Nursing Students Experience in Learning of Caring

Professional value is needed in professional nursing practice. Caring plays an important role for nursing students in providing nursing intervention to clients. The purpose of the study was to determine the phenomenon of the student learning process of caring to improve their caring competence. The study used a descriptive qualitative design of phenomenology. The number of participants was 15 students, both at the academic and internship levels. Convenience sampling and analysis content were used to analyze data. The result of this study found three themes with eight categories. The first theme, caring was focused on physical, psychological, social, and spiritual conditions aimed at patient ’ s healing. The second theme, caring was influenced by themselves, family, and the learning environment. The Third theme students need competent lecturers, adequate facilities, and good learning strategies to improve their caring competence. Learning that focuses on increasing students' caring competence become a need felt by nursing students. Lecturers and faculty need to review the existing curriculum and curriculum tools to ensure that these needs are met


INTRODUCTION
Nursing is a profession that carries out its responsibilities based on professional values as its framework (ICN, 2012). They have widely recognized caring as an important part of nursing care and is highly valued as a professional value shared by nurses and nursing students. They also valued caring as the essence of humanity and the major focus of the nursing profession (Halldosdottir, 2014;Poorchangizi et al., 2019;Watson, 2009). In professional nursing practice, we need caring to guide nurses to do what is best for patients (Karlsson & Pennbrant, 2020).
The education period is seen as an important period in instilling professional values and strengthening the caring behavior of students as prospective nurses. Caring is an important aspect of nursing students to apply in practice and underlie nursing interventions. The five basic aspects for caring for nursing students are the ability to provide care, personal character, helpful attitude, communication skills, and the ability to build relationships (Setiawan et al., 2019). Research by Seman (2021) and Setiawan et al., (2019) recommends efforts to improve nursing education outcomes, and caring competency. Several previous studies have also explained that caring should be studied and measured in the nursing education system (Kuntarti et al., 2018;Seman, 2021;Setiawan et al., 2019).
The description above shows that caring is a necessity in nursing services and education, so it requires efforts to be improved. Likewise, the Universitas Faletehan is one university that runs a professional nurse education program. The caring ability of graduates is one that gets attention in the input of graduate users in a satisfaction survey of graduates (Universitas Faletehan, 2022). How caring is learned by nursing students during their education period is an interesting thing to explore. Research on the Nurse Education Program that describes caring learning is still limited, even though it is important to be the basis for developing learning strategies and learning programs that are more structured in building nurse caring behavior as a competency that must be possessed before students become a nurse. This study aims to determine the phenomenon of the student learning process in studying caring to improve their caring competence.

Research design
This study uses a phenomenological descriptive design. The researcher explores in depth the students' experiences in studying caring. This design was chosen to deepen the understanding of the behavior, actions, and ideas of each individual toward the world of his life (Afiyanti & Rachmawati, 2014).
This phenomenological research comprises four stages, (1) the Bracketing Stage where researchers store information related to assumptions, knowledge, and beliefs about everything that is known regarding the phenomenon being studied, (2) the sensing Stage where researchers at this stage enter the phenomenon. being researched, (3) Analyzing stage, where the researcher identifies the essence related to the phenomenon under study. (4) The Describing and Interpreting stage, where the researcher describes and interprets the results of his research as a discussion related to the phenomenon under study (Polit & Beck, 2017).

Participant Selection and Data Collection
The research was conducted at Universitas Faletehan, it carried the data collection process out for 3 weeks in July 2022. The participants in this study were 15 students from various levels, both at the academic and professional stages. Participants were selected based on consideration of the participant's ability to provide information related to the phenomenon under study. The sampling technique used was convenience sampling.
Instruments in qualitative research are the main researcher and research members. The main researcher has previously attended qualitative training and has experience in conducting qualitative research with the theme "The experience of mothers in caring for children with thalassemia". Research members have experience conducting qualitative research with the themes "Family support in treating diabetes mellitus patients: from a patient perspective" and "Nurse's experience in treating Covid-19 patients". Data were collected using Voice Recorder and field notes.

Data analysis
Data was analyzed using seven steps of phenomenological descriptive analysis from Colaizzi which included data recognition, identification of meaningful statements, formulating meaning, grouping themes, developing complete descriptions, forming basic structures, and verifying basic structures (Polit & Beck, 2017).

RESULTS AND DISCUSSION Characteristic of Participant
Participants in this study comprised 15 students, spread over various semesters and years of education. Participants in this study were then given a "P" code in the interview order. Based on table 1, the participants are in the early adulthood age range, and based on gender, the comparison between men and women is in equal proportion.

Theme and Category
The results of the analysis got 3 themes: (1) Caring nurses are nurses who pay attention to physical, psychological, social, and spiritual conditions aimed at healing patients, (2) Caring for students is influenced by themselves, family, and learning environments, and (3) competent lecturers, adequate facilities and good learning strategies are hopes to increase student caring.
Theme 1: Caring nurses are nurses who pay attention to physical, psychological, social, and spiritual conditions aimed at healing patients. This theme is supported by two categories, (1) the nurse's attention to the patient's physical, psychological, social, and spiritual aspects and (2) the concern for the patient's recovery. First Category was obtained from 7 of 15 participants' statements stating that nurse caring is a concern for the patient's physical and psychological.
"…caring is about paying attention to the patient's condition, both psychologically and physically…"(P2).
The second category, nurse caring is aimed at patient recovery.
"…a caring nurse who cares about her patient to help the patient's recovery process…"(P5).
"…Caring is an attitude, the caring nature between the nurse and the patient, he does it seriously, aiming to provide healing to the patient…" (P9).
The results of this research indicate that what students have understood about nurse caring behavior is under expert statements, which state that in professional nursing practice, caring becomes important to determine what is best for patients (Karlsson & Pennbrant, 2020). Caring is the central behavior of nursing, the heart of nursing, and should also be a core value in nursing education. Caring is a practice of nursing action that can be carried out with process actions nursing that aims to improve healing, which can paying attention to the patient, focusing on patient care mutual respect, always by your side of clients during the nursing process take place, give praise for patient care outcomes, providing additional knowledge about the patient disease and good attitude in patient care (Nusantara & Wahyusari, 2018).
Theme 2: Caring for students is influenced by oneself, the family environment, and the learning environment.
Theme two is supported by three categories: (1) the influence of oneself (2) the influence of the family and (3) the influence of the learning environment. The personal experience of the participants affects the participants' ability to empathize with the patient.
"…to be more caring of course depends on ourselves…"(P11).
"…maybe everything arises because of a feeling from myself because what I feel is oh I've felt pain myself, it's not good, don't let other people feel…" (P3).
The results of this study support the findings of previous research (Kuntarti, 2018…contributing individual) the participant argued that human caring is innate. An individual's personality has also been shown to have a significant relationship with a person's caring behavior (Pangestika et al., 2021). The self factor in this research can be related to the student's internal motivation in learning. Students who have strong internal motivation will certainly affect their learning achievement (Tokan & Imakulata, 2019).
The second category is the influence of the family environment. This was obtained from the statements of five participants. Five participants stated family influenced their caring. Two participants stated especially their mothers. Mothers are parents who have a lot of influence on how students become caring.
"… to be caring… of course the main factor is family, especially mother …" (P10) The results in line with previous research by Robbiyah et al. (2018) which stated that the mother is the first education that will be experienced by the child, education in the mother's environment can affect the social life of the child to grow and develop under the level of achievement of the child's development such as morals, religious, social and emotional. The education and encouragement of mothers strongly influenced the development of social intelligence, the extent to which the success of mothers' education is the extent to which the involvement and role of mothers in the lives of their children. Mother's education is excellent and right will affect the social development of children. The manifestation of children's attitudes and behavior is an internalization process of parenting by instilling confidence and awareness of the truth of the values instilled at home. The role of parents who are carried out properly and responsibly can guide and direct children to face challenges in their lives (Parhan, 2020).
The third category was obtained from the statement that the learning environment both in the clinic and on campus had an influence on caring. Almost all participants stated that in the clinical learning environment, patients, patient's families, and nurses are the people who influence student caring.
"…I felt like I was happy there, then I started to slowly talk to the patient…I feel oh, I'm happy, for example, if I become a nurse, what do I need and remember about the patient…" (P4).
"…oh I was so happy when the patient said thank you, sis, even though I only helped a little, I was touched… so I felt meaningful… and I want to do it again…" (P5) "…when the patient's family believes in us, They think we are the intermediary for his family to recover. His eyes are full of hope…they really believe that, so if we disappoint it will hurt them…" (P7).
"... I was inspired yesterday that there was a nurse who was gentle, she spoke to her patients was good and she worked fast too..." (P9).
The experience of students undergoing learning in the clinic is also not always pleasant. There were participants who felt panicked and cried because previously they did not get a clear picture of the situation they would face in the clinic.
"…campus didn't tell me that you would be like this, like this, like this in a field like this. It's really a valuable experience…" (P6).
"…there was also a nurse who made me down… really dropped… I was asked to put in a transfusion even though I've never had one…".
The results of this study indicate that clinical practice facilitates students to learn caring directly from patients and their families. Student interactions with patients facilitate emotional engagement that affects each other. This interaction will result in a positive or negative experience influenced by other factors, one of which is the presence of a supervisor. Nurses as student mentors directly in clinical practice greatly affect the quality of clinical learning. A study shows that the supervisor's competence is the most dominant factor compared to the guidance settings, Faletehan Health Journal, 9 (3) (2022) 290-297 www. journal.lppm-stikesfa.ac.id/ojs/index.php/FHJ ISSN 2088-673X | 2597 learning methods, and learning environment (Ahmad et al., 2020). Other studies have shown that environmental factors that influence the development of caring in nursing students include role models from education and professional nurses, a conducive clinical environment, effective communication skills, good simulations, and alternative clinical placements (Inocian et al., 2022).
Unpleasant student experiences during clinical learning have also been found in other studies. Fear and unpreparedness of students can cause low-quality clinical nursing education. This can be overcome by using models and methods of nursing education, communication between faculties, and practice sites and holding an orientation stage at the beginning of the training (Farzi & Mohsen Shahriari, 2018). Student interaction with patients is expected to be able to build clinical wisdom in nursing practice in the future. This of course must begin to be studied in nursing education. Clinical wisdom can be described as a collective and shared attribute that can be learned through sharing and interaction. Although the clinical environment is seen as the best environment for learning clinical wisdom, introducing the practice of wisdom into nursing education can be done through writing assignments, mentoring, and case scenarios that can be done on campus (Taylor, 2014).
The campus environment is also stated to affect student's caring. Twelve of the fifteen participants stated that their lecturers and friends had an influence on the development of their caring.
"... like a lecturer telling stories about his experience meeting patients like this, it became a trigger for me to want to be like them because I want to be more useful..." (P3) "…every lecturer who I think can be close to him is comfortable to interact with, there is a feeling I have to care because he also cares for me…" (P4).
"...lecturers who may already have caring experience earlier than me, so I am inspired to imitate…" (P8).
Besides lecturers, friends have an influence on student's caring. Interaction between students gives influences one another.
"…caring with friends might happen because we often see each other… so to transfer energy from heart to heart, it has to be… once I was very moved when a friend said thank you because I was ready to be his patient during laboratory exams…"(P1).
"... Friendship is enough to help us to do something..., especially our positive friendship... we have to tell each other something to make our patient happy..." (P5) "...the closest one is a friend... when a friend has a problem, we listen and we share what we feel, it is caring, including empathy…" (P8).
The results of this study are in line with previous research where lecturers and friends are factors that influence the caring behavior of nurses (Kuntarti et al., 2018). A learning model on caring also states that caring for a graduate nurse is influenced by the leadership, curriculum, and standards applied to the educational institution, including one of the lecturers. Individually, nursing graduates are influenced by individual affective characteristics (Hayne et al., 2020). Gisbert and Rivas (2021) tested peer tutoring learning to increase the empathy of nursing students in which students in pairs alternately being tutors in exploring experiences that have emotional meaning were able to increase the empathy scale of students.
Theme 3: Competent lecturers, adequate facilities, and good learning strategies are needed to increase student caring.
This third theme is supported by three categories: (1) lecturer competence, (2) adequate facilities, and (3) good learning strategies. Students have the perception that lecturers who are smart, have good clinical skills, have empathy and are role models for students will help develop their caring behavior.
"... I need a smart lecturer, who keeps smiling, speaks softly, doesn't just get angry, has a good practice, and has empathy for students..." (P1).
"...actually the formation of caring is easy if for example what the lecturer teaches looks like the real thing…caring is easy for students to learn from the figure…" (P7).
Students' expectations about lecturers that they hope or need can help them in studying caring show that lecturers have a significant role in developing nurses' caring behavior. The results of this study support previous research which states that employing experienced clinical educators, seeking to improve the learning environment, and developing the relationship between education and practice fields can improve nursing clinical education (Farzi & Mohsen Shahriari, 2018). Lecturers as nurse educators have a duty to ensure that their students have a caring competency for professional practice. The fundamental caring competency of the student that can be built during the education period with students is the ability to build relationships (Setiawan et al., 2019).
The second category, regarding adequate facilities, was expressed by 3 participants. students think that mastery of clinical skills is an important part of building caring of nurse.
"…actions that are not in accordance with procedures mean that they are not caring, laboratory facilities are important so that we are skilled and become more caring…" (P11).
"...When we practice in the laboratory when we meet the patient, we care about touching, keep smiling, facial expressions when practicing any action, greet the patient first, smile and say hello and ask how they are…" (P13).
Being a caring nurse, of course, cannot be separated from the ability to have good clinical skills. Silalahi et al., (2019) shows that skilled and professional nurses are associated with patient satisfaction. Research by Meilina and Bernarto (2021) also shows that patient satisfaction of 55.5% is influenced by the skills of nurses along with their knowledge and respectful attitudes. Likewise, the results of Layuk et al., (2017) show that nurse skills have a positive and significant relationship with patient satisfaction. A systematic review conducted by Nehrir et al., (2016) regarding competencies in nursing students found that skills and practice-based and clinical competencies were one of the six basic competencies of nursing students.
The third category of learning strategies was expressed by many participants. mastery of material both in general and material about caring which is then given more real examples and applied in practice in the form of special targets in skills that support caring into learning strategies that are seen as being able to help build student caring. Together with lecturers, going to the community is also seen as providing benefits in building student's caring.
"…Hopefully, in every course, they really go into the field. We are really given what kind of provision is true caring for patients, there is a target book that is not only action skills but skills to practice communication, caring, which is also targeted from the beginning…"(P4).
"... maybe by going directly to the community, it could be through counseling to the community or by serving the community, it can grow the nature of our care for us to the community (P9) "... more deeply about caring so that it is not only theoretical but more practical as well... why is there no such thing as caring for caring practice ..."(P13).
Caring is a skill that is expected to be possessed by students as prospective nurses need to get serious attention in the learning process and even the curriculum. Hsu et al., (2022) showed an increase in the Attitude scale and willingness scale of the intervention group students after undergoing a well-designed program from providing material to direct practice to patients.

CONCLUSIONS AND SUGGESTIONS
Based on the results of the study, it can be concluded that students' understanding of caring for nurses and the importance of caring in their practice as prospective nurses are an integral part of what they want to achieve. Clinical practice becomes a learning experience that facilitates the development of caring for students directly with their patients. However, the students considered that the learning process to emphasize the caring aspect both in clinical practice as well as in the laboratory and classroom was not fully in line with expectations. Competent lecturers are lecturers who have clinical practice skills not only theoretically, but adequate facilities also to hone clinical skills and learning strategies including a supportive clinical learning environment are the expectations raised by students to improve their caring competence. Learning that focuses on increasing students' caring competence become a need felt by nursing students. Lecturers and faculty need to review the existing curriculum and curriculum tools to ensure that these needs are met.

ETHICAL CONSIDERATIONS
Funding Statement.