The Relationship Between Nurses' Perceptions of Caring Behaviors based on Watson's Theory and of Professional Ethics: A Cross-Sectional Study

Background and purpose: Caring is a central concept in nursing. It is essential that nurses adhere to ethics toward improving the quality of their performance as nurses. This study aims to explore the relationship between nurses' perceptions of caring behaviors and of nursing professional ethics. Methods: 210 nurses from hospitals in Shiraz, Iran, participated in this cross-sectional study. The participants were selected via stratied random sampling. The data collection tool consisted of demographics, Watson's caring dimensions inventory, and Petty's work ethics scale. The collected data were analyzed in SPSS v. 25 using descriptive and analytical statistics. Results: There was not a statistically signicant relationship between the nurses' demographics on the one hand and their perceptions of caring behaviors or of nursing professional ethics on the other. The mean of the participants' perception of caring behaviors scores was 142.49±10.71 and the mean of their professional ethics scores was 102.21±5.32. A signicant positive correlation was found to exist between the two variables under study (P<0.001, r=0.46). Conclusion: There is a positive correlation between nurses' perceptions of caring behaviors and of professional ethics. This nding can be used by nursing administrators and policy-makers to design interventions to improve the quality of nursing care.


Background & Purpose
Over the past decades, the concept of caring has been thesubject of many theories and much research (1). Caring is de ned as guided measurestaken to help, support, and empower individuals with obvious andpredictable needs. Without caring, curing and healing cannot berealized (2).Patients who feel cared for experience higher levels ofsatisfaction, psychological adaptation, and adherence toregimen (3) .As acentral and uniform concept, caring distinguishes nursing fromother healthcare-related professions (4). According to Leininger (1988), caringbehaviors are characterized by soothing, sympathizing, showingcompassion, and sharing (5).
In the last two decades of the 20th century, it was argued thatcaring was the essence of nursing(6). Leininger (1977) was the rst person topresent caring as the essence of nursing and a mental, theoretical,exploratory, and practical framework for it (7). After her, Watson (1985) describednursing as a combination of the art and science ofcaring(6) .Bennerand Wrubel (1989) refer to caring as the main form of being in theuniverse(8). Newman (1991) de nes nursing as the study of caring in relation tomankind's experience of health (9). According to Smith (1994), nursing is thestudy of human health and being cured throughcare(6).
As the outcome of care, caring behaviors are affected bypatients and their families, nurses, organizations, andsocieties(1).One's understanding of care has a direct impact on his/her workbehaviors for different individuals have different perceptions,characteristics, needs, interactions, and perspectives onlife (10).
Since,compared to other members of healthcare teams, nurses spend themost time with patients, an understanding of their perception ofcaring behaviors is essential (11). Furthermore, an understanding of thefactors involved in caring behaviors can help improve the qualityof care. By obtaining a better comprehension of the physicalaspects of caregiving behaviors, nurses can better identifypatients' needs and establish a more effective relationship withpatients (12).hence the need for studying nurses' perception of caregivingbehaviors.
On the other hand, care is the kernel of such professionalvalues as compassion, kindness, and the ability to respond toothers' pain, stress, anxiety, and needs (13), all of which are rooted in nurses'professional ethics. Professional ethics are closely related toholistic care, but, despite their obvious signi cance, have oftenbeen neglected in nursing science (14). Many studies report nurses' observance ofprofessional ethics to be unsatisfactory (15). According to a study in Iran, whennurses fail to respect ethical values, negative consequences,including nurses' distancing themselves from patients andindifference to providing ethical care, follow(16). Professional ethics arevital to meeting the challenges which arise from constant changesin healthcare systems and societies (14). As professional values affectindividuals' attitudes to their jobs and can be used to improve thequality of care, they deserve special attention for personal andorganizational growth to happen (17). Thus, it is necessary that the topic ofprofessional ethics of care in nursing be studied in depth.
Among the existing care theories, Watson's theory seeks todeepen our understanding of the universe, ethics, andhuman-centered aspects of care as well as our awareness ofourselves, others, and the system(18). The theory of human caring andrelationship-centered care is a main plank in the ethics of care:the idea of a human caring for a human lie at the center of theresponsibilities and roles of professional nurses and forms theethical basis of the profession(5). Watson believes that education and thedistribution system in healthcare must be according to human valuesand respect for others' welfare (5,19). This belief system emphasizes the humancomponents of caring and continuous interaction between thecaregiver and care-receiver. The main concept of this theory isthat humans are not to be treated as objects and that they cannotbe considered in isolation from themselves, others, nature, and thelarger workforce. She clearly rejects mechanical and reductionistperspectives on life in favor of the human scienceperspective (19,20). The presentstudy aims to explore the relationship between nurses' perceptionsof caring behaviors based on Watson's theory and of theirprofessional ethics. A study of these two variables and thepossible relationship between them can pave the way for planninginterventions in the future toward improving nurses' perceptions ofcaring behaviors and the code of ethics for nurses, therebyimproving the quality of care which will bene t patients and helpthe advancement of nursing.

Material And Methods
The present study is a cross-sectional work conducted on 210nurses practicing in hospitals a liated with Shiraz University ofMedical Science, located in Shiraz, the largest city in the southof Iran, in 2019. The participants were selected via strati edrandom sampling. Sample size was determined according to theresults of similar studies(21) and the following sample size formula inwhich r = 0.192 at a con dence level of 0.95 and the power of0.8 in MedCalc. The result was 210 subjects.
Con dence interval for correlation coe cient→ The inclusion criteria were being in practice as a clinicalnurse, having at least a bachelor's degree in nursing, and beingwilling to participate in the study. The nurses who refused toprovide an answer in interviews or completed their questionnairesimperfectly were excluded.
Data were collected using a demographics form, the caringdimensions inventory (CDI-35), and Petty's work ethic scale. Thedemographics form addressed age, gender, marital status, workexperience, and academic degree. The scale for evaluation ofnursing students' caring behaviors was developed by The nurses' perception of professional ethics was measured usingPetty's standardized work ethic scale which has 4 dimensions:interest in work (6 items), perseverance at work (6 items), humanrelations at work (5 items), and participation in work (6 items).This questionnaire is scored on a 5-point Likert scale ("Completelydisagree" to "Completely agree") with the score range of -23 to115. Its content validity has been veri ed by a panel of expertsand its construct validity has been tested and con rmed withcon rmatory factor analysis. A total Cronbach's alpha of 0.96indicates that the scale possesses satisfactory internalconsistency-for each dimension, the Cronbach's alpha is 0.85, 0.79,0.87, and 0.74 respectively (24-26).
The collected data were entered into SPSS v. 25 and analyzedusing descriptive (mean and frequency distribution) and analytical(correlation coe cient and independent t-test) statistics at asigni cance level and work experience of the nurses were 31.11 ± 6.74and 7.46 ± 5.89 years respectively. The values of Pearson'scorrelation coe cient for the quantitative variables andSpearman's correlation coe cient for the qualitative variablesshowed that there was not a signi cant correlation between thenurses' demographics on the one hand and their perceptions ofcaring behaviors or of professional ethics on the other (Table 1).  The results of the independent t-test showed that there was nota signi cant difference between the participants' perception ofcaring behaviors and professional ethics mean scores in terms ofgender, marital status, and education ( Table 2).  Table 3 showsthe means of the participants' perceptions of caring behaviors andprofessional ethics scores along with the dimensions of workethics. As the variables were quantitative in nature and considering thesample size, the relationship between perception of caringbehaviors and perception of professional ethics was analyzed usingthe Pearson correlation coe cient test. The results showed thatthere is a statistically signi cant positive correlation betweenperception of caring behaviors on the one hand and perception ofprofessional ethics and its dimensions on the other (Table 4).

Discussion
The results of the present study show that nurses' demographics,including age, gender, work experience, marital status, andeducation, do not correlate with their perceptions of caringbehaviors and of professional ethics. Also, there was not astatistically signi cant difference between the participants'perceptions of caring behaviors and professional ethics mean scoresaccording to gender, marital status, and education( Table 2). These ndings are consistent with the results of many other studies. Ina study in Iran, except for age, none of the demographic variablesunder study correlate with the medical staff's adherence to code ofethics (27). Inanother study in Iran, the results do not show a correlationbetween nursing students' age and academic semester on the one handand awareness of professional ethics on the other(28). However, according to areview study in Finland, age, gender, and work experience correlatewith nurses' respect for professional ethics (14).
With regard to the existence of a correlation between nurses'demographics and their perception of caring behaviors, a study onIndonesian nurses reports that the correlation between thesubjects' age, gender, education, and clinical experience on theone hand and perception of caring behaviors on the other is notsigni cant (29). Similarly, a study in Slovenia shows thatthe care factors in Watson's theory do not have a signi cantcorrelation with nurses' education (30). Yet, according to a study conducted in anIranian city, marital status is a predictor of caring behaviors (31). Theseinconsistencies in research ndings about the existence of arelationship between nurses' demographics on the one hand and theirperceptions of professional ethics or of caring behaviors on theother underline the need for more research in this area.
The results of the present study show that nurses' perceptionsof caring behaviors and professional ethics are relativelysatisfactory. A study on nurses selected from 4 hospitals in anIranian city reports the subjects' caring behaviors mean score tobe very satisfactory (31). According to another study in Iran, fromthe perspective of patients hospitalized in oncology units, nurses'caring behaviors are very satisfactory (32). With regard to professional ethics,a study on 210 inpatients in Iran shows nurses' adherence to codeof ethics for nurses to be satisfactory, which is consistent withthe ndings of the present study (33). However, a study in Gambia reportsnurses' respect for ethical values to be inadequate and that nursesdo not comply with code of ethics in that country (15). The majority of nurses ratetheir perception of caring behaviors or their caring behaviors andobservance of professional ethics as satisfactory; however, thesevariables need to be studied from the perspectives of other groups,including patients, colleagues, and other members of healthcareteams, for richer data to be obtained.
According to the results of the present study, there is arelatively signi cant positive correlation between nurses'perception of caring behaviors and their perception of professionalethics. A review of the available literature did not yield anystudies which address the relationship between nurses' perceptionsof caring behaviors and of professional ethics. Yet, the results ofa study on intensive care unit nurses in Iran shows that, contraryto the ndings of the present study, there is not a correlationbetween nurses' ethical sensitivity and caringbehaviors (34).
Based on Watson's theory, caring is a core idea and ethicalideal in nursing which seeks to protect, support, and empowerhumans (35,36). In a reviewstudy, Woods states that the concepts "caring", "nursing", and"ethics of care" have always been inseparable and that nurses'professional practice is recognized by their ethicalcommitment (37).According to Lachman, when an individual decides to become a nurse,he/she is making an ethical commitment to care for patients. Caringcan be regarded as exclusively an ethical act; consequently, caringcan be seen as a duty. Also, caring can be regarded as a commitmentto be present and a passion for becoming involved in patients'needs(38). Manystudies make references to the relationship between caring andethics. In some of them, ethics is introduced as the outcome ofcaring, and in others, caring is introduced as the outcome ofethics. The present study only focuses on the linear relationshipbetween the two. In view of the signi cance of caring behaviorsand professional ethics in the nursing profession, it is vital thatthese concepts be studied more deeply.
One of the limitations of the study is that the questionnaireswere completed on a self-report basis, which could have createdbias in the results. Therefore, the participants were assured thatall information was con dential and that their responses would nothave any impact on evaluation of their professional performance.They were reminded that the questionnaires had to be completedhonestly and accurately.

Conclusion
The results of the present study show that there is a relativelysigni cant positive correlation between nurses' perception ofcaring behaviors and their perception of professional ethics. Asthe largest group of care-providers in healthcare teams, nursescan, by increasing their awareness of ethics and adherence to thecode of professional ethics, provide holistic care to patients andtheir families. Accordingly, it is necessary that nursingadministrators and policy-makers pay special attention to theconcepts of caring behaviors and professional ethics and, bydesigning educational programs, encourage adherence to ethicalprinciples in nursing schools to improve the quality of care. Theyshould also design interventions to raise nurses' awareness ofcaring behaviors and professional ethics, thereby helping theadvancement of the nursing profession. It is recommended thatfuture studies explore other factors which may affect thesevariables.

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Declarations Ethics approval and consent to participate Before completing the questionnaires, the nurses were informedabout the objectives of the study, the voluntary nature of theirparticipation, their anonymity, and con dentiality of theirinformation. All the participants signed the written informedconsent form. The study has been approved by the ethics committeeat the research department of Shiraz University of Medical Sciencesunder the registration number IR.SUMS.REC.1398.1086. Theresearchers complied with the Helsinki Statement (2010) and COPE(2018).

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and analysed during the current study areavailable from the corresponding author on reasonable request.