Study design and data collection
The participants in this study were qualified clinical nurses working in general hospitals at all levels across the country, and did not have any cognitive behavioral disorders. Interning nurses or those on probation were excluded from this survey. Participation was voluntary and an electronic informed consent had to be submitted before participating in the online survey.
The study was conducted using convenience sampling method. The data were collected through Questionnaire Star (https://www.wjx.cn/), a professional online survey platform in China. The survey was anonymous and had to be completed by nurses on a computer or mobile terminal, and each IP address could be used only once. Each item was checked individually. Data for questionnaires that were completed within 300 seconds and in which more than 15% of the information was lost to achieve high consistency of answers, were eliminated.
The link was distributed through the surgical specialty committee of the Hunan Nursing Association to distribute the questionnaire in the province and through the alumni group to distribute it outside the province. Uniform guiding words were used to explain the purpose of the survey, the method of filling the forms, and obtaining informed consent from the respondents.
Measures
The questionnaire was developed by a multidisciplinary research team. It is divided into two parts. The questions asked in each part are as follows: (i) general information related to humanities and (ii) data to measure nurses’ humanistic care behaviour.
The self-developed general information questionnaire. This form included basic information such as gender, age, nursing age, marital status, family location, single child, educational background, professional title, hospital, department, and others.
The caring behaviour inventory (CBI). This was developed by Wolf in 1981 [24], and was reduced to 42 items in 1994. CBI is used to assess five dimensions of caring: ‘assurance’ of humanity presence, professional ‘knowledge and skill’, ‘respectful’ deference to others, positive ‘connectedness’, and ‘attentiveness’ to the experiences of others. Considering the cultural background of China, Da [25] divided and attributed the items again based on the questionnaire that was modified by Wu in 2015. Finally, 24 items were identified and the dimensions of the scale were divided into respect and connection, knowledge and skills, and support and assurance. The Cronbach’s alpha coefficients of the three dimensions were 0.897, 0.906, and 0.928, respectively. The reliability coefficient of the total scale was 0.959, and the test-retest reliabilities of the three dimensions were 0.794, 0.633, and 0.575, respectively. This suggests that the scale has good reliability. A six-point Likert scale was used to assess the frequency of multiple-choice items (1 = never, 2 = almost never, 3 = generally, 4 = often, 5 = almost always, 6 = always). The scores for each dimension and total scale can be summed, with higher scores representing a better level of nurses’ concern for the patient.
Data analysis
Statistical analyses were performed using the SPSS version 26.0. The clinical characteristics and general data were compared. The differences in continuous variables were analysed using a t-test. And the differences in categorical variables were analyzed using the test of variance. A regression analysis was performed to examine the factors influencing nurses’ humanistic care behaviour. Factors that affected the score of caring behaviour were included in the regression equation for the binary logistic regression analysis and р<0.05 indicated that they were statistically significant.
Participants and research context
In August 2020 and 9 August 2020—On August 2020 and August 9, 2020, a link to the online questionnaire was posted on Nurse WeChat and through snowball sampling aimed at Chinese general hospital registered nurses. The study was conducted at a time when the COVID-19 outbreak in China was normalizing.
Ethical considerations
The research participants received a link to the survey with the following message: “We will appreciate your participation in a study carried out at the Xiangya School of Nursing at Central South University focusing on the level of nurses' caring behavior during the COVID-19 outbreak. To complete a short and anonymous survey please press the following link.” After the potential participants clicked the link they reviewed an explanation sheet detailing about the research purposes and significance, the researcher’s background, the expected structure of the survey, its ethical approval, funding issues, and protection of privacy and anonymity of participants. Participants were asked to give their consent to completing the survey by clicking Yes or No, following a specific acknowledgement that they can stop participation at any time. All information obtained from participants was coded and kept in the researcher’s computer and no other use of the information has been made.
Demographic characteristics
A total of 5,623 questionnaires were received from all levels of general hospitals in 15 provinces and cities across seven geographical regions of the country. A total of 5,364 valid responses were received with an effective rate of 95.4%.
Respondents were mostly female (97.6%) in the age group of 25 to 30 (42.5%), 66.9% were urban dwellers, 62.8% were married, and 77.5% were not an only child. A total of 73.9% had either a university or higher education degree, 29.7% had between six to ten years of nursing work experience, and most were senior nurses (44.6%). (Table 1)
Table 1 Distribution of descriptive characteristics of nurses(n=5364)
Factors
|
n
|
%
|
Gender
|
Male
Female
|
125
5239
|
2.4
97.6
|
Age
|
<25Y
25~30Y
31~40Y
≥41Y
|
1109
2333
1453
469
|
20.7
42.5
27.1
8.7
|
Home Location
|
Rural
City
|
1776
3586
|
33.1
66.9
|
Marital status
|
Unmarried
Married
|
1990
3366
|
37.2
62.8
|
Only a child or not
|
only child
Non-only child
|
1205
4157
|
22.5
77.5
|
Highest degree
|
College
University
|
1399
3965
|
26.1
73.9
|
Nursing age
|
<2Y
2~3Y
4~5Y
6~10Y
11~15Y
≥16Y
|
651
794
769
1595
620
935
|
12.1
14.8
14.4
29.7
11.6
17.4
|
Professional title
|
nurse
senior nurse
supervisor nurse
co-chief or chief superintendent nurse
|
1309
2395
1365
295
|
24.4
44.6
25.5
5.5
|
Subordinate department
|
Department of surgery
Department of internal medicine
Department of obstetrics and gynaecology, paediatrics
ICU, Emergency room
Logistic service and management centre
|
2010
1613
591
605
545
|
37.5
30.0
11.0
11.3
10.2
|
Attention degree of hospital humanities
|
Unclear
Very
More
General
Less
none
|
36
2815
1745
684
65
19
|
0.7
52.5
32.5
12.8
1.2
0.4
|
Factors associated with nurses’ humanistic care behaviour
The total CBI score of nurses was 117.59±22.434, and the mean score was 81.25% of the highest score. The mean CBI score was 4.899±0.9348. (Table 2)
Table 2 The score of each dimension and the average score of each item of the Nurses’ Caring Behaviours Inventory (n=5364)
Dimension
|
Mean
|
Standard Deviation
|
Mean score of items
|
Respect and Connection dimensions points
|
46.12`
|
10.267
|
4.612±1.0267
|
Knowledge and Skill dimensions points
|
25.57
|
4.876
|
5.114±0.9752
|
Support and Assurance dimensions points
|
45.90
|
8.621
|
5.100±0.9579
|
Total points of CBM
|
117.59
|
22.434
|
4.899±0.9348
|
Nurse caring behaviours varied based on gender and age (p < 0.05), and multiple studies communicated that a difference was observed between the two genders. The female nurses’ scores in respect and connection dimensions (t=-2.003, p=0.047), knowledge and skill dimensions (t=-2.940, p=0.004), support and assurance dimensions (t=-3.128, p=0.002), and caring behaviour (t=2.201, p=0.028) were higher than those of male nurses. It was also established that nurses aged between 25 and 30 had the lowest respect and connection dimensions (F=2.726, p=0.028), knowledge and skill dimensions (F=7.605, p=0.000), and caring behaviour (F=2.818, p=0.024) scores, than nurses of other ages.
Statistically significant differences were observed in marital status, nursing age, professional title, and degree of attention focused on hospital humanities (p < 0.01). In multiple comparisons conducted to determine the factors leading to significant differences, it was observed that married nurses have higher care behaviour than unmarried nurses (t=4.096, p < 0.001). Furthermore, nurses’ caring ability scores decreased and then increased with nursing age and professional title. Nurses with nursing age of two to three years (F=3.466, p=0.002) and senior nurses (F=4.385, p=0.002) had the lowest scores for care behaviour. Nurses who worked in hospitals with a high degree of humanistic care scored higher in the respect and connection dimension (F=112.79, p=0.000), knowledge and skill dimension (F=45.06, p=0.000), support and assurance dimension (F=68.71, p=0.000), and caring behaviour (F=90.38, p=0.000) than nurses who worked in hospitals with a low degree of humanistic care.
There was no significant difference due to factors like home location, being an only child, degree, subordinate department, when using CBI to measure caring behaviour at an overall level and on dimensional levels (p>0.05). (Table 3)
Table 3 Scores of different dimensions of nurse caring behaviour (n=5364)
|
Respect and Connection dimensions points
|
Knowledge and Skill dimensions points
|
Support and Assurance dimensions points
|
Total points of CBM
|
Gender
|
Male
|
44.31±10.18
|
24.17±5.43
|
43.52±9.21
|
111.9923.79
|
Female
|
46.16±10.27
|
25.61±4.86
|
45.96±8.60
|
117.72±22.39
|
Statistical analyses
|
t
|
-2.003
|
-2.940
|
-3.128
|
2.201
|
P
|
.047*
|
.004**
|
.002**
|
.028*
|
Age
|
<25Y
|
46.19±10.41
|
25.09±4.82
|
45.84±8.34
|
117.13±22.48
|
25~30Y
|
45.64±10.33
|
25.42±4.89
|
45.66±8.71
|
116.12±22.56
|
31~40Y
|
46.60±10.12
|
26.06±4.80
|
46.34±8.43
|
118.99±22.02
|
≥41Y
|
46.64±10.09
|
25.95±5.05
|
45.83±9.04
|
118.42±23.06
|
Statistical analyses
|
F
|
2.726
|
7.605
|
1.577
|
2.818
|
P
|
.028*
|
.000***
|
.178
|
.024*
|
Home Location
|
Rural
City
|
45.84±10.32
46.25±10.24
|
25.32±4.81
25.70±4.91
|
45.77±8.51
45.96±8.68
|
116.93±22.19
117.92±22.55
|
Statistical analyses
|
t
|
-1.391
|
-2.663
|
-.771
|
1.530
|
P
|
.164
|
.008**
|
.441
|
.061
|
Marital status
|
Unmarried
Married
|
45.71±10.34
46.3610.23
|
25.12±4.86
25.84±4.87
|
45.59±8.53
46.08±8.68
|
116.42±22.36
118.28±22.47
|
Statistical analyses
|
t
|
-1.937
|
-5.142
|
-1.825
|
4.096
|
p
|
.053
|
.000***
|
.067
|
.000***
|
Only a child or not
|
only child
Non-only child
|
46.28±10.70
46.07±10.13
|
25.54±5.10
25.58±4.81
|
45.89±9.02
45.91±8.50
|
117.70±23.60
117.59±22.43
|
Statistical analyses
|
t
|
-.597
|
-.283
|
-.073
|
-1.154
|
p
|
.550
|
.777
|
.942
|
.249
|
Highest degree
|
College
University
|
46.12±10.52
46.12±10.18
|
25.51±4.98
25.60±4.84
|
45.89±8.87
45.91±8.54
|
117.52±23.18
117.62±22.17
|
Statistical analyses
|
F
|
.000
|
.326
|
.006
|
.021
|
p
|
.983
|
.568
|
.939
|
.886
|
Nursing age
|
<2Y
2~3Y
4~5Y
6~10Y
11~15Y
≥16Y
|
46..65±10.29
45.63±10.62
45.33±10.19
45.68±10.28
46.78±10.55
47.09±9.77
|
24.94±4.82
25.12±5.00
25.22±4.90
25.64±4.83
26.03±4,90
26.26±4.76
|
46.15±8.57
45.35±8.90
45.34±8.85
45.83±8.54
46.61±8.52
46.32±8.47
|
117.74±22.416
116.09±23.31
115.89±22.70
117.15±22.14
119.42±22.61
119.67±21.81
|
Statistical analyses
|
F
|
3.629
|
7.796
|
2.286
|
3.466
|
p
|
.001**
|
.000***
|
.033*
|
.002**
|
Professional title
|
nurse
senior nurse
supervisor nurse
co-chief or chief superintendent nurse
|
46.48±10.51
45.48±10.35
46.55±9.97
47.75±9.50
|
25.22±4.980
25.39±4.86
26.06±4.79
26.41±4.69
|
45.97±8.80
45.63±8.65
46.15±8.43
46.71±8.39
|
117.67±23.11
116.50±22.43
118.76±21.88
120.86±21.40
|
Statistical analyses
|
F
|
5.539
|
8.674
|
2.011
|
4.385
|
p
|
.000***
|
.000***
|
.090
|
.002**
|
Subordinate department
|
Department of surgery
Department of internal medicine
Department of obstetrics and gynaecology, paediatrics
ICU, Emergency room
Logistic service and management centre
|
46.05±10.23
45.67±10.33
46.88±10.06
46.45±10.37
46.48±10.27
|
25.61±4.84
25.44±4.93
35.83±4.63
35.48±4.99
25.66±4.97
|
46.08±8.56
45.72±8.71
46.16±8.23
45.71±8.75
45.72±8.85
|
117.74±22.24
116.84±22.64
118.87±21.67
117.63±23.02
117.86±22.70
|
Statistical analyses
|
F
|
1.912
|
.839
|
.665
|
.976
|
p
|
.106
|
.500
|
.617
|
.419
|
Attention degree of hospital humanities
|
Unclear
Very
More
General
Less
none
|
42.17±9.62
49.08±10.75
43.45±8.57
41.65±8.44
40.23±6.85
43.11±12.49
|
24.72±4.87
26.48±4.97
24.81±4.51
24.07±4.60
23.97±4.21
23.42±7.30
|
43.28±8.14
47.86±8.77
44.25±7.88
42.63±7.86
42.31±7.31
43.11±10.62
|
110.17±20.99
123.42±23.30
112.51±19.46
108.35±19.27
106.51±16.38
109.63±28.66
|
Statistical analyses
|
F
|
112.79
|
45.06
|
68.71
|
90.38
|
p
|
.000***
|
.000***
|
.000***
|
.000***
|
*р<0.05,**р<0.01,***р<0.001
Binary logistic regression analysis of nurses' humanistic caring behaviour
Binary logistic regression analysis was conducted with the factors of significance in univariate analysis as independent variables and the CBI score (with an average score of 117 as the cut-off point) as the dependent variable (backward: LR method, p < 0.10 as inclusion criteria and p > 0.15 as exclusion criteria). It was established that when the independent variables are ordinal and the direct substitution into the regression equation is not meaningful or the effect is suspected to be unequal between the grades, the dummy variable treatment has to be performed before regression analysis. The assignment of the independent variables is shown in Table 4.
Table 4 Description on the assignment of a variable
variable
|
The description of the assignment of a variable
|
|
Gender
|
X1
|
Male=1, Female=2
|
Age
|
X2
|
≥41Y=0000, <25Y =0100, 25~30Y=0010, 31~40Y =0001
|
Marital status
|
X3
|
Unmarried=0,Married=1
|
Nursing age
|
X4
|
≥16Y=000000, <2Y,=010000, 2~3Y =001000, 4~5Y=000100, 6~10Y =000010, 11~15Y =000001
|
Professional title
|
X5
|
co-chief or chief superintendent nurse=0000, Nurse=0100, senior nurse=0010, supervisor nurse =0001
|
Attention degree of hospital humanities
|
X6
|
Very=000000, Unclear=010000, None=001000,Less=000100, General =000010, More =000001
|
The score of nurse humanistic care ability
|
y
|
Not low (CBI score≥117.59 points)=0, low (CBI score<117.59 points)=1
|
The results of the binary logistic regression analysis are presented in Table 5. The underlying model for the binary logistic regression is “logit P = -1.069-0.261*Marital status+0.502*Nurse+0.526*senior nurse+0.252*supervisor nurse+1.844* Unclear+0.733* None+2.034* Less+1.661* General+1.126* More”. It shows that only marital status, professional title, and degree of attention of hospital humanities have been included in the regression equation. In this survey, the probability of a married nurse with a low caring behaviour score was 0.770 times more than that of other unmarried nurses (95% CI = 0.670–0.885). Nurses and senior nurses were 1.651 (95% CI from 1.231 to 2.215) and 1.692 (95% CI from 1.295 to 2.211) times more likely to have low scores in caring behaviour than the co-chief or chief superintendent nurses, respectively. However, when nurses were unclear about the degree of attention focused on nurses' humanities in the hospital, the probability that they had a lower caring behaviour score was 6.325 times more that of nurses who worked in hospitals that paid close attention to nurses' humanities (95% C.I. = 0.727 – 0.925). In the case of hospitals that did not pay attention to nurse humanities, the probability of low scores in nurse care behaviours was 7.641 times (95% C.I., 4.300 to 13.576), 5.263 times (95% C.I., 4.377 to 6.328), and 3.084 times (95% C.I., 2.719 to 3.498) lesser than that of hospitals that paid attention to the same. The results of the binary logistics analysis indicated that the equation could explain 13.8% of the variation in the dependent variable(F=131.979, р<0.001).
Table 5 The result of binary logistic regression analysis on the influencing factors of humanistic nursing behavior of nurses
Model
|
b
|
P
|
OR
|
OR95%C.I.
|
constant
X3
|
-1.069
-0.261
|
<0.001
<0.001
|
0.343
0.770
|
—
0.670~0.885
|
X5
co-chief or chief superintendent nurse
Nurse
senior nurse
supervisor nurse
|
—
0.502
0.526
0.252
|
—
0.001
<0.001
0.073
|
—
1.651
1.692
1.286
|
—
1.231~2.215
1.295~2.211
0.977~1.693
|
X6
Very
Unclear
None
Less
General
More
|
—
1.844
0.733
2.034
1.661
1.126
|
—
<0.001
0.114
<0.001
<0.001
<0.001
|
—
6.325
2.082
7.641
5.263
3.084
|
—
3.049~13.118
0.839~5.164
4.300~13.576
4.377~6.328
2.719~3.498
|
a. R2=0.138 F=131.979 р<0.001
X3= Marital status, X5=Professional title, X6= Attention degree of hospital humanities