Experiences of Nurses in Providing Care for Patients on the Cancer Journey: A Cross-Sectional Survey

Ali Hussein Alek Al-Ganmi*, Haider Mohammed Majeed, Massara Abdulla Najm

Department of Adult Nursing, College of Nursing, University of Baghdad, Baghdad, 14149, Iraq

*Corresponding Author’s Email: ali.h@conursing.uobaghdad.edu.iq

ABSTRACT

Background: The interaction between nursing care and cancer patients is beneficial for patients' health outcomes, as they successfully manage and live with cancer. This study was conducted to assess the quality-of-care interaction between nurses and patients in oncology hospitals. Methods: A cross- sectional survey was conducted among 113 cancer patients in oncology teaching hospitals in Baghdad, Iraq, from August 14th, 2023, to January 30th, 2024. The Caring Nurse-Patients Interaction-23 Scale was utilized to examine the nurse-related orientation of caring interaction between nurse and patient. It is assessed on a 5-point Likert scale and contains 23 questions pertaining to four primary domains: “humanistic care, relational care, clinical care, and comforting care." Data were analyzed by descriptive and inferential data analysis. Results: The findings showed that most of the study sample were female (72.6%), unemployed (75.2%), and patients were not smokers (88.5%). Most of the patients had breast cancer (44.2%); and more than half of them were treated with chemotherapy (68.1%). The mean patients’ interaction with caring provided by oncology nurses was moderate in most domains, and the humanistic and comforting interactions were more impacted. There was a significant relationship between patients’ employment status, cancer type and type of treatment that they received (p value = 0.001), and their caring interaction with oncology nurses. Conclusion: The study concluded that the majority of the cancer patients felt a moderately caring interaction with oncology nurses. Nurses must focus on humanistic and comforting interactions with patients to build a positive caring relationship and improve patients’ health outcomes.

Keywords: Cancer; Oncology Nurses; Patients; Quality-of-Care Interaction

INTRODUCTION

Cancer is the leading cause of death worldwide, with an estimated 19,000,000 cases and 10,000,000 related deaths in 2020 (Xia et al., 2022). Long-term patterns in cancer rates and burden are a reflection of both shifts in medical practice, such as the adoption of cancer screening tests, and patterns in behaviors linked to cancer risk. Other countries may be able to learn from the comparatively successful advancements in cancer research, prevention, and treatment (Schilsky et al., 2020). Patients must not only deal with the physical agony of their condition but also intense psychological strain. The elderly have a high incidence of most cancer types, accounting for 50% of all cancer cases (He et al., 2023).

Cancer and its treatments have a significant effect on the quality of life of patients with cancer. Nursing care and patients’ interactions might be beneficial for patients’ health outcomes as they successfully managed and lived with cancer (Bahrami, Parnian, & Samimi, 2012). Applied caring behaviors during interaction between nurses and patients create a productive working environment and the best healthcare quality (Villacarlos & Daño, 2020; Vujanić, Prlić, & Lovrić, 2020). Patients should expect and experience comprehensive care to ensure their satisfaction with their nursing services. Patients and nurses could achieve a higher level of satisfaction and a healthy working environment by adopting specific nurse-patient interactions (Fortuno, Oco, & Clores, 2017).

Nurses and other medical professionals are mainly in the first line of providing cancer patients with expert medical treatment as well as regular psychological counseling (Karlou et al., 2018). Thus, service attitudes are important since nurses who provide medical services directly and have the most direct interaction with patients (Lake, Germack, & Viscardi, 2016) and the medical skills of nurses (Gebhardt, Wolak, & Huber, 2013) greatly affect patient satisfaction. Factors that influence the perception of nurses' caring behaviors range from their level of knowledge and formal education to the length of time they have spent working with cancer patients. It is crucial for nurses to possess a certain level of caring behavior as part of their formal education, in order to effectively contribute to care attribution during their oncology nursing journey (Labrague et al., 2015). Research has shown a deficiency in comprehending the caring behaviors that occur during interactions between a nurse and a patient with cancer. The paucity of research in this field hinders the global comprehension of the significance of caring and its behaviors, thereby hindering criticism and self-evaluation, which are crucial for the development of personal and professional skills, as well as the overall workplace environment (Mulyadi & Katuuk, 2017). Consequently, the study was undertaken to assess nursing care through "nurse-patient interactions" and to explore the correlation between sociodemographic and clinical profiles of oncology patients and the compassionate actions exhibited by nurses in oncology units.

METHODOLOGY

Study Design

A cross-sectional survey was carried out to assess the quality-of-care interaction between nurses and patients in the two oncology teaching hospitals in Baghdad, Iraq, starting from August 14th, 2023, up to January 30th, 2024.

Sample and Sampling

A non-probability (purposive) sample of 113 patients with cancer recruited from oncology wards at Baghdad Teaching Hospital and AL-Amal National Hospital for Tumor, both sexes (males and females), was selected. These included patients aged 18 and over who were diagnosed with cancer by their physicians, as well as those who consented to participate in the study.

Data Collection and the Study Instrument

Data was collected using a structured paper-based self-report questionnaire administered via interviewing techniques by the researchers and interviewers. All survey questionnaires were completed through face-to-face interviews and took approximately 10–15 minutes with each patient. The study used “the Caring Nurse-Patient Interaction Scale (CNPI-23P)” (Sharour, 2021) to assess the caring interaction between nurses and patients in oncology hospitals. A generic scale, "CNPI-23P," is used to assess how a nurse and patient interact from a caring standpoint. It consists of 23 questions and represents 4 primary domains: "humanistic care (4 items), relational care (7 items), clinical care (9 items), and comforting care (3 items)." A 5-point Likert scale, ranging from 1 = not at all to 5 = highly, measures the items. The range of scores for the CNPI-23P is 23 to 115. Participants age, sex, marital status, level of education, disease duration, type of cancer, and type of treatment were also collected.

Validity and Reliability of the Questionnaire

To verify the validity and reliability of the scale, factor analysis and internal consistency were assessed by a previous Arabic study (Sharour, 2021). The α coefficients for the four domains were 0.61 to 0.76, 0.90 to 0.92, 0.80 to 0.94, and 0.63 to 0.74, respectively, indicating that the instrument was valid and dependable. A panel of experts determines the content validity of the instrument format. They are professors at the University of Baghdad's College of Nursing. These experts have more than 10 years of experience in their field. The experts' review of the questionnaire revealed that all of them agreed that the items were clear and adequate for measurement in the study. Minor changes were performed on a few Arabic items. Such changes were made according to the expert proposal.

Data collection was started after getting approval from the University of Baghdad, the College of Nursing authority, and official approval. Prior to data collection, participants in both hospitals were asked to sign an informed consent form indicating that they had been informed about the study, its objectives, and their rights to refuse or accept participation. Confidentiality of the participants' information was respected, and only the researchers and the ethics committees have the right to access the data. The questionnaire was anonymous, and the data was analyzed group-wise, so there was no link between the results of this study and any of the individual participants. The privacy of the respondents was maintained by preparing and setting a place and time for data collection.

Ethical Consideration

The study received the Ethical Permission from the College of Nursing, University of Baghdad, Iraq for approval of the study through the College of Nursing to the Ministry of Health (Ethics committee) with the Reference No.2087 on 8th August 2023.

Data Analysis

The statistical package of social sciences (SPSS), version 26.0, is used to analyze data. Sociodemographic data were analyzed descriptively, and continuous data were presented as means and standard deviation. The comparison of CNPI-23P scores in relation to different sociodemographic and clinical variables was carried out using Chi-Square. All the tests were carried out at a 5% level of significance. The value of p<0.05 was considered statistically significant.

RESULTS

Table 1: Socio-Demographical and Clinical Characteristics of Patients with Cancer

Table 1 shows that most cancer patients within a mean age of M (SD) = 50.87 (14.76). The majority of patients were female (72.6%), unemployed (75.2%), living with a wife or husband (72.6%), and been married (74.3%). The vast majority of patients were not smokers within (88.5%). Most of the patients had breast cancer (44.2%) and other types of cancer (44.2%); more than half of them were treated with chemotherapy (68.1%); and they had a mean cancer duration of Mean= 2.81 (3.044).

Table 2: Mean of Score of Caring Nurse-Patient’s Interaction in the Oncology Ward

M.S. = mean of score (1-2.33 = poor, 2.34–3.66 = moderate, 3.67–5 = high), SD = standard deviation.

Table 2 shows that the mean patients’ interaction with caring provided by oncology nurses was moderate in the most domains, with a total mean score of Clinical Care = 30.33 (2.98); Relational Care = 20.46 (4.55); Humanistic Care = 14.28 (2.21); and Comforting Care = 9.91 (2.57).

Table 3: Association Between Participants Socio-Demographic and Health Characteristics and Their Total Caring Interaction with Oncology Nurses

(N = number, % = percentage, df = differential of freedom, significant P value = ≤ 0.05, level of interaction = (1-2.33 = poor, 2.34–3.66 = moderate, 3.67–5 = high).

Table 3 shows that there is a significant relationship between patients’ employment status (p value = 0.008), cancer type (p value = 0.001), and type of treatment that they were treated with (p value = 0.001) and their caring interaction with oncology nurses.

DISCUSSION

The present study revealed that the majority of cancer patients were female, with an average age of 50 years. These findings, supported by a previous cross-sectional study to assess the quality of oncology nurse-patient care, revealed that female patients were represented 52.8% of the study sample, and their mean age was 57.1 (Gomes et al., 2024). Also, this finding, agreed upon by He et al., (2023) stated that 99% of participants were females, and they were in the range of 35 years old. The current study also shows that three-quarters of patients were unemployed, and this result aligns with a recent mixed- methods study conducted on older patients with cancer that found that they were unemployed (50.8%, n = 248) (Cecon-Stabel et al., 2023). The majority of the patients in the study were married and lived with their partners. This is a mirror of a previous cross-sectional survey in Saudi Arabia to examine the quality of nurse-patient care and patient satisfaction, which found that 54.8% of the cancer patients were married (Alhussin et al., 2024). Surprisingly, the study highlighted that the vast majority of oncology patients were not smokers. A recent pooled cross-sectional study argued that 71% were previous former smokers who quit smoking prior to being diagnosed with cancer (Upadhyay & Jones, 2024). The results are also supported by Lai et al. (2022), who noticed that 90.6% of breast cancer patients were not smokers. They also discovered that 73.5% of the patients received chemotherapy treatment. Clinical data revealed that nearly half of the study's patients received a breast cancer diagnosis. Sharour et al. (2022) conducted a cross-sectional study in three Arab countries, which revealed a dominant presence of breast cancer patients among the study sample.

Twenty-three questions concern the nurses' quality-of-care interaction with cancer patients. Overall, the mean interaction between patients and oncology nurses was moderate in most domains. In the “humanistic care interaction," the item “the nurses do not have an attitude of disapproval” has a high mean of 3.84 (0.82987). In the "comforting care interaction," the item "the nurses perform treatments or administer medications at the scheduled time" has a high mean of 4.46 (0.669). The study by Vujanić, Prlić, and Lovrić, (2020), which found that nurses deemed both the clinical and humanistic aspects of care equally significant, is similar to these findings. Caring perceptions were expressed highly by oncology nurses. However, patients gave high ratings to items about clinical aspects of their care. This means that various forms of touch—consoling, orienting, working, connecting, and social touch—are examples of nursing behaviors in various care contexts (Sandnes & Uhrenfeldt, 2022). Oncology hospitals should intensify a specific program aimed at raising nurses' awareness of the benefits of the therapeutic relationship between them and oncology patients in order to improve their health outcomes (Qassim, Sadeq, & PourGhaznein, 2023). Increasing patients' health awareness is crucial for understanding their cancer disease, self-care, and coping strategies during the long-term journey of the disease, which can be facilitated through in-hospital rehabilitation programs (Ahmed & Hassan, 2022). Conversely, factors such as nurses' workload, role conflict, psychological strain, resource scarcity, and a growing sense of responsibility may influence the therapeutic relationship between nurses and patients (Lilu & Al-Jubouri, 2023). Hospital policies should encourage nurses to bridge the gap between socially marginalized patients and healthcare services (Antonsen et al., 2024).

The relationship between socio-demographic and clinical and quality of care interaction score was explored as a significant relationship between patients’ employment status (p value = 0.008), cancer type (p value = 0.001), and type of treatment that they were treated with (p value = 0.001) and their caring interaction with oncology nurses. A study by Donmez et al. (2022) supports this, reporting a low level of interaction between unemployed and low-income patients and nurses (t = -2.739, p = 0.006). Furthermore, the nurse-patients care interaction was affected in patients with different types of cancer with stage 4 metastatic (F = 9.017; p < 0.001) (Donmez et al., 2022). Another study (Ntarangwi, Mutunga-Mwenda, & Nkoroi, 2019) agreed with this study's findings that chemotherapy has a significant impact on the nurse-patient caregiver interaction. The socio-demographic characteristics such as age, sex, marital status, level of education, and occupation had no significant relationship with the overall nurse-patient caring interaction. The study recommends that nurse managers take into account the impact of nurses' socio-demographic characteristics on patient outcomes, which in turn influences the degree of care dependency (İspir Demir, Yilmaz, & Sönmez, 2024). Therefore, nurse managers should eliminate miscommunication due to nurse-related individual factors and focus on strategies that resolve nurses' socio-demographic dilemmas.

Limitations

This study implied that using a globally validated and translated self-reported questionnaire as a standard instrument would certify the rateability of the study results and their interpretation. The study has some limitations. This includes the study location (oncology settings), which is known as a busy clinical area, making oncology patients less focused on answering and finishing the questionnaire. This causes patients to feel fatigued, potentially affecting the accuracy of their responses to the questionnaire. This, in turn, could affect the evaluation of the nurse-patient care relationship and potentially lead to inaccurate rates. Also, because cancer patients are often busy and under time pressure, recruiting in an oncology unit can be particularly difficult. Even with a sufficient sample size, must carefully compared to the results for various cancer patient groups in future.

CONCLUSION

Overall, this cross-sectional survey demonstrated that there is a moderate effect of clinical interaction, humanistic interaction, and comforting interaction with care provided by oncology nurses at oncology wards. It was found that unemployment, type of cancer (breast cancer), and type of treatment have a significant effect on nurse-patients interaction. Thus, the study implies that enhancing humanistic and comforting interactions in nursing care can significantly improve the health outcomes and overall experience of cancer patients in oncology hospitals. More studies are needed regarding assessment of caring nurse-patient’s interaction in the oncology hospitals with more sample size from different hospital locations.

Conflict of Interest

The authors declare that they have no competing interests.

ACKNOWLEDGMENT

The authors express their gratitude to the Nurse Managers of Oncology Hospitals, Iraq for their collaboration and assistance. The involvement of all oncology patients in this survey is duly recognized and appreciated.

REFERENCES

Alhussin, E. M., Mohamed, S. A., Hassan, A. A., Al-Qudimat, A. R., Doaib, A. M., & Alhawsawy, E. D. (2024). Patients’ satisfaction with the quality of nursing care: A cross-section study. International Journal of Africa Nursing Sciences, 20, 100690. https://doi.org/10.1016/j.ijans.2024.100690

Ahmed, F. F., & Hassan, H. B. (2022). Effectiveness of an instructional program on patients with ulcerative colitis adherence for medication and diet to prevent colorectal cancer: Case and control study. Iraqi National Journal of Nursing Specialties, 35(1), 70-81. https://doi.org/10.58897/injns.v35i1.505

Antonsen, L. K., Lassen, A. T., Nielsen, D., & Østervang, C. (2024). Receiving person‐centred care in a hospital—a qualitative study of socially marginalised patients' experiences of social nursing. Scandinavian Journal of Caring Sciences, 38(1), 220-230. https://doi.org/10.1111/scs.13212

Bahrami, M., Parnian, R., & Samimi, M. A. (2012). The effect of nursing consultation involving cancer survivors on newly diagnosed cancer patients’ quality of life. Iranian Journal of Nursing and Midwifery Research, 17(5), 338-342.https://journals.lww.com/jnmr/fulltext/2012/17050/The_effect_of_nursing_consultation_involving.3

.aspx. Accessed on 23rd June, 2023.

Cecon-Stabel, N., Salm, S., Pfaff, H., Dresen, A., & Krieger, T. (2023). Patients’ perspectives on the quality of care of a new complex psycho-oncological care programme in Germany–external mixed methods evaluation results. BMC Health Services Research, 23(1), 759. https://doi.org/10.1186/s12913-023-09714-y

Donmez, E., Dolu, I., Dulger, Z., Bayram, Z., Can, G., & Akman, M. (2022). Care needs and satisfaction with nursing care quality of cancer patients, 9: e2312. https://doi.org/10.32113/wcrj_20225_2312

Fortuno, A., Oco, D., & Clores, M. (2017). Influential components of caring nurse-patient interaction (cnpi) in a tertiary hospital in the Philippines: Towards improving health outcomes of patients. International Journal of Nursing Science, 7(4), 84-90. https://doi.org/ 10.5923/j.nursing.20170704.02

Gebhardt, S., Wolak, A. M., & Huber, M. T. (2013). Patient satisfaction and clinical parameters in psychiatric inpatients—the prevailing role of symptom severity and pharmacologic disturbances. Comprehensive Psychiatry, 54(1), 53-60. https://doi.org/10.1016/j.comppsych.2012.03.016

Gomes, P., Ribeiro, S., Silva, M., Cruchinho, P., Nunes, E., Nascimento, C., & Lucas, P. (2024). Cross-Cultural Validation of the Portuguese Version of the Quality of Oncology Nursing Care Scale. Cancers, 16(5), 859. https://doi.org/10.3390/cancers16050859

He, H., Zhu, N., Lyu, B., & Zhai, S. (2023). Relationship between nurses’ psychological capital and satisfaction of elderly cancer patients during the COVID-19 pandemic. Frontiers in Psychology, 14. 1121636. https://doi.org/10.3389/fpsyg.2023.1121636

İspir Demir, Ö., Yilmaz, A., & Sönmez, B. (2024). Relationship between care dependency, adverse events, trust in nurses and satisfaction with care: The mediating role of patient‐reported missed care. Journal of Advanced Nursing. https://doi.org/10.1111/jan.16176

Karlou, C., Papadopoulou, C., Papathanassoglou, E., Lemonidou, C., Vouzavali, F., Zafiropoulou- Koutroubas, A., Katsaragakis, S., & Patiraki, E. (2018). Nurses’ Caring Behaviors Toward Patients Undergoing Chemotherapy in Greece: A Mixed-Methods Study. Cancer Nursing, 41(5), 399-408. https://doi.org/10.1097/ncc.0000000000000562

Labrague, L. J., McEnroe-Petitte, D. M., Papathanasiou, I. V., Edet, O. B., & Arulappan, J. (2015). Impact of Instructors’ Caring on Students’ Perceptions of Their Own Caring Behaviors. Journal of Nursing Scholarship, 47(4), 338-346. https://doi.org/10.1111/jnu.12139

Lai, Y.-C., Chen, Y.-H., Wu, Y.-C., Liang, F.-W., Wang, J.-J., Lim, S.-W., & Ho, C.-H. (2022). The Association between Smoking and Mortality in Women with Breast Cancer: A Real-World Database Analysis. Cancers, 14(19), 4565. https://www.mdpi.com/2072-6694/14/19/4565 . Accessed on 28th April, 2023

Lake, E. T., Germack, H. D., & Viscardi, M. K. (2016). Missed nursing care is linked to patient satisfaction: a cross-sectional study of US hospitals. BMJ Quality & Safety, 25(7), 535- 543.https://doi.org/10.1136/bmjqs-2015-003961

Lilu, F. K. A., & Al-Jubouri, M. B. A. (2023). Assessment of Challenges Encountering Nurses in Delivering Care to Patients with Cerebrovascular Accident. Iraqi National Journal of Nursing Specialties, 36(2), 80-91. https://doi.org/10.58897/z4e4z448

Mohammed Alhussin, E., Mohamed, S. A., Hassan, A. A., Al-Qudimat, A. R., Doaib, A. M., al jonidy, R. M., al harbi, L. I., & Alhawsawy, E. D. (2024). Patients’ satisfaction with the quality of nursing care: A cross-section study. International Journal of Africa Nursing Sciences, 20, 100690. https://doi.org/10.1016/j.ijans.2024.100690

Mulyadi, N., & Katuuk, M. E. (2017). Hubungan motivasi kerja dengan perilaku caring perawat di instalasi gawat darurat dan intensive care unit di rsu pancaran kasih gmim manado. Jurnal keperawatan, 5(2). [Mulyadi, N., & Katuuk, M. E. (2017). The relationship between work motivation and the caring behavior of nurses in the emergency department and intensive care unit at the Radian Kasih General Hospital, GMIM Manado. Nursing Journal, 5(2).] https://doi.org/10.35790/jkp.v5i2.25159

Ntarangwi, T. K., Mutunga-Mwenda, C. S., & Nkoroi, B. (2019). Satisfaction with nursing care among cancer patients admitted in oncology wards at a national referral hospital in Kenya. Saudi Journal of Nursing and Health Care, 2(11), 374-380. https://doi.org/10.36348/sjnhc.2019.v02i11.005

Qassim, S. K., Sadeq, A. F., & PourGhaznein, T. (2023). Efficacy of a Pre-Radiotherapy, Nurse-Led Instructional Program to Enhance the Level of Awareness of Patients Receiving Radiotherapy for First Time. Iraqi National Journal of Nursing Specialties, 36(2), 67-79. https://doi.org/10.58897/7201ep84

Sandnes, L., & Uhrenfeldt, L. (2022). Caring touch in intensive care nursing: a qualitative study. International Journal of Qualitative Studies on Health and Well-being, 17(1), 2092964. https://doi.org/10.1080/17482631.2022.2092964

Sharour, L. A. (2021). Translation and Validation of the Arabic Version of the Caring Nurse-Patient Interaction Scale–Patient Version (CNPI-23P). Cancer Nursing, 44(2), E62-E67. https://doi.org/10.1097/ncc.0000000000000755

Sharour, L. A., Al Sabei, S., Al Harrasi, M., Anwar, S., Salameh, A. B., & Al Qadire, M. (2022). Quality of oncology nursing care as perceived by patients with cancer: Results from three Arab Countries. Cancer Nursing, 45(2), E545-E551. https://doi.org/10.1097/ncc.0000000000000993

Schilsky, R. L., Nass, S., Le Beau, M. M., & Benz Jr, E. J. (2020). Progress in cancer research, prevention, and care. The New England Journal of Medicine, 383(10), 897-900. https://doi.org/10.1056/NEJMp2007839

Upadhyay, S., & Jones, J. (2024). Patient–provider communication quality: Socioeconomic disparities in smoking outcomes. Tobacco Prevention & Cessation, 10(March),14. https://doi.org/10.18332/tpc/184050

Villacarlos, F. A., & Daño, J. C. (2020). Impetus Of Clinical Nurse Managers: Countless Stories of Nurses. Malaysian Journal of Medical Research (MJMR), 4(1), 9-19. https://doi.org/10.31674/mjmr.2020.v04i01.002

Vujanić, J., Prlić, N., & Lovrić, R. (2020). Nurses’ Self-Assessment of Caring Behaviors in Nurse– Patient Interactions: A Cross-Sectional Study. International Journal of Environmental Research and Public Health, 17(14), 5255. https://doi.org/10.3390/ijerph17145255

Xia, C., Dong, X., Li, H., Cao, M., Sun, D., He, S., Yang, F., Yan, X., Zhang, S., Li, N., Chen, W., & Ni, J. (2022). Cancer statistics in China and United States, 2022: profiles, trends, and determinants. Chinese Medical Journal, 135(05), 584-590. https://doi.org/10.1097/CM9.0000000000002108