Caring Professional Attitude Of Nursing In Palliative Nursing Care

Background: Caring is an important part of nursing care. Caring is a behavior that interacts emotion with the patient's response. This research aims to determine the caring behavior of nurses in providing palliative nursing care Methods: The research employed qualitative method (FGD), using hermeneutic phenomenology approach (n=7, chemotherapy nurses) and interview guide instruments. The data analysis used was Interpretative Phenomenology Analysis and has obtained ethics worthy of KEP UNISA Yogyakarta: 1342/KEP-UNISA/IX/2020 and KEP Yogyakarta Regional Public Hospital: 41/KEP/RSUD/X/2020. Results: Based on the results of the study, there are 2 major themes of professional caring attitudes of nurses in providing palliative care, that are the emotional closeness of nurses to patients and their families and an attitude full of empathy with


INTRODUCTION
Palliative nursing care is a nursing intervention approach for patients who have chronic diseases and prolonged suffering condition (World Palliative Care Alliance, 2014), (Rodin et al., 2020). Nurses have the main competence that are caring for patients and their families and make benchmarks for the professionalism of nurses that consist of empathy, therapeutic communication skills, and patient-centered care (Griffiths et al., 2012), (Kim et al., 2020). Caring is a basic concept of nursing that includes interpersonal interpretation of patients with some characteristics such as professional knowledge, skills, professional maturity and nurse sensitivity (Drahošová & Jarošová, 2016). Nurses' age and work experience will influence caring attitudes towards patients and their families. (Lovell, 2006).
Caring has a positive effect on the patient's health development. The relationship between the nurse's attitude and the patient and their family is an important thing in nursing interventions (Yoo & Cho, 2020), (Schroeder & Lorenz, 2018). Professional nurses must have attitudes and skills such as: good communication, good nursing service systems and documentation, intervention based on evidence based practice, policies and salaries (Head et al., 2018). Good communication (including empathy) will benefit the patient and family and have a direct impact on the patient. Empathic communication to patients is a predictor of attitude and quality of nursing care (caring professional) (Giménez-Espert et al., 2020). Patients will more comfortable when nurses communicate that focus on the patient, not only on the disease he is experiencing (Lam et al., 2020). Another study states that nurses face a dilemma in providing nursing care, namely the issue of patient problems with the activities of nurses both professionally and individually. However, nurses must be able to behave in a good caring manner and adapt to conditions: speaking slowly and in easy-to-understand language (Emaliyawati et al., 2020).
The problem that exists is that nurses actually always want to carry out activities in accordance with the goals of care, but sometimes they cannot run perfectly due to high nurse activity. A full caring attitude will have a positive effect on patients with chronic disease (Lusiani, 2019), (Ibrahim et al., 2017), (Gautun & Bratt, 2017). This study tries to understand more deeply about the attitude of nurses in providing palliative care. There is a difference between the results of the study and the previous research. It was shown that the respondents indicated that they had a feeling of sympathy even though it was not deep and there was humor from the nurse to the patient. It is unique and requires more detailed development. This research aims to determine the caring behavior of nurses in providing palliative nursing care.

MATERIALS AND METHOD
The research employed qualitative method (FGD), using hermeneutic phenomenology approach (n=7, chemotherapy nurses) and interview guide instruments without triangulation. The data analysis used was Interpretative Phenomenology Analysis and has obtained ethics worthy of KEP UNISA Yogyakarta: 1342 / KEP-UNISA / IX / 2020 and KEP Yogyakarta Regional Public Hospital: 41 / KEP / RSUD / X / 2020.

RESULTS
Based on the research results, it was found that the characteristics of the respondents were as follows  Table 1 shows that most of the respondents were female (85.7%), the highest education level was Nurse Profession (57.1%) and the longest years of service in chemotherapy room was 3-5 years with a presentation of 57.1% and 1 -3 years with a presentation of 28.6%.
Based on the qualitative analysis, there were 2 themes of caring for nurses, that are 1) the emotional closeness of the nurse with the patient and the family 2) an attitude of empathy and a sense of humor.

Emotional Closeness Between The Nurse And The Patients And Their Family
The emotional closeness between the nurse and the patient has been developed since the first meeting So, when we meet the patient for the first time, we act normally, (but then it developed) when they are worry, we will try to help their family. It will take some time for the patient to accept that we are the part of their family. When they come, the greet us "Assalamualaikum ….. We keep in mind that the patients are our friends, so the relationship is more like friendship, not between nurses and patients, because it will be too stiff. So when the patient are here, you will see, like in the poly, they usually control routinely in the polyclinic. If you have a chemo, they are used to it. Just relax, they will tell story of this and that, we never keep the same distance because of this (the disease) hahaha .. (R1) She (the patient) confides while crying, we listen, we give her support, we raise her heart, we say "do not think too much about it, the most important thing is that you still have many friends here, we, the nurses, are also your friends, ma'am", Ya, just like that (R1) Even though the chemo was not finished yet, she has one more chemo, Masya Allah, she thought that we were her family, If she didn't care about us, she will not be here (R7) The closeness to the family continues until the mourning period For the patient, for example, the pain is so severe and they are dying, we usually take care of them if they are hospitalized here, for example (they go home), we as nurses visit him, if their house is far, we call them or their family through WA (R2) Patients and families also apologize to each other, as stated by one of the research respondents Yes, we also continue to send pray to each other, then we also apologize if while taking care of the patient, we are also doing a lot of mistakes we also apologize, we also visit and send pray to the patients who are hospitalized here (R2) With patients we talk, yesterday after chemo "Sist, yesterday I got home can do nothing" it turns out that they are sharing their thoughts (R1) Another respondent reported similarly To us, to the patients is smaller than in here. We, I'm sorry, embrace the patient to make him/her motivated (R7)

Empathy And Humor
Nurses also show empathy when communicating with patients and their families Ehh…sorry Sir, maybe I want to add little bit as my friends already answered many like our daily in chemo. We make approach to the palliative patient is not an empathy anymore but more on sympathy. Yes

DISCUSSION
The provision of nursing care to chronic or critical patients is influenced by several factors: communication, patient and family decision making, the continuity of emotional and spiritual care for nurses and support of nurses (Efstathiou & Clifford, 2011). Emotional closeness is part of the effect of deep experience, a more focused voice, a more positive inner feeling, a deeper clarity than an empathic attitude (Clarke, 1989). Research shows that nurses' emotional expression to patients is an important and possible strategy for providing professional nursing care (Cecil & Glass, 2015). Nurses' emotional intelligence in providing nursing care is apparently influenced by compassion (care) (Heffernan et al., 2010). This research shows that emotional closeness to the patient and family is very important and affects the patient's enthusiasm for care.
When carrying out nursing care and implementing a caring attitude, nurses, of course, have to pay attention to the condition and environment of the patient and family (Alvariza et al., 2020). Caring attitude is influenced by (Griffiths et al., 2012), (Head et al., 2018). The educational background of the respondents were almost half of them were Diploma III nursing or 42.9%, and more than 80% of them have experiences in the chemo room for less than 5 years. The caring attitude given to patients, which is shown by their emotional intelligence, has a very significant effect on the patient's healing process and nursing interventions (Heffernan et al., 2010). The nurse considers that the patient being treated is his own family so that it fosters a strong sense of kinship and emotion to the patient and family (Leuna, 2018). The consequence of this activity is that the patient and family also consider the caregiver to be part of the patient's family.
During the mourning period, the nurse also gave a positive response to the family by encouraging them to visit. This condition indicates that nursing interventions still continue even though the patient has died. This behaviour reflects a good and normative attitude (Funk et al., 2017). This attitude is actually very reasonable because the professionalism of the caretaker when the patient dies is to continue the caring by considering: communication and maintaining the survival of children and families left behind (Montgomery et al., 2017). This study shows that nurses maintain emotional and professionalism while maintaining their closeness to their families Four things that must be considered by nurses when a patient is nearing death or preparing for a period of mourning are preparing for death, the ability / challenges to communicate with the family, the relationship between the nurse and the family and the readiness of the nurse (Bloomer et al., 2015). Grief can sometimes also be felt by patients and nurses (Shore et al., 2016). Nurses should still be empathetic, but sometimes nurses experience a sympathy condition even without realizing it. Empathy is a nurse's professional attitude to show a sense of comfort to patients and still provide quality care (Guerrero, 2019), (Ruiz-Junco & Morrison, 2019).
Nurses are also required to be able to comfort patients and their families, as was done by the respondents in this study, that under any circumstances, nurses must entertain/ make a joke, but still considering the patient's condition. Other studies have shown that a given sense of humour can be used as a medium for coping mechanisms when accepting death and alleviating suffering (Robalo Nunes et al., 2018). Another study through a literature review shows that humour is one of the intervention methods for palliative and hospice patients (Claxton-Oldfield & Bhatt, 2016) although there are studies that say that this technique has not been widely used but it is possible to practice it if needed (Pinna et al., 2018), (Pouthier, 2017).
In addition, nurses also need to provide encouragement in the form of prayer and provide an understanding that death is normal (Gerow et al., 2010) (World Palliative Care Alliance, 2014). Besides, nurses also need to prepare themselves by understanding the nature of death and meeting the basic needs of patients (Siagian, 2020).

CONCLUSION
There are two major themes of professional caring attitudes of nurses in providing palliative care i.e. the emotional closeness of nurses to patients and their families and an attitude full of empathy but with a sense of humour.