The views of nurses regarding caring in the wori ( place

This survey describes caring in the workplace in selected health services and is part of a greater study conducted in KwaZulu-Natal, South Africa. This study describes the views of nurse managers and nurses regarding caring in the workplace. Human competence, recovery and healing are central to caring. To ensure caring and healing of patients in health services it is of the utmost importance for nurse managers to ensure a healthy and caring environment in the management of nurses. When caring is present in the workplace, nurses are more able to render caring nursing practices in the patient care environment. It is clear that to become a caring person, one must be treated in a caring way and that caring may be impaired or reinforced by the environment. The environment of interest to this study was the environment in which nurses practise. A descriptive survey with a convenience sampling explored caring in the workplace of nurses. The questionnaire was divided into two sections. Section A comprised demographic information and in section B the questionnaire consisted of Likert type questions, open-ended questions and yes/no questions. Analysis included descriptive statistics. It was found that caring was not experienced in the hospitals by nurses in the major management tasks such as respect for human dignity, two-way communication, trust between nurses and nurse managers, wellness, cultural sensitivity, support and the recognition and handling of the concerns of nurses. It was clear that although nurse managers and nurses have the knowledge and structures for the implementation of caring in the hospitals, the everyday practical application of caring needs attention. Nurse managers were aware of caring practices but nurses did not always experience caring in their places of work in the hospitals. Nurse managers and nurses should all accept responsibility for finding means to improve communication and, in particular, participative leadership strategies in the hospitals. Previous research showed that a large majority of nurses agreed on which caring concepts were important aspects in nursing management. Introduction and problem statement In current health care services in South Africa, the emphasis is being placed on quality care. The key to quality health care is a humane culture in health care organizations in which human dignity of both patients and staff will be preserved (Molzahn 1997:247). The major task of management is to combine, allo­ cate, co-ordinate and deploy resources or inputs in such a way that the organization’s goals are achieved (Covey 1996:4-9). Human resource management should also improve the eco­ nomic well-being and quality of life of nurses. Economic well­ being presumes that a job well done entitles people to earn enough money to feed, clothe and educate themselves and their families. Human resource management defines people as assets, intrinsically valuable, and not just as assets to the com­ pany (Covey 1996:4). This study explored the presence of hu­ man values in the workplace of nurses and the experiences thereof by nurses in the workplace. Steward as long ago as 1929 noted that “Caring in nursing practice is not the mechanical details o f any execution, nor the dexterity o f the performer, but is in the creative imagina­ tion and the sensitive and intelligent spirit lying at the back o f these skills. Without these, nursing may become a highly skilled trade but it cannot be a profession orfine art” (Gormley 19%:585) The purpose and objectives of the study The study describe the views of nurse managers and nurses regarding caring factors in nursing management environments in three hospitals. The focus was to obtain data by means of a Likert type instrument which would provide information by nurses on their knowledge of the presence of human values in their places of work in the hospitals. Theoretical framework and literature review The study was guided by the human resource management process as described in Swanepoel (1998:18) and others such as Smit & Cronje (1997:95), Plunkett & Attner (1992:12), Bratton (1999:3). Caring was studied from the perspective of Watson (1985:9). Watson (1985:9) identified certain human caring fac­ tors which encouraged health and development of individuals, families and communities as listed in Table 1. The human resource processes are interdependent and closely linked to each other and aspects in the various processes over­ lap. Swanepoel (1998:18) described human resource manage­ ment as an intervening process which establishes continu­ ously an optimal fit between people and the employing organi­ zation. This model provided a structure where the human be­ 37 Curatlonis May 2003 ing as an employee and the organization as an employing en­ tity could be explored in a systematic way. Research design Data were collected during July and September 2000. The sam­ ple consisted of nurse managers and nurses who worked in patients (Gold 1999: 189-208). Three hospitals were included in the study and the sample consisted of a non-government hos­ pital (Hospital 1) where patients pay the costs of the services, and a mission hospital (Hospital 2) which is funded by a cer­ tain church group and private individuals and organizations, and a general provincial hospital (Hospital 3) which is govern­ ment funded. The respondents were randomly selected and asked to complete the questionnaire. A 47% return rate was Table 1 The ten carative factors for a science of caring by Watson (1985) FACTOR CARATIVE FACTOR Factor 1 The formation of a humanistic-altruistic system


Introduction and problem statement
In current health care services in South Africa, the emphasis is being placed on quality care.The key to quality health care is a humane culture in health care organizations in which human dignity of both patients and staff will be preserved (Molzahn 1997:247).The major task of management is to combine, allo cate, co-ordinate and deploy resources or inputs in such a way that the organization's goals are achieved (Covey 1996:4-9).Human resource management should also improve the eco nomic well-being and quality of life of nurses.Economic well being presumes that a job well done entitles people to earn enough money to feed, clothe and educate themselves and their families.Human resource management defines people as assets, intrinsically valuable, and not just as assets to the com pany (Covey 1996:4).This study explored the presence of hu man values in the workplace of nurses and the experiences thereof by nurses in the workplace.
Steward as long ago as 1929 noted that "Caring in nursing practice is not the mechanical details o f any execution, nor the dexterity o f the performer, but is in the creative imagina tion and the sensitive and intelligent spirit lying at the back o f these skills.Without these, nursing may become a highly skilled trade but it cannot be a profession orfine art" (Gormley 19%:585) The purpose and objectives of the study The study describe the views of nurse managers and nurses regarding caring factors in nursing management environments in three hospitals.The focus was to obtain data by means of a Likert type instrument which would provide information by nurses on their knowledge of the presence of human values in their places of work in the hospitals.

Theoretical framework and literature review
The study was guided by the human resource management process as described in Swanepoel (1998:18) and others such as Smit & Cronje (1997:95), Plunkett & Attner (1992:12), Bratton (1999:3).Caring was studied from the perspective of Watson (1985:9).Watson (1985:9) identified certain human caring fac tors which encouraged health and development of individuals, families and communities as listed in Table 1.The human resource processes are interdependent and closely linked to each other and aspects in the various processes over lap.Swanepoel (1998:18) described human resource manage ment as an intervening process which establishes continu ously an optimal fit between people and the employing organi zation.This model provided a structure where the human be Curatlonis May 2003 ing as an employee and the organization as an employing en tity could be explored in a systematic way.

Research design
Data were collected during July and September 2000.The sam ple consisted of nurse managers and nurses who worked in patients (Gold 1999: 189-208).Three hospitals were included in the study and the sample consisted of a non-government hos pital (Hospital 1) where patients pay the costs of the services, and a mission hospital (Hospital 2) which is funded by a cer tain church group and private individuals and organizations, and a general provincial hospital (Hospital 3) which is govern ment funded.The respondents were randomly selected and asked to complete the questionnaire.A 47% return rate was

Table 1
The ten carative factors for a science of caring by Watson (1985) FACTOR CARATIVE FACTOR Factor 1 The formation of a humanistic-altruistic system of values.
Factor 2 The installation of faith and hope.
Factor 3 The cultivation of sensitivity to one's self and to others.
Factor 4 The development of a helping-trust relationship between the care-receiver and the caregiver to ensure a relationship of quality.
Factor 5 The promotion and acceptance of the expres sion of positive and negative feelings.
Factor 6 The systematic use of the scientific problem solving method for decision-making.
Factor 7 The promotion of interpersonal teaching and learning.
Factor 8 The provision of a supportive, protective, and (or) corrective mental, physical, socio-cultural, and spiritual environment.
Factor 9 Assistance with the gratification of human needs.

Factor 10
The allowance for existential-phenomenological forces.
three hospitals with a history of caring practices and with a reputation for caring in KwaZulu-Natal province in South Af rica.KwaZulu-Natal is situated on the east coast of South Af rica in a sub-tropical climate with an estimated population of 8,5 million people of whom the majority speak Zulu.
Convenience sampling applied and hospitals were selected according to the researcher's judgement of the most repre sentative hospitals on caring practices and to include hospi tals with different financial and service systems to ensure a broad spectrum of the health care that is offered to general achieved.All the respondents were woman, including nurse managers and nurses on day and night duty, with 19% nurse managers and 80.9% nurses, as indicated in Table 2 & 3.The questionnaires were distributed at three participating hos pitals and were collected after two weeks by the researcher.In a few cases extension for the completion of the questionnaires was given because of staff absenteeism following a flu epi demic during the time of data collection.For the purpose of the discussion of the results in this study the following guidelines applied: level of agreement that good human practices were present in the hospitals.50-69 percent indicated a moderate level of agreement that good human practices were present in the hospitals.Lower than 50 percent of agreement among respondents was an indication that good human practices were not experienced to an acceptable level in the hospitals.

Reliability of the questionnaire
The instrument was evaluated for content validity by using the theoretical framework from the literature on human resource management and caring concepts according to Watson to con struct the instrument (Watson 1989:9).Content validity was further ensured by asking professional nurses with expertise in management of nurses, research and nursing practice to evaluate the questionnaire.The reliability coefficient for the questionnaire was calculated using the computer program.Sta tistical Programs for Social Sciences (SPSS) with a Cronbach's alpha value of: Alpha (p =0.95).

Ethical considerations and permission
Permission to conduct the research was granted by the au thorities of the different hospitals concerned.The researcher complied with the ethical guidelines for research as described by Polit & Hungler (1991:355).Informed consent was sought from the respondents and appropriate documentation was kept.Hospitals were not identified in the research report and ques tionnaires were coded to guarantee anonymity.No names of respondents were revealed at any time during the research and respondents were selected by their willingness to participate without any discrimination and no risks to the respondents could be identified at any stage of the research.Respect and courteous treatment applied throughout the research process (Polit & Hungler 1991:355).

Data analysis
The SPSS, Statistical Package for Social Sciences version 11.0 was used to analyse the data statistically.Data was coded and entered into the computer.Cross tabulations between nurse managers and nurses were done.The descriptive analysis aimed to describe the data by exploring the distribution of scores on each variable Polit & Hungler (1991:432).

Results
It was found that caring was not experienced in the hospitals by nurses in the major management tasks such as respect for human dignity, two-way communication, trust between nurses and nurse managers, wellness, cultural sensitivity, support and the recognition and handling of the concerns of nurses.It was clear that although nurse managers and nurses have the knowl edge and structures for the implementation of caring in the hospitals, the everyday practical application of caring needs attention.The low percentages on the issue of comfort and wellness of nurses is a reason for concern.Very few nurses indicate the fact that they received support in their workplace (See item 9 in 39 Table 4).It is clear from Table 4 that the majority of nurses did not experience that their concerns were addressed by nurse managers.Nurses also did not feel valued by management in their workplaces (See Item 16).The time spent in the hospitals was not experienced as enriching by the nurses (See Item 17).The absence of two-way communication in the hospitals was clearly illustrated in the response of nurses in the study (See Item 18).Nurse managers and nurses indicated a lack of trust in the workplaces (See Item 19).

Discussion
Nurses expressed dissatisfaction with the degree to which cer tain human concepts were manifested in their hospitals.Kind ness to people was identified by nurses as an aspect which was addressed in the philosophies of their hospitals.But nurses did not experience kindness, love and respect in the hospitals.According to Gaut (1983:313) respect for the other person is of the utmost importance as it determines the attitude towards the other.Nurses expect a high standard to apply to patient care and if the standard slips, the morale of nurses slips with it.If nurses are not able to nurse the patients for reasons of short ages of human resources and equipment, then nurses who believe in the caring ethic, feel violated and guilty and often seek a better environment in which to practice (Nyberg 1993:11 -17).
Nurses felt that they do not work in environments which facili tate support and caring to nurses as demonstrated in (Item 9) (See Table 4).Holden (1991: 893) found that the lack of support and reassurance could be particularly painful for nurses, who were expected to deliver care to patients themselves.Accord ing to Holden (1991: 893) the fact that nurses do not receive the support causes difficulty for nurses to render quality patient care.Only 41.7% of nurses felt that their personal values matched those of the hospital (Item 12).This finding is in con trast to the view of Gruber (1991:12), who said that when an organisation and its staff share the same goals and values, the staff knows what the organisation stands for, and their per formance and behaviour support those values.The formation of an altruistic value system grounded in human values such as kindness, concern and love is the most basic factors for a science of caring in nursing (Watson 1985:10-12).The nurses indicated they did not feel valued by the nurse managers (Item 16& 17), and that their experiences in hospitals were not enriching.Respondents indicated that two-way com munication was not present in their hospitals and it highlighted the fact that open communication in the hospitals was at low levels.This was alarming according to Blattner (cited in Macdonald 1993:26), as he stated that human resource man agement is an interactive process by which nurses could help each other to grow, actualise, and transform professionally, towards higher levels of well-being.From Table 4 it is clear that nurse managers and nurses did not experienced trust in their hospitals.Mayeroff (1971:9) stated that trust includes an ele ment of risk and the process of leaping into the unknown, and it takes courage from the nurse manager to take the risk.In the situation currently in the hospitals, where staff shortages and minimum resources are present, the lack of trust could be the reason for nurses to have feelings of not being valued by their institutions and therefore they would describe their experience in the hospitals as one where they do not experienced their work as an enriching experience.

Implications for nursing practices
The task of nurse managers is aimed at the wellness of nurses in the organisation as a whole.Nurse managers and nurses should receive information on the theory of Watson (1985) on This research study found that caring in the workplace is not at satisfactory levels in the health services.The majority of nurses did not receive enough support and caring from their nurse managers and this lack contributes to the problem of recruitment of nurses into the hospitals.They also did not experience their work as an enriching experience.The absence of two-way communication remained a problem in the hospi-Table 2 Sample realization for each participating hospital (N = 184)  the human science of caring to enable them to provide a caring human environment in the services.The practical application of human values in the management of nurses should be em phasized in nursing management programmes to promote a more human environment to promote quality care in the hospi tals.Clearly caregivers can no longer define quality by their standards only.
tals and nurses did not experience a trusting relationship with the nurse managers.These findings should be seen in connec tion with the fact that South African nurses are leaving the country for employment elsewhere in the world.The task is now to ensure that processes such respect, com mitment, cultural sensitive approaches, support and two-way communication, are in place in the hospitals to ensure quahty of work life for nurses in the different health services.Nurse managers and health care decision makers should assess the current staffing situation in the hospitals in KwaZulu-Natal in the light of the previous findings on HlV/AlDS among nurses and the additional responsibilities which nurse managers have to deal with and plan to address the problems, as described by Minnaar (2001;10-26).Furthermore nurse managers need spe cialized skills, in dealing with the impact of HIV/AIDS on nurses and health services.Therefore the decision to train nurse man agers and to upgrade the management knowledge and the im plementation of the practice of caring concepts in nursing man agement with relevant care and support for HIV/AIDS nurses, is of the utmost importance, to equip nurse managers for sur vival and to ensure the quality of service in the hospitals.

Conclusion
In this research study it was found that caring and a human culture was not present to satisfactory levels in the workplace of nurses.The analysis of the workplace of nurses showed that nurse managers failed to show respect for the human dig nity and concerns for the cultural needs of nurses.It seemed that nurses did not experience nurse managers as sensitive regarding their comfort and wellness during the every day nurs ing activities in the hospital.The majority of nurses did not receive enough support to do their job.And did not experience their work as an enriching experience.The problem regarding communication and interaction in the hospitals between nurse managers and nurses remained a problem.

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Table 4 : A comparison of the views of nurse managers and nurses regarding caring in Human Resource iVlanagement of nurses in selected hospitals in KwaZulu-Natal
*A low significant value for T-test (typically less than 0.05) indicates a