The Effect of Work Setting and Demographic Factors on Nurses’ Caring Behaviour in Sabah, Malaysia

Background: The uniqueness of nursing profession contributes to the development in knowledge, and experience along with increasing age, education, economy, and position as well as forming a unique gender role throughout the life of this profession. Thus, the development and advancement of the demographic characteristics of nurses developed while in this profession exerts a very large inuence on the caring behaviour of nurses. The aim of this study was to identify the effect of work setting and demographic factors on nurses’ caring behaviour and to identify the differences in nurses’ caring behaviors based on demographic factors between nurses in public hospitals and in public health services in Sabah, Malaysia. Methods: This research is a cross-sectional study using the survey method. Data were collected from 3,532 nurses in public hospitals and public health services within Sabah, Malaysia. Data were analysed using two-way ANOVA. Results: The ndings reveal that age, education, economy, position, and experience had a signicant effect on caring behaviour. Additionally, there are differences in nurses’ caring behaviors based on demographics factors between nurses working in public hospitals and public health services. Conclusion: The present research has provided convergent evidence on the effect of demographic factors on nurses caring behavior and the differences in caring behavior based on demographic factors among nurses in public hospitals and public health services in Sabah, Malaysia.


Introduction
Caring Behavior (CB) is a core value that must be practiced by all staff in Ministry of Health Malaysia (MOH). The application of these values is to realize the vision and mission of MOH, which is to promote and facilitate the use of health care services in the community to achieve optimal health and a highquality health system (Ghazali et al., 2007). To achieve the objectives of MOH, several efforts have been implemented to improve caring services, such as conducting caring service training from time to time to seniors and those who have just joined the health services department and encourage all staff to exhibit CB while serving patients or clients. Nevertheless, however, there is still dissatisfaction with health care services provided. The MOH receives about 7,000 complaints annually covering various aspects including services and facilities (Shazwani, 2017). Among the complaints received from the public were poor services and communication skills among doctors and nurses, long waiting times before receiving treatment, and inadequate equipment. Apart from that, the ministry has to spend about RM20 million every year as compensation for negligence. In the ministry's efforts to address the problem and provide the best treatment to the community, many initiatives have been taken including providing community simulation laboratories in nursing colleges.
Nurses are the backbone of every health care organization and their presence in every space of the health care services and contribute signi cantly to the achievement of the objectives of the national health service. Since caring is the essence of nursing (Huynh et al., 2008), therefore they are more synonymous with CB than other health care workers in in uencing patient's satisfaction (Abdullah et al., 2021;Kaur et al., 2015). Nurses are the largest workforce in Public Hospital (PH) and Public Health Service (PHS), and they spend continuous time around the clock with patients in both settings. CB is often described as more often practiced by nurses who work in PH because they care for patients for 24 hours (shift duty). While nurses in PHS with clients only for 9 hours (o ce hour). It is likely that there are differences in the nurses CB performance due to the differences in the duration of nurses with the patient and client between the two work settings. In addition, nurses in PH take care of critically ill and chronic patients. While nurses in the PHS provide health care services for the community. Therefore, there are differences in workload, workplace environment, and patient and client characteristics between the two settings. Previous studies have identi ed that factors in uencing nurses' CB are workload, job satisfaction, workplace conditions, educational background, as well as the nature of patient characteristics. This condition is considered a major challenge for nurses especially workload and job satisfaction as the main factor in uencing their CB (Shalaby et al., 2018). Due to nurses have different demographic backgrounds then the incompatibility of the workplace with the demographic characteristics of the nurses will affect the caring behavior of the nurses.
Apart from the above challenges, there are also several factors that may in uence the performance of nurses' CB. Previous studies have con rmed that employee biographical factors are one of the determinants of employee performance that contribute to organizational success. Demographic factors that have an in uence on performance include age, gender, education, work experience, and the number of family dependents (Hendrawijaya, 2019). The uniqueness of nursing profession contributes to the development in knowledge, and experience along with increasing age, education, economy, and position as well as forming a unique gender role throughout the life of this profession. Thus. the development and advancement of the demographic characteristics of nurses developed while in this profession exerts a very large in uence on the CB of nurses. Therefore, demographic factors make a signi cant contribution to this profession and should be given attention.

Literature Review
Nurses Caring Behavior Henderson de ned nursing as the unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible (Parker & Smith, 2010). To perform this function, nurses adhere to the values and attitudes of the nursing profession, which is to focus on nursing care and health care. These duties and responsibilities are part of the need to apply a humanistic vision, taking into account the emotional and cognitive aspects of the disease, while respecting the principle of con dentiality, according to a scienti c-clinical perspective but beyond the physical sphere (Fernández-Feito et al., 2019). In performing activities that contribute to the health or recovery of the patient is through the CB of the nurse. The theory of human caring stated that the relationship-focused caring is fundamental for healing practice which honour human holistically besides creating a healing environment. The combination of a caring-healing approach and nursing art is crucial to ensure the focus is on quality of life, inner healing experience, and caring practices that affect the outcome of patient. The existence of human caring value-guided ethic for professional practice and the existing nursing theory is in line with what is required by the public (Watson, 2006).
Nursing has openly evolved as central to the human phenomenon of nursing practice. Nursing's values, ethics, philosophy, knowledge, and practices of human caring require language order, structure, and clarity of concepts and worldview underlying nursing as a distinct discipline and profession. The philosophy and theory of human caring sought to balance the cure orientation of medicine, giving nursing it's unique disciplinary, scienti c, and professional standing with itself and its public. (Watson, 2009). CB makes up the philosophical and ethical foundation for professional nursing and is a major focal point in nursing which is regarded as both an art and a science. This underpinning offers a framework that takes up and cuts across art, science, humanities, spirituality and new dimensions of mind-body-spirit medicine. Nurse-patient caring includes dimensions such as respectful deference to others, assurance of human presence, positive connectedness, professional knowledge and skills, attentiveness to the other's experience (Wolf et al., 2003).
Nurses' CB have long received attention abroad. Locally, however, studies on CB focused on nurses are limited (Kaur et al., 2015) especially related to nurses' demographic factors and work setting. Needlessness, Zhang et al. (2021) found that there are differences in nurses' behavior according to where they work, and demographic factors have signi cant differences between different work environments. In applying CB, nurses give great priority to providing health care to meet the human needs and the environment in which they work (Vujanić et al., 2020). By considering demographic factors, nurses with 15 years of work experience, rated their CB signi cantly lower than 30 years of work experience. Meanwhile, nurses with a Bachelor of Science in Nursing (BSc) rated lower CB than nurses with basic training. The authors explain that since BSc nurses are oriented on organizational work, management, administrative work, and communication with other healthcare professionals. Therefore, nurses with BSc have less time to interact directly with their patients. Whereas Aupia et al. (2018) found that nurses, patients, and nursing students have similar perceptions of CB. Male students had higher mean scores than female students in knowledge and skills assurance and attention. While students with clinical experience of 8 weeks got higher scores in the domain of CB relationships compared to students with experience of only 4 weeks. While the patient assumes the nurses' CB is more important, despite considering knowledge and skills is crucial (Zhang et al., 2021). By creating a caring environment and improving the nurses' CB can improve the quality of patient care and ultimately increase patient satisfaction (Soliman et al., 2015).

Public Hospital and Public Health Service
Nurses working in PHS have a duty to provide nursing care to injured, sick, and disabled patients. They treat patients individually and even treat several patients at one time. While, in PH, nurses are working in the larger community. In addition to caring for clients individually, they also take care of the entire population and strive to protect the health of the population as a whole. The duties of public health nurses include providing health education to the community regarding potential health problems, promoting health, healthy eating, safety, and good hygiene, and improving community access to health services. These different duties and responsibilities is often seen to have unequal workloads as nurses in the PH are considered to be more often involved with CB all the time compare to nurses in PH. For example, nurses who served in outpatient and inpatient units in hospital observed that when the workload of nurses is less due to nurses performing more unproductive activities resulting in a lack of frequency of nurses performing nursing care that re ects CB. A signi cant positive relationship between workload and CB through comfort care and the signi cant positive correlation between work commitment and CB through clinical care indicated that when nurses workload increases and their commitment decreases in achieving organizational goals, therefore can in uence the CB of nurses, in turn, will affect patient satisfaction with health services (Fitriani et al., 2019).
Although nurses in PHS were observed to have higher demands for CB, however, nurses in PH also faced their own challenges. McCullough et al. (2020) found that nurses in remote settings considered primary health care to be a holistic social model of care that included caring for the community as well as the individual. However, they nd it di cult to provide health care consistently to meet their intentions due to the resource-poor nature of the remote setting. The nurse also did not get inadequate physical resources, limited specialist health services, and lack of time was found to affect the ability of nurses in rural areas to provide better primary health care. In addition, although there has been an increase in health care needs, this does not indicate there has been a reasonable increase in the rate of nurses in primary health care services. This imbalance is related to a decline in the quality of care and patient safety, and also the impact on the health of professional groups. Hence, there is high stress among primary health care nurses, who experience many health changes due to burnout syndrome which contributes to a decline in the quality of care and patient safety (Pérez-Francisco et al., 2020). This situation may add further barriers to the practice of CB of nurses in PHS.

Objectives
The aim of this study is to identify the effect of work setting and demographic factors on nurses CB. The study also aimed to identify differences in nurses' CB based on demographic factors between PH and PHS.
The research question is therefore proposed;

Measurement
The questionnaire consists of a demographic information (age, economic status, education level, position, and working experience) section and The 24-item CB Inventory (CBI-24) which is considered to be the third-generation instrument for the measurement of caring (Papastavrou et al., 2011). The current study adopts the CBI-24 by Wu et al. (2006) to explore the perception of the frequency of CB as practiced by nurses. It is based upon a conceptual de nition of nurse caring as an interactive and inter-subjective process that occurs during moments of shared vulnerability between nurses and patients (Watson, 2008). This scale consists of four components, namely, "assurance of human presence" (8 items), which deals with patients' needs and security; "knowledge and skill" (5 items), related to nurses as skillful and educated persons; "respectful deference to the other" (6 items), dealing with how nurses show interest in the patients; and "positive connectedness" (5 items), which corresponds to the need for nurses to be ready to help patients (Wu et al., 2006). For each item, respondents are requested to answer using a 6-point Likert scale (1 = never and 6 = Always). The CBI-24 demonstrated good internal consistency, Cronbach's α = .96 (Wu et al., 2006). The researchers translated the CBI-24 into the Malaysian language and requested help from bilingual experts (two Malaysian nursing experts who can read and write in Malay and English) to translate the translated instrument (Malay version) back into the English version using the backtranslation technique.
Reliability of the instrument A pilot study was conducted to ensure the suitability of this instrument in the local context as this instrument is from abroad. Respondents were composed of various categories of nurses from PH and PHS who came to the College of Allied Health Sciences to attend the local preceptor course. A total of 120 questionnaires were distributed before the program started, only 101 questionnaires were returned, only 95 questionnaires were lled in the demographic data section, and 98 questionnaires were lled in the Nurse Behavior Scale section. The results of the reliability evaluation of the 24-Item CB Inventory (CBI-24) instrument, were found to be at the overall level of Cronbach's alpha reliability coe cient of .960. The results of the reliability assessment for each scale found different Cronbach's Alpha values. The highest Cronbach's Alpha coe cients, was the 'assurance" (Cronbach's alpha = .912), followed by the scale of "respectful" to patients scale (Cronbach's alpha = .887), the "knowledge and skills" scale (Cronbach's alpha = .870), and the "connectedness" scale (Cronbach's alpha = .821).

Data sources
This study used multistage cluster sampling to collect data. At the rst stage, multistage cluster sampling was used to choose hospitals and district health o ces. Followed by selecting the larger hospitals that had many wards and units, and district health o ces that had many health clinics, rural clinics, and other units. For PHS, seven district health o ces out of 24 in the state were chosen involving 10 health clinics, nine maternal and child health clinics, 73 rural clinics, and three traveling or mobile clinics. As for PHS, a total of 12 hospitals were chosen with a total of 244 wards and units out of 24 hospitals across the state. At the second stage, the sample was clustered according to ward or units in PHS and health clinics, rural clinics, and other units in the PH for distribution of questionnaires.
Before data collection, the researchers met with every hospital director, hospital matrons, area health o cer, and district health matrons to discuss the administering of questionnaires. They proposed that the questionnaires be administered by the nursing sister or nurse-in-charge to avoid disruption to the nurses on duty. All personnel involved in the data collection procedure were briefed on how to administer the questionnaire on purpose, con dentiality, how to collect the data, how to respond to any respondents' inquiries and to inform the respondents that they had the right to decline to answer any question for any particular reason or withdraw from the study at any time. Completed questionnaires were kept in sealed envelopes or sealed paper boxes to ensure con dentiality and were not accessible to anyone.
To collect completed questionnaires, the researchers and research assistants re-visited each research site, though some o cers, matrons, nursing sisters, and nurses were kind enough to volunteer to send the completed questionnaires by mail or through o cially recognized individuals. Nevertheless, some challenges arose in the collection process. First, the geographical location of hospitals throughout the state is such that road access is di cult and takes time, especially for health clinics which are mostly located in remote areas. Also, some of the responsible person for administering the data collection unable to cooperate even though the researchers had explained the purpose of the study along with evidence of ethical considerations. Therefore, the study location was shifted to the nearest hospital or clinic that was willing to participate.
Notwithstanding that, a total of 4000 questionnaires were distributed to the respondents. The response rate was n = 3867 (96.68%). However, during the process of data entering, two questionnaires were found not lled, three questionnaires were unusable due to missing data, and three questionnaires had similar responses presumably lled by the same respondent. Next, a straight line was identi ed in 327 responses in which respondents gave a similarly high response rate in the questionnaire, which was considered a biased response to the data (Hair et al., 2017). This brought the total number of questionnaires that could be used to n=3532 (88.3%) which was considered a very high response rate.
Data analysis IBM Statistical Package for Social Sciences (SPSS) version 26.0 program used for data analysis. Descriptive analysis was used to obtain mean, standard deviation, and frequency to represent demographic pro les such as gender, age, education level, economy, position, and experience. Two-way of ANOVA was used to identify the effect of work setting, and demographic factors on nurses' CB and to analyze the differences in nurses' CB based on demographic factors between PHS and PH. The signi cance level was set at p<0.05 and p<0.001.

Results
The respondents aged range from 20 -59 years. The majority level of education was at Diploma level, 2096 (59.3%), followed by Certi cate, 1293 (36.6%). More than three-quarters have economic status at the medium level, 2485 (70.3%). The majority of respondents held the position of Staff Nurse U29, 1795 (50.8%), followed by Community Nurse U19, 1072 (30.5%). The majority of the respondents had less than ve years of working experience, 1229 (34.8%), followed by 5 to 10 years, 815 (23.1%), and 10 to 15 years, 578 (16.4%) ( Table 1). The result of Two-way ANOVA test did not indicate signi cant effect of work setting on CB. The effect of interaction between work setting and demographic factors did not show a signi cant effect on nurses CB. The effect of the demographic factors (gender, age, education, economy, position, and experience) had a signi cant effect on CB ( Table 2). The results of estimated marginal means of nurses CB indicate a signi cant difference in nurses CB between PH and PHS as shown in  .021

Discussion
The purpose of this study was mainly to examine the effects of work setting and demographic factors on nurses' CB. This study also considers the differences in CB based on demographic factors between nurses in PH and PHS. The results showed that there was no major effect of work setting on nurses' CB. behavior according to where they work. They found that the demographic factors (age, work experience, and education level) have signi cant differences between different work environments. They argue that the work environment climate factors greatly in uence the behavior and practice of nurses which greatly in uences patient satisfaction and also re ects the image of the health provider organization. For example, in PH, in addition to performing direct nursing care, nurses also perform indirect nursing care which contributes to the workload of nurses. Shalaby et al (2018), found that 80% of military hospital critical care unit nurses perceived factors of workload, job satisfaction, workplace conditions, and educational background, as well as patient characteristic traits, were highly in uencing nurses' CB and were a major challenge for nurses. Among these factors, workload and job satisfaction were placed by nurses as the rst category factors that in uence nurses' CB. Their nding supported Oluma and Abadiga's (2020) study in which they revealed that nurses who had personal satisfaction with their jobs had high CB.
The results of the two-way ANOVA showed that the age factor had a signi cant effect [F(3,3524) = 18.43, p<.05] on nurses' CB. The sample aged 20-29 years showed a lower level of CB in PH compared to those in the PHS. The level of CB was found to increase when reaching the age of 40-49 in both settings. However, the nurses' CB will decrease when it reaches the age of 50-59 years for samples in the PHS but continues to increase for samples in PH until they reach the age of 50-59 years. Zhang et al. (2021) identi ed the group differences in in-role and extra-role service behavior showed that nurses who work in a PH have a high level of in-role and extra-role service behavior were aged above 40 years. This indicates that the above 40-year-old sample has high behavior in performing the required tasks or can ful ll the core duties and responsibilities in caring for patients. They also had a high level of action behavior in performing tasks that were not included in the actual task but were related to their position or role as a nurse that added value to the client and health care provider (Paulssen et al., 2019). This may be attributed to nurse's maturity in the above 40-year-old and 50-59 years old age group that has more work experience that contributes to more skill full in delivering nursing care in tandem with nurses' CB in the PH setting. While in the PHS nurses in the age category of 50-59 years are senior nurses who are usually among the nurse supervisors or head nurses who mostly perform supervisory duties on junior nurses and perform more administrative duties.
The results of the two-way ANOVA showed that the education factor had a signi in the eld of community health nursing. Therefore, their CB is higher in PHS because they are more pro cient in their knowledge and skills in PHS. In contrast, CNU24 and U26 in PHS showed lower CB levels than in PH. In addition to having specialized knowledge and skills in the eld of community nursing they are also given the responsibility of supervising CNU19, and help prepare the report in PHS. This to some extent attracts part of their time to be with clients. Unlike in PH, they are more involved with direct nursing care. SNU29 and NsrU32, showed a high level of CB in PHS compared to those who work in PH. The categories of these two positions are very important in both settings either with or without the required advanced diploma or post-basic courses. In PHS, their function is to carry out family health care services (Malaysian Civil Service Commission, 2020). This suggests that nurses at PHS are more focused and in control of their clients' health care and only refer to physicians if problems and risks are identi ed. While at PH, they conduct nursing care, and assist doctors in patient care. In addition, they also supervise AN, CN, and other subordinate staff. They also assist NsrU32 in ward administration and supervise trainees as well as perform other tasks based on instructions from superiors and other professionals in the patient care team. Therefore, this may cause them to be burdened with indirect nursing care that may affect their job satisfaction as a nurse which may in uence CB (Shalaby et  Meanwhile, nurses working in PHS showed a decline in CB levels starting after 25 years to more than 35 years. As explained earlier in PHS aged 50 to 59 years has a lower level of CB than the sample in the PH due to this age category is an experienced nurse who holds management and administrative positions and does less clinical work in the PHS. Therefore, CB levels will decrease when nurses have more than 25 to 35 years of work experience in PHS as most of them will be promoted and carry out nurse management roles and responsibilities.
Overall, the results of this study show that demographic factors have a signi cant effect on the CB of nurses. An alternative hypothesis is partially supported. An alternative hypothesis for differences in nurses' CB based on demographics factors between nurses in PHS and PH is supported. The level of nurses CB in PHS is higher than nurses in the PH. This is contrary to the argument at the beginning that the CB of nurses in PH is higher than in PHS.

Limitations
Studies in examining the effects of work setting and demographic factors on nurses caring behavior and to identify the differences in nurses' CB based on demographic factors between PHS and PH are relatively lacking. Therefore, it is quite di cult to compare the results of this study with the nding of previous studies. Like other studies, this study also faces limitations. First, the questionnaires were distributed through various levels, which should be distributed through the top management in each PH and PHS.
Then distributed to Nursing Matron or Nursing Sister for distribution to wards and units in PH and health clinics, and rural clinics in PHS before distributed to the respondents. This is for the reasons to avoid interference to the nurses who are on duty. Therefore, con dentiality is beyond the control of the researcher as a researchers have no opportunity to collect data face to face. It is recommended that future studies use observation methods on direct and indirect nursing care and caring behavior of nurses.
Second, this study was a cross-sectional survey in which no explanation was given to explain the relationship between nurses' CB and demographic factors for both settings. The generalization of the ndings of this study is potentially limited, as this study was only conducted in Sabah, Malaysia. It is hoped that the results of this study can be extended by researchers who are interested in studying this matter in the future.

Implications for Nursing Management
The present research has provided convergent evidence on the role of the demographic factors in nurses CB in PHS and PH settings. The results of this study can be used to nd the best strategy by considering demographic factors to deliver nursing care with the best CB appropriate to the nurse's work environment.
It is hoped that this study can further explore the shortcomings of nurses CB based on their demographic factors in both settings so that remedial action can be taken for the bene t of health care recipients and health care providers especially the nursing workforce.

Conclusion
Nurses form the largest group of workers in PHS and PHS. Overall, the CB of nurses in the PHS was higher than that of nurses in PH as nurses in the PHS had greater control over their duties and responsibilities as nurses. It is hoped that this study can attract the attention of local researchers to explore further related to the perspective of local nurses, especially to determine the relationship between nursing staff, resource adequacy, support, and CB. The results of this study can help to understand the caring behavior of nurses concerning their demographic characteristics to provide quality care with the best patient outcomes and provide satisfaction to health care recipients. This study has added to theoretical contributions in the academic and research elds as well as in practical implications in the eld of nursing practice by addressing the effects of demographic factor on CB and the differences in CB based on demographic factors between nurses in PHS and PH. Through a literature search, this study is the rst local study to evaluate the CB based on demographic factors among nurses in PHS and PH.