Evaluation of nursing care behavior culture program’s implementation at Dharmais Cancer Hospital

Nurses use the concept of caring in providing nursing care. However, factors that influence nurses’ caring attitudes, such as job stress and dehumanization, make caring behavior decrease. Previous research showed that 52.9% of patients reported that the implementation of caring behavior by nurses in Dharmais Hospital was lacking. Our program offers a solution for building a caring culture among oncology nurses. Researcher team activities were carried out, including the socialization of a caring culture with 84 nurses, training for 16 head nurses as the change agent for guiding nurses, and a guidance program for 16 head nurses to act as champion to the rest of the nurses. The researcher evaluated the implementation of caring culture using focus group discussion (FGD) with the 16 head nurses. Eight themes were obtained from the FGD: observation guidance about caring behavior to help champions monitor and increase the nurses’ caring attitudes; training about caring to help nurses change their caring attitudes; excessive workload makes nurses display less-caring behavior; the WhatsApp application helps socialize a caring culture; spiritual power from the inside fosters caring behavior; support from hospital leaders is needed to encourage caring behavior; need for caring behavior training and therapeutic communication for all health care providers and administrative staff; and need for caring behavior standard operating procedures (SOP) and guidance from senior nurses. The number of nurses who perform caring well also increased by 38% after intervention (p = 0.021). Based on the FGD results, it was recommended to improve the caring culture behavior in the hospital through several efforts.

Caring is an important value in nursing practice. Caring behavior is the essence of nursing care services that makes it different from the other health care services (Watson, 2007;Mc Millan, 2017). Nurses' caring behavior can be seen through empathy, approaching patients without judgment, a warm attitude, respect for clients, unending patience, and having good skills. Patients feel comfortable during treatment if the nurses perform their duties with caring behavior.
Caring behavior is influenced by several types of factors: individual, organizational, and psychological (Pramudjono, 2015;Sibandze, 2018). Individual factors are associated with nurses' ability and skill, their family and working experience backgrounds, and demographics (age, gender, educational background, working period, marital status, and employment status). Organizational factors include resources, leadership, rewards, organizational structure, and job design. Psychological factors are related to perceptions, attitudes, learning desires, personality, and motivation.
Nursing is a profession with a moral responsibility to maintain and improve the public health status. Nurses are expected to provide good nursing care services to achieve optimal client health. Some nurses do not fully implement caring behavior while they are doing their job. Previous research shows that 52.9% of Dharmais Hospital patients reported that the implementation of caring behavior by nurses was lacking (Talenta, 2016).
Non-optimal caring behavior by nurses who work in a cancer ward is caused by work stress and the continuous exposure to grief or news of death. These conditions can lead to a decrease in empathy and caring behavior. If this is not brought to attention, it can affect patient satisfaction (Bucco, 2015) and nurses' working motivation, which ultimately reduces health service quality. In addition, a suboptimal implementation of caring behavior creates less trust between nurses and patients, longer physical healing times, and the loss of the patient's sense of security and comfort (Watson, 2007). Other studies show that caring behavior can reduce anxiety for pre-operative patients, increase the patient's loyalty to nurses, and shorten the length of stay (Aliftitah & Suprayitno, 2017;Rufaidah, Qurrotul, & Istioningsih, 2018). These results show that nurses' caring behavior significantly impacts patients and health services. Therefore, caring behavior needs to be improved to improve patient comfort and health service quality.
Caring behavior by nurses needs to be nurtured. Several theories posit the reinforcing factors of forming a person's behavior, including praise (The Operant Conditioning Theory), practice (Pavlov's and Thorndike's theories), and individual intellectual development factors (Piaget's theory). According to the Health Belief Model (HBM) theory, behavior is set according to an individual's belief. Behavior can also be formed on the basis of behavioral intentions as described in the Theory of Planned Behavior, which was developed from the Theory of Reasoned Action (Ajzen, 1991).
Based on these theories, individual behaviors are based on two major sources: cognitive theory and stimulus respond theory.
Health practitioners and educators commonly use the HBM to design and evaluate behavior-shaping interventions (Glanz, Rimer, & Viswanath, 2008). This model is based on the understanding that people are motivated to act based on their concern for health.

Internal motivation is controlled by an individual's ethics or values of individual
behavior (Marquis & Huston, 2015). This theory furthermore suggests that changing individual knowledge and behavior is easier than changing group attitudes and behavior. The key concept of the HBM influences individuals to determine and choose good actions (Glanz et al., 2008). This concept includes perceived barriers and benefits and cues to action. That is, understanding the cues to elicit the correct level of acceptance regarding the vulnerability of hazards, benefits, and barriers to action.
An individual who believes that caring for another vulnerable or sick human is a rewarding thing, he/she may be more likely to act in that way. This behavior certainly benefits people who need help. Every individual action or behavior is basically driven by internal or external motivation. Other influencing factors include a person's cognitive ability and self-regulation. An individual's behavior is influenced by the response patterns of others (Handiyani, Kurniawidjaya, Irawaty, & Damayanti, 2017). They recommend a social learning theory approach (Bandura's Theory) for forming behavior. This is because reciprocal relationships and interactions among cognitive, environmental, and behavior influences form the basis for individual behavior (Bandura, 1978). The researcher team used the champion formation approach to shape behavior. Champions are expected to be able to influence the people around them to have caring behavior.
In this program, we apply experts' Watson and Swanson's concept of caring. In the implementation, we adjust the concept for conditions in Indonesia. Caring is generally defined as one of these abilities: to be dedicated to others, show attention, feel empathy, feel love or affection, and have to have a relationship with others (Potter & Perry, 2009).
Patients with cancer need greater care compared to other patients (Novieastari & Gunawijaya, 2017). Therefore, oncology nurses must perform caring behavior for cancer patients, and the hospital must develop and support a caring environment to create a supportive caring foundation for the nurses.
The pioneer of caring theory, Jean Watson explained that caring is central to nursing practice because it requires a dynamic approach; nurses cannot do their job without caring for patients. Therefore, caring is an action that provides the basis of nursing services for clients by fulfilling their health care needs. Watson stated that the core of nursing is helping clients to reach higher levels of mind, body, and spirit harmonization, which can be achieved through caring transactions (Tomey & Alligood, 2010). Watson describes the 10 "carative" (related to caring) factors as follows: to form humanistic and altruistic values; to create hope and expectations; to foster sensitivity to oneself and to others; to develop a relationship of mutual help and mutual trust; to enhance and accept the expressions of positive and negative feelings; to use scientific and systematic problem-solving methods to make decisions; to improve the interpersonal teaching and learning process; to create supportive, protective, and corrective physical, mental, sociocultural, and spiritual environments; to help fulfill basic human needs; and to appreciate the existence of power from spiritual phenomena.
Kristen Swanson's theory is slightly different from Watson's. Swanson believes that caring contains five categories or components. These components are integrated and related to each other and cannot stand alone. The process of merging these components forms a nurse's caring behavior (Potter & Perry, 2009). Swanson's caring components are knowing, being with, doing for, enabling, and maintaining belief (Alligood, 2014).
Knowing means understanding the events patients are experiencing, avoiding making assumptions, focusing on patients, making in-depth assessments, seeking clues, and getting involved.
Being with means that the nurses' emotions are present; they are being there when they are needed, sharing feelings, not creating a burden, and conveying abilities. Doing for means doing something as if it were for oneself, staying calm, anticipating, doing something based on ability, and maintaining and protecting dignity. Enabling means facilitating life transitions and unusual events, informing, explaining, and supporting, providing alternative solutions, and validating and giving feedback. Lastly, maintaining belief means maintaining trust, a hopeful attitude, and optimism. These theories and concepts of caring form the underlying basis for the program implementation of developing caring culture behavior for nurses in the hospital.
The goal of the program activity is to improve caring behavior of oncology nurses through strengthening nurse and hospital engagement. And, training alone is not enough to improve caring behavior. First, it should be made part of the organization's culture, which requires support from relevant stakeholders (Glembocki & Dunn, 2010).
In this community engagement project, we used several approaches to garner support, including nurse training, champion formation, and reform agents who guide and assess nurses' caring behavior. At the end of the program, after two months of implementation, the program was evaluated through FGD.

Methods
Our program provides a solution for optimizing the caring culture of oncology nurses, specifically nurses who work at Dharmais Cancer Hospital (RSKD). The targets of our program were practical nurses and head nurses who would become champions, responsible for guiding and assessing oncology nurses. The results of workforce analysis at RSKD showed that of approximately 300 nurses, the majority have education that resulted in a diploma. There were approximately 22 head nurses for the outpatient and inpatient wards. There were 84 nurses involved in this activity and 16 head nurses.
The head nurse and the nurses who participated in training were tasked with disseminating information to their colleagues who have not yet received training.
The researcher designed the application of this caring concept in several phases. The first phase was coordination with the Nursing Division (Bidper) and Training Education Division (Diklat) at RSKD. The next activity was socialization and training for 84 oncology nurses about caring cultural awareness. The third phase was to train 16 head nurses who would guide and assess the nurses' caring behavior. The instrument used for assessing caring behavior was the Caring Behavior Inventory (CBI). The following guidance was provided for the head nurse in acting as a reformer champion agent to improve caring behavior for oncology nurses. The role of champion provides guidance for approximately two months. This guidance was based on versions of Swanson and guidance for observing nurse caring behavior included 41 items.

Data collection
Eight participants were recruited for each of the two focus groups. The interview technique used was focus group discussion or FGD. The FGD technique was useful for efficiently assessing information. With a dynamic group, it was able to overcome the participants' introversion, resulting in the collection of enough information.
FGDs were held in August 2018 in the RSKD Diklat room. All participants in each focus group were interviewed for 100 total minutes. The team recorded the conversation and transcribed the information provided by the participants.
Participants' responses were video, and audio recorded for verbatim transcription.
Interviews were carried out until all desired data was obtained.

Analysis
The FGD used a thematic analysis technique. The data analysis employed a coding process with systematic steps. The activity began with data organization and preparation, reading all the data, and coding (Creswell, 2014). Computer software was used for coding. The researchers made a transcript of data from each FGD. The stages in data analysis included: listening to participants' verbal descriptions, making a list of significant statements, and creating themes. The researcher read the transcriptions line by line, marked key words, categorized them, and defined themes from several categories.

Ethical considerations
The Ethic Committee Faculty of Nursing University of Indonesia conducted a thorough ethical review.

Results and Discussion
Sixteen head nurses were recruited for this activity. The age range of participants was 30-50 years, with an average age of 42.5 years and a standard deviation of 5.47.
Furthermore, we evaluated the results of program implementation using two FGDs.
Each FGD was comprised of eight nurses. The following questions were addressed in the FGD: (1) What is the strategy to form a nurse's caring culture after training and after two months of program implementation?; (2) What has been done to form a nurse's caring culture?; (3) What are the factors that influence its successes and failures?; (4) What is the response from nurses and other health care providers to your efforts?; (5) What are the obstacles to establishing a caring culture?; (6) How can these obstacles be overcome?; (7) What is a head nurse's role in forming a caring culture?; (8) What are your suggestions for institutions, hospitals, and nurses?
The results of the qualitative study from the FGDs produced the following eight themes: 1) Observation guidance about caring behavior to help champions monitor and increase nurses' caring attitudes; 2) training about caring to help nurses improve their caring attitudes; 3) excessive workloads create less-caring behavior; 4) the Whatsapp application helps socialize a caring culture; 5) spiritual power from the inside fosters caring behavior; 6) support from hospital leaders for caring behavior; 7) needs for caring behavior training and therapeutic communication for all health care providers and administrative staff; 8) needs for caring behavior standard operating procedures (SOP) and guidance from senior nurses.

Observation guidance about caring behavior to help champions monitor and increase the nurses' caring attitudes
In the FGD, the head nurse described his experience conducting assessments of caring behavior displayed by their subordinates. The head nurse's statement was as follows: "…… After joining the caring culture training, we immediately applied it. The nurses who joined the training share the knowledge with nurses who did not participate.
When giving an assessment, don't feel bad when evaluating caring behavior. Make an assessment as it is …… (N1)" "…… Three months of observation is enough to increase caring behavior. After training, many nurses provide time to listen to patients' feelings …… (N2)" "…… So, for the nurses, caring behavior could be seen from the patient's condition when nurses do a handover and from the number of complaints from the patient and family. (N10) ……" The head nurse felt that became easier to apply and teach the concept of caring to his staff with the guidance of caring behavior. The unclear concepts of caring must be applied in an easy way so that everyone can feel the benefits (Drake, 2016;Sibandze, 2018). According to Drake (2016), nurses can change their caring behavior using evidence-based practice models. Nurses need clear guidance to apply the caring concepts that various experts have described.
The head nurse felt that three months was enough to make effective changes in caring behavior using this program. Head nurses were provided with the concept of (4) Creating an agenda; (5) Solving problems; (6) Implementing the change plan; (7) Having a vision for the future of the organization; (8) Motivating others to participate in creating and implementing that vision. Therefore, to achieve a culture of caring, the role of change agent or head nurse is very important in motivating, creating, and implementing the vision.
We call change agents "champions." A champion is a person who successfully optimizes others' potential and trains others to achieve their best performance. A champion is also a person who can increase the quality of staff commitment and contribution, allowing them to be more involved in line management, to create workforce contributions within the organization, and to be able to understand and meet staff needs. Every individual has the inherent capability to be a champion, especially team leaders.
A champion also plays a role in forming a caring culture. Tomey & Alligood (2010) state that caring cannot be passed down from one generation to the next through genetics, but through professional culture. Professional culture can be achieved by cultivating a spirit of caring among nurses through a continuous process of socialization, management, cooperation, symbols, and rituals or habits. Nurse leaders or head nurses in this program have an important role in improving the health of patients and staff through the delivery of behavior change intervention (Fuller, 2015).

Training about caring to help nurses change their caring attitudes
Training can change both knowledge levels and behavior. The head nurses' experience of applying changes in caring behavior showed that it greatly helped that the nurses had already attended the previous caring training. Here are some observations by the head of the room: "…… After taking the caring culture training, I applied it immediately. Nurses who took the training shared their knowledge with nurses who did not participate …… (N1)" "…… After training, many nurses provide time to listen to patients express their feelings …… (N2)" "…… In my opinion, if we want to influence other people to build a caring culture, we must start with ourselves first and show them that we care about patients …… (N10)" "…… Caring culture starts from the handover activity. We are habituated to greeting and praying in the morning. Then there is another activity which problem is solving or preconference about things that happened yesterday afternoon …… (N12)" "…… Basically, my nurse friends have done it from pre-interaction, greeting with smiles until spiritual things were facilitated. In the ICU, the nurses' concerns about critical patients are facilitated, so that patients have psychological contact with their families …… (N13)" "…… With the training that has been done yesterday, we have made small changes.
For example, when we accompany and help a patient in a wheelchair, we pay attention to make the patient comfortable by explaining that the patient must be ready when the road slopes down or there are obstacles on the road …… (N12)" Changes in caring behavior were aligned with the increased knowledge of caring after training. The number of nurses who had improved caring also increased by approximately 38% after intervention (p = 0.021) (See Table 2). The researcher conducted caring training behavior for nurses and champions (See Figure 3.2). This activity was also supported by hospital leadership. Training with expert resources in the field of caring greatly improves knowledge and behavior levels (Ramchandran & Von Roenn, 2013

Excessive workload causes nurses to display less-caring behavior
Participants emphasized the importance of caring behavior. Refresher training reminded them about the importance of caring behavior in taking care of cancer patients. However, excessive workload causes nurses to be unable to carry out caring behavior in accordance with the provided guidelines. The following are explanations from the head nurse about why this can happen: "…… Caring behavior is of value of nurses, especially oncology nurses, the caring value must be higher than other nurses. But excessive workload can cause less attention …… (N4)" "…… After the training, nurses' colleagues applied caring behavior according to the guidelines, but because there were many patients, about 300 people per day, time after time they forgot to apply it anymore …… (N4)" "…… Most of my colleagues have done it, but the time is lacking because there are many other works demands …… (N5)" "…… A lot of work is outside of nursing duties, but should this be gets done by the nurses …… (N6)" "…… Sometimes the failure factor is when we handover, we found the patient's needs have not been fulfilled. Then we examine why; it turns out that one nurse worked on five total care patients …… (N12)" "…… Overseas, nurses can focus on caring because they are not burdened by other cases, but in Indonesia there are things that affect it …… (N14)" "…… I do not ask much from my nurse, if she is still taking care of me, it is already extraordinary seeing that nurses have many patients. It is already great if the nurses are not frowning at patients …… (N14)" "…… Everything becomes our tasks. Light problems, water, bed, everything becomes our tasks …… (N16)" Nurses know and are eager to apply the caring concept, but their heavy workload impedes their ability to do it well. Fatigue is one factor that affects someone's ability to care, but great affection can defeat fatigue (Sibandze, 2018). Nurses understand the importance of applying caring concepts in carrying out nursing care, but excessive workload makes them unable to apply the concepts optimally. In nursing care management, it is necessary to consider the maximum workload that nurses can handle.
Nurses workload calculations are a concern for hospital leaders in the effort to create an optimal working situation for nurses. Although nurses feel these large workloads are an obstacle to carrying out caring behavior, the compassion they feel makes them do their best work. Compassion, comfort, and competence can help keep nurses applying caring concepts in their work (Feudtner et al., 2007;Drake, 2016).

The WhatsApp application helps socialize a caring culture
Technology advancements affect communication patterns. Socialization is made easier by existing technology. Currently, the distribution of information is easier using the WhatsApp (WA) application. This application can contribute to the successful dissemination of a more caring culture. "…… Regarding the success of socialization with existing facilities, especially through the WA group, actually everything is already exposed …… (N13)" "…… Keep reminding health team about strategy. Then don't forget to always make a coordination in health team …… (N13)" Cancer patients and families expect to receive quality health services. Effective coordination is needed so that the health team can provide patients with quality health services. The health team can use communication technology such as WhatsApp to maintain effective communication and provide optimal health services. Generally, when sick patients and their families arrive at the hospital, they do not know what to do. The health team providing meaningful and accurate information can help improve patient health. Using WhatsApp to coordinate communication worked effectively. Sophisticated use of the internet has been proven to improve health services (Yoo et al., 2013). Nurse caring behavior can be demonstrated by good communication and coordination.

Internal spiritual power fosters caring behavior
Almost all participants were highly spiritual and transmitted these abilities to their colleagues and subordinates. In fact, this has become the most important thing in helping oncology nurses in Indonesia develop caring behavior. Indonesia is a country with many religious citizens, so spiritual ability is an important part of daily life. The following are the participants' statements relating to the spiritual ability of building caring behavior: "…… We always remind ourself that the goal of working is to find rewards from God …… (N1)" "…… We do not deserve a complaint because God has given many gifts …… (N4)" "…… I am interested in doing Morning Gratitude (giving thanks and praying in the morning) before starting work. Pray that no patient will complain …… (N5)" "…… Always pray for patience because all VIP patients ask for special services. Do your best, we will reap it …… (N7)" "…… Caring is from the heart, it cannot be forced, it must be a lot of gratitude …… (N6)" "…… Give as much as we can, let God judge. We almost never go home on time …… High emotional intelligence is proven to improve empathy and caring behavior (Johnson, 2017 "…… Always be reminded that caring culture must be consistent. Caring behavior is included in the JCI Hospital assessment …… (N1)" "…… There has been no reward from the hospital, as the nurse announced with the criteria of caring, discipline, and responsibility …… (N1)" "…… Oncology nurses need capacity building and gathering to avoid boring …… (N4)" "…… This suggestion is about the fulfillment of human resources proportions. So, that there is no reason for the nurse to be busy with many patients. The patients here are patients with partial care with the infusion installed. After chemotherapy, the patient is weak and nauseous, so they need nurses …… (N13)" "…… Need facilities that can support the nursing service …… (N13)" "…… Reinforcement for the responses of nurses that do cultural things is a positive thing …… (N14)" The hospital's policy certainly affects changes. The hospital's support of the nurses is an important aspect that determines success. Advanced communication skills, knowledge of business principles, finances, and health policy affect how services are provided to patients (Walker & Polancich, 2015).
The hospital leadership strongly supports the program for caring behavior. The nurses' suggestions are very meaningful to them. These suggestions are taken into consideration so that the hospital leadership can determine the next strategy. Thus, candid and open communication is needed between hospital leaders and subordinates.
Subordinates can provide input to leaders and leaders can accommodate input from subordinates to ensure good service production. The results of previous studies show that there is a positive relationship between nurse leadership style, span of control, staff nurse practice environment, climate safety, and nurse-sensitive patient outcomes (Merrill, 2011).

Needs for caring behavior training and therapeutic communication for all health care providers and administrative staff
Caring behavior is not only required from nurses; health professionals and other health care providers who work in hospitals also need to show caring behavior.
Participants provided opinions about how caring behavior training was needed for all health care providers and administrative staff who work in hospitals to achieve the hospital's vision and mission.
"…… Caring behavior training and therapeutic communication need to be done for all health care providers other than nurses, such as doctors, radiographers, physiotherapists, and hospital administrative staff …… (N5)" "…… From my experience in the polyclinic, sometimes this complaint is not directed at the nurses but at the doctor, who often comes late …… (N10)" All hospital staff should demonstrate caring behavior, not only nurses. Therefore, all staff who are involved in providing service to patients must demonstrate caring behavior. The results of this study prove an increase in nurse caring behavior by 37%, in line with previous studies conducted by Glembocki & Dunn (2010). Reigniting the Spirit of Caring from Creative Healthcare Management would enhance the perception of caring behavior as an educational intervention (Glembocki & Dunn, 2010 Participants shared the opinion that even though nurses and head nurses had joined the training sessions, not all of them could run optimally because of some obstacles.
Therefore, participants suggested that SOP need to be created for caring behavior. In addition, young inexperienced nurses must be guided by senior nurses who have experience with the implementation of caring behavior.
"…… Nurses' work has not been directed, work is still about routine, caring awareness is still rare …… (N1)" "…… SOP for caring does not exist yet; providing time for patients to express their feelings is still lacking …… (N2)" "…… Guidance from senior nurses is needed by young nurses who do not have experience exploring patient problems …… (N8)" "…… Sometimes time and patience are reduced because you listen too long to patients and family …… (N5)" The need for guidance to continue demonstrating caring behavior is part of the change to make it better. As humans, nurses must be reminded constantly so they will not forget. Familiarizing themselves with a clear SOP guide will help nurses change gradually and ensure that previous behaviors will not return.
Guidance from senior nurse leaders is also important in the process of younger nurses forming caring behaviors (Fuller, 2015). More senior nurses have more experience and are expected to transmit it to younger nurses.

Conclusion
All nurses are aware of the importance of caring behavior in providing nursing care services. Training and guidance from champions or experts are very useful for reminding them of the importance of caring behavior. However, there are still some obstacles that must be overcome in order to improve caring behavior of all hospital staff, including excessive workloads, lack of experience, lack of reward by leaders, and other untrained staff. Conversely, spiritual power is a positive aspect in an individual that strengthens caring behavior. This spiritual ability must be improved continuously through various spiritual enhancement activities.
Cancer patients and families experience hard times in their life. They deserve to have quality health care services. Caring behavior by health care providers is what they expect to reduce the burden of suffering they experience during their illness.
Hopeful thinking and level of comfort regarding providing pediatric palliative care: a survey of hospital nurses. Pediatrics, 119(1), e186-e192.