How Do We Enhance Oncology Nurses’ Caring Utilizing Resilience And Professional Quality of Life?: A cross-Sectional Descriptive Study


 Background: Degree of caring behavior in oncology nurses is a crucial factor in caring for patients with cancer. It is important to understand factors related to oncology nurses' caring including their own resilience and professional quality of life. The purpose of this study was to investigate oncology nurses’ resilience, professional quality of life, and caring.Methods: A cross-sectional descriptive correlational study was conducted on 107 oncology nurses using self-report questionnaires. Data analysis included descriptive statistics, Pearson's correlations, and stepwise multiple regression to examine factors affecting oncology nurses’ degree of caring behavior, using SPSS/WIN 20.0 program (IBM).Result: Oncology nurses presented a low level of resilience and degree of caring behavior, a high level of compassion satisfaction, burnout, and secondary traumatic stress. There was a statistically significant relationship between degree of caring behavior, resilience (r = .43, p < .001), compassion satisfaction (r =.51, p < .001), and burnout (r = -.42, p < .001) as well as between secondary traumatic stress and burnout (r = .34, p < .001). Factors affecting oncology nurses’ degree of caring behavior were compassion satisfaction and education level. Conclusions: This study demonstrated that oncology nurses’ degree of caring behavior relates to professional quality of life, and education. This association suggests several implications for nursing practice to encourage holistic nursing. It will be necessary to study the factors affecting nurses' compassion satisfaction, and to try to promote compassion satisfaction according to the study.


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This study is a cross-sectional descriptive correlational study conducted with the oncology nurses working at a tertiary hospital located in Seoul, Korea. Participants were oncology nurses who received information about the study through poster advertisements at patient care unit and informational brochures distributed to their work mailboxes. Those eligible for the study were all nurses who worked cancer patients care unit in the oncology ward, outpatient chemotherapy treatment center, and hematopoietic stem cell transplant ward. Participants also had to be willing. Interested participants initially were interviewed to ensure their understanding of the study and its anticipated bene ts and risks. During the survey, if participants want to stop, they can stop at any time. After the participants expressed their intention to participate, researchers obtained participants' written informed consent In this study, the G*Power 3.1 program was used to estimate the sample size, with the signi cance level set at .05, a power of .80, and an effect size of . 15, a median effect size of regression, and with 6 independent variables (resilience, professional quality of life's three subdomains, education, job satisfaction) based on the literature. This resulted in a minimum sample size of 98. Considering a dropout rate of 12% [5] the target sample size was determined at 118 nurses. This questionnaire was distributed among 118 nurses, from which 111 responses (recovery rate 96.52%) were collected, and 107 were used in the nal analysis, excluding four incomplete responses.
We used a structured self-report questionnaire consisting of 89 questions, 25 items for resilience, 30 for the professional quality of life, 20 for the degree of care, and 14 for general characteristics with the approval of the original author and the translator. The total time required to complete the questionnaire was 20 min.

1) Resilience
Connor-Davidson Resilience Scale (CD-RISC) developed by Conor and Davidson [21]. The Korean Connor-Davidson Resilience Scale (K-CD-RISC), adapted and validated by Baek Hyun-sook [22], was used to measure resilience in oncology nurses. This tool consists of a total of 25 questions and ve subdomains; toughness, perseverance, optimism, support, and spirituality, measured on a 5-point Likert scale (0 not at all, 4 very so). And the tool's total score ranges from 0 to 100. Higher scores indicate higher levels of resilience. Regarding the reliability of the tool, Cronbach's α was .91 in Baek's study [22] and .92 in the present study.
2) Professional quality of life Professional Quality of Life Scale: Compassion Satisfaction and Compassion Fatigue Version 5 developed by Stamm [23]. This tool consists of a total of 30 questions, 10 questions for each of the three subdomains: compassion satisfaction, burnout, and secondary traumatic stress, measured on a 5-point Likert scale ranging from 1 'not at all' to 5 'very often'. The total score of each sub-factor is independently evaluated without using the total score of the 30 questions, for a possible range of scores from 10 to 50. Additionally, to determine the high-risk group with low professional quality of life, the total score of each subfactor is standardized with a Z score of 50 and a variance of 10, and then the standardized score is compared with the average of the population. A percentile range of 75% or higher is categorized as high; 25-75% as medium; and 25% or lesser as low [22]. Regarding the reliability of the tool, Cronbach's α in Stamm's study [23] was .88 for compassion satisfaction, .75 for burnout, and .81 for secondary traumatic stress. In this study, Cronbach's α was .91 for compassion satisfaction, .78 for burnout, and .75 for secondary traumatic stress.

3) Caring
The Care Factor Survey-Care Provider Version developed by Watson and Nelson [24]. It was subsequently translated and discussed by a bilingual expert through a committee method [25]. We used this tool to measure degree of caring behavior which are humanistic practice, faith in decision making, instilling faith and hope, learning and teaching, spiritual beliefs and practices, holistic care, helping and trusting relationships, creating a therapeutic environment, promoting emotional expression, and accepting miracles. Each of these ten perception factors for caring consisted of two questions, measured on a 7-point Likert scale ranging from 1 'disagree' to 7 'strongly agree'. The total score ranges from 20 to 140; the higher the score, the higher the level of care. Regarding the reliability, Cronbach's α was .92 in Johnson's study [24] and .94 in the present study.

Procedures
Data collection was done from May 18 to 24, 2015. We provided written information, including the purpose and nature of this study, anonymity of data, guaranteed con dentiality, and the option to withdraw from the study at any time, to potential nurses and obtained their signed consent to participate. Those who read the explanation and agreed to participate in the study completed a self-report questionnaire.

Data analysis
The collected data were analysed using IBM SPSS/WIN 20.0 statistical program. Using an independent t-test, one-way ANOVA, and the Scheffé post-hoc test, we analysed the difference in resilience, professional quality of life, and degree of caring behavior, according to the general characteristics of the nurses. Then, we calculated Pearson's correlation coe cients to investigate the relationship between the nurses' resilience, professional quality of life, and degree of caring behavior. Lastly, stepwise regression was performed to identify the factors affecting the degree of caring behavior of the nurses. average of 4.96±4.54 years. As for the position held, 56.1% of them were more than charge nurses. Regarding their working department, the internal surgery ward was common to 82.2%, and 78.5% worked in three shifts. The highest job satisfaction reported was by 47.7%, with 4-6 points in the middle, and an average of 5.84±1.78 points out of 10 points, and 59.8% of them were able to take a break on the desired holiday. (Table 1). The nurses' total resilience was slighter higher than midpoint, i.e., 57.81±11.49 out of 100 points, and the average score was 2.31±0.46 out of 4 points. And nurses' compassion satisfaction as one of the professional quality of life (average score of 3.36±0.5 points/5 points) and degree of caring behavior (average 4.76±0.67 points/7 points) were higher than midpoint. (Table 2). As a result of the group analysis of professional quality of life, the median group showed the most compassion satisfaction, burnout, and secondary traumatic stress, with 43%, 45.8%, and 60.7%, respectively. Furthermore, 75.7% of the nurses indicated moderate or higher levels of burnout, 83.1% indicated moderate or higher secondary traumatic stress, and 26.2% indicated high compassion satisfaction (Table 3). Additionally, in the transformed z-values to identify high-risk groups with low professional quality of life, we found that 5.61% belonged to the high-risk group. In this group, the average of resilience (42.83+7.14 points) and degree of caring behavior (87.67+11.34 points) were lower levels than the overall average. , and degree of caring behavior (F=17.39, p<.001) were signi cantly higher. And higher job satisfaction than lower was lower burnout (F=45.18, p<.001). When others were available to consult with, they were higher compassion satisfaction (t=3.10, p=.002) and lower burnout (t=-2.35, p=.021). The burnout was higher for those with the total clinical experience between 1 and 3 years than for those with 7 years or more (F=3.45, p=.019) and in the staff nurses than the charge nurses and head nurses (t=2.15, p=.034). Secondary traumatic stress was higher in the case of the third shift than in the case of full-time jobs (t=2.25, p= 026), and when working in the ward than in the case of working for both outpatients and the ward (t=2.52, p=.013). The degree of caring behavior for the charge nurses and head nurses was higher than that of the staff nurses (t=-2.09, p=.039). Additianally degree of caring behavior was signi cantly higher in nurses who were enrolled in a graduate school or higher than in those who graduated from a vocational college or a four-year university (F=6.34, p=.003) ( Table 4).  The factors affecting Caring For the multiple regression analysis using the stepwise method. As independent variables, resilience and three subdomains of professional quality of life were selected which had a statistically signi cant correlation with the nurses' degree of caring behavior. As a result of the univariate analysis, education and job satisfaction with a statistically signi cant difference from nurses' degree of caring behavior were included. Education, the nominal variable, was converted to a dummy variable and analysed. As a result of verifying the variance expansion factor and correlation to con rm the multicollinearity between the independent variables, the variance in ation factor (VIF) of caring was 1.01~2.74, which was less than 10, con rming that there was no correlation between the independent variables. Additionally, the Durbin-Watson value was 1.62, within the range of 1.5 to 2.5 which satis es the assumption of independence between the independent variables and can admit the suitability of the regression model analysis. The nal regression model set in this study was found to be statistically signi cant (F=26.48, p<.001). Through the stepwise multiple regression analysis, it was con rmed that the factors affecting nurses' degree of caring behavior were compassion satisfaction (t=6.00, p<.001) and education above graduate school (t=3.45, p=.001). The degree of caring behavior showed a signi cant strong correlation with compassion satisfaction and education above graduate school, and it was found that it also increased when compassion satisfaction or education above graduate school increased. This model explained the degree of caring behavior by 32.5% (Adjusted R2) ( Table 6).

Discussion
This study aimed to provide basic data for interventions to improve caring for oncology nurses by investigating the resilience, professional quality of life, and degree of caring behavior of oncology nurses and the factors affecting nurses' degree of caring behavior.
In the regression model derived from the results of this study, it can be observed that it is di cult to fully understand caring, as it only explained 32.5% to the variance of caring. Among the factors in uencing the degree of caring behavior of the study participants, compassion satisfaction (t=6.00, p<.001) and education above graduate school (t=3.45, p=.001) were signi cant among the professional quality of life of the nurses. It could be estimated that the degree of caring behavior will increase if they receive graduate school, or higher, education. This estimation is supported by results from other research [26], which found that a person with high compassion satisfaction tends to show eagerness to enter school or that compassion satisfaction increases through higher education. In addition, oncology nurses' caring de ned in this study means holistic nursing, which includes physical, emotional, and spiritual nursing. Interestingly, education above graduate school may be thought to have increased the degree of caring behavior, owing to learning about integrated nursing, including compassion satisfaction and physical nursing, which are the basics of holistic nursing. Although resilience, professional quality of life, and the degree of caring behavior had statistically signi cant correlations with each other in the correlation analysis, the regression analysis was insu cient to explain caring. In order to improve the caring for oncology nurses, a wide range of studies will be needed to elucidate other variables or parameters that are associated with resilience, professional quality of life, and caring.
The resilience of the nurse participants was slightly lower than that of general ward nurses (Averge mean 2.33±0.46), intensive care unit nurses (Averge mean 2.41±0.47), and operating room nurses (Mean 75.9±11), using the same instrument [16, 27,28]. This relates to our nding that 75.7% of the nurses in this study showed higher burnout than average. We found the signi cantly negative relationship between burnout and resilience has been demonstrated in other study for general nurses [29]. According to them, we may think that high burnout of the nurse participants related to low resilience. It can assume that the reason that the oncology nurses' burnout is higher than that of nurses in other specialties is due to the characteristic of oncology nursing. In other study, the American and Canadian oncology nurses also presented high levels of burnout and compassion fatigue [30]. Perhaps it can be predicted that oncology nursing is because the nurses tend to sacri ce their personal and psychological needs to meet the patient's needs more prominently [30].
As for the professional quality of life, 75.7% of the nurse participants showed moderate or higher burnout, 83.1% showed moderate or higher secondary traumatic stress, and 26.2% showed high compassion satisfaction. Similarly, in other studies, job stress and burnout in oncology nurses were higher than in general ward nurses and nurses in other specialities [11,20]. In other study of the professional quality of life of oncology nurses in the United States and Canada, oncology nurses in the United States reported high compassion satisfaction (58%), low burnout (52%), and low secondary traumatic stress (52%). In addition, Canadian oncology nurses reported high compassion satisfaction (59%), low burnout (54%), and low secondary traumatic stress (52%) [30]. As a result, we founded that there was a difference from this study. It can be expected that the age and marital status of the study participants had an effect on their professional quality of life. 67.3% and 75.7% of the participants in this study were under 30 years of age and unmarried. In contrast, only 13% and 5% of study participants in the United States and Canada were under 30, and 18% and 14% were unmarried. This is because, in this study, we founded that compassion satisfaction and burnout, which are subdomain of professional quality of life, were related to age and marital status. Therefore, it will be necessary to develop an intervention to improve the professional quality of life, targeting unmarried oncology nurses under the age of 30 who are at risk of declining professional quality of life.
The results of this study showed that job satisfaction was also signi cantly related to resilience, professional quality of life, and caring. Therefore, in order to increase the resilience of oncology nurses, who show higher burnout than nurses in other specialities and generally have low resilience, interventions should be considered necessary to increase job satisfaction by lowering burnout, leading to an increased degree of care. In order to perform proper interventions, it will be necessary to study the factors affecting job satisfaction and implementation.
The average caring score of the nurse participants in this study was 4.76 points, which was lower than the average level of care 5.27 reported in general hospital nurses, measured using the same tool in the other study [32]. It is possible that a low score was obtained because the hospital to which this study's participants belong is a tertiary hospital. Tertiary hospital is where the severity of patients in need of physical care is prioritized based on the acute stage of the disease. So holistic nursing is important, we found that oncology nursing, which is currently important in this study's clinical settings, is centred on physical nursing. This can be inferred through the fact that the education received by the nurse participants who answered yes to the question regarding whether they had ever received education related to cancer patients was education on physical care such as chemotherapy or coping with the side effects of cancer treatment. Nevertheless, since the degree of caring behavior measured in this study assesses physical, mental, and spiritual care as a whole, it seems that the degree of caring behavior in this study centered on physical nursing may have been low. Therefore, it is necessary to emphasize the importance of holistic nursing and encourage the practice of emotional and spiritual nursing, in addition to physical nursing.

Limitations of the study
Since the resilience de ned in this study measures only individual factors, excluding organizational factors, there were limitations in understanding the resilience of nurses. Therefore, a research study including not only individual factors but also organizational factors is necessary. Furthermore, since the regression model obtained in this study only explains 32.5% of care, it will be useful to explore the remaining unexamined variables and to nd other parameters.

Conclusions
This study found that the oncology nurse's resilience, professional quality of life, and degree of caring behavior in uence each other, and factors that in uence these characteristics were identi ed. We demonstrated that oncology nurses' caring relates to resilience, professional quality of life, and education. In order to increase oncology nurses' caring, it will be necessary to study the factors affecting nurses' compassion satisfaction, and to try to promote compassion satisfaction according to the study. It is also suggested to conduct research on additionally needed education in the graduate school to increase caring.
Oncology nurses with 1 to 3 years of total clinical experience or without a support system can be a high-risk group with high burnout and low resilience, and low professional quality of life. Therefore, oncology nurses with these characteristics should be selected in advance and, if necessary, intervention programs should be developed to present coping strategies to these nurses. In addition, adequate emphasis on the importance of mental and spiritual nursing as well as physical nursing in tertiary hospital must be encouraged as a practice. This study provides oncology nurses with the importance of mental and spiritual nursing as well as physical nursing, professional quality of life that enables a positive coping system, such as resilience, and subjective quality assessment of nurses' jobs. There is an applied signi cance which is expected to be helpful in applying holistic nursing to cancer patients in the future and providing practical guidelines for the nursing practice.

Abbreviations
Nurses: Registered nurses Declarations Availability of data and materials Additional data les in Korean are available upon request to the corresponding author.