some cultural factors do influence perceptions of nurses about caring, they usually focus on the technical skills of nurses.
The influence of therapeutic communication skills, the success of the nurse-patient communications and the cultural values of nurses may change nurses' perception of nursing care. Different studies related to caring in nursing should be conducted to specify why a psychosocial aspect of nursing is not considered a priority by nursing staff. Also, studies related to caring in nursing should be conducted to specify how cultural factors influence the perceptions of caring among nurses.

| CONTRIBUTI ON S
NA, RW, NV and AÖ: Study Design. NA and AÖ: Data collection.
RW: Data analysis and Review of the manuscript. NA, RW, NV and AÖ: Manuscript preparation.
All authors approved the final version of the manuscript.

ACK N OWLED G EM ENTS
We would like to thank all the nurses who volunteered to contribute to this study.

CO N FLI C T S O F I NTE R E S T
The authors declare that there are no potential conflicts of interest related to research, authorship and publishing of this article.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data can be provided by the corresponding author on reasonable request.