The quantitative data was collected through a self-administered questionnaire. The outcome variable (nurse perception about their caring behavior) was assessed by the latest revised version of the Nurse caring behaviors Inventory (CBI-16) internationally accepted and standardized self-administered questionnaire and validated for Ethiopian health care providers and adopted one (21, 22). The general questionnaire of this study has three parts: socio-economic factors, associated factors related questions, and Perception of Nurse Caring Behaviors. The CBI-16 measures four dimensions of nurse caring: Assurance (five items), Knowledge and skill (four items), Respectfulness (four items) and Connectedness (three items). It was designed and validated for administration to nurses, rating the frequency of caring behaviors on a 6-point Likert scale from 1 “never” to 6 “always” (21, 22). The internal consistency of the instrument was checked using Cronbach's alpha (α = 0.935). Evaluation of the scale is done based on the total scores and each dimension's scores. Thus, a low score below mean indicates a low perception of Nurse caring behaviors and a high score above mean indicates a high perception of Nurse caring behaviors (21, 22).

Job satisfaction was assessed by 15 items and each item has a 5-point Likert-type scale (very dissatisfied, dissatisfied, neutral, satisfied, and very satisfied) developed by Warr et al. (36). The internal consistency of the instrument was checked using Cronbach's alpha (α = 0.896). The overall job satisfaction score was estimated by taking the average score of all the subscales (23). Nurse–Staff relationships and conflict with supervisors was assessed by the Nurse–Staff Collaboration Scale item, which consist of 23 items (24). The internal consistency of the instrument was checked using Cronbach's alpha (α = 0.985). Workplace stress full environment was assessed by Occupational stress scale: A three-point Likert scale was used where stress low = 1, moderate stress = 2, and extreme stress = 3. The total number of statements included in the scale was 15; whereas, the total mean score was calculated by summating all statements for every nurse and then dividing by the total (25). Work load was assessed by 15 items and each item has a 5-point Likert-type scale (26). The internal consistency of the instrument was checked using Cronbach's alpha (α = 0.934). Professional satisfaction was assessed by 12 items and each item has a 4-point response scale (strongly disagree to strongly agree) (27). The internal consistency of the instrument was checked using Cronbach's alpha (α = 0.745).

The qualitative data collection was conducted by using semi-structured Afan oromo interview guide questions, which were primarily prepared in English by the principal investigator based on previous studies and then translated into Afan Oromo by a fluent speaker of the language. The participants were purposively selected to share their experiences and thoughts related to the phenomena. The interview took place in a quite private room. The interview was facilitated by the investigator, and the mean average time taken for the interview was 15 min. The interviewer took mobile phone records and field notes.

The result of this study revealed that nurses' perception of nurse caring behaviors in assurance and knowledge subscales were found to be mean of 4.62 and 4.78, respectively. Nurses' perceptions of nurse caring behaviors in respectfulness and positive connectedness subscales were 4.79 and 4.77, respectively. The total CBI-16 score of nurses' perception of nurse caring behaviors was found to be mean of 4.74 (Table 4).

Among the subscales of caring behaviors, more than half (n = 219, 58.7%) of nurses had high “assurance of human presence,” (n = 208, 55.8%) of nurses had high “knowledge and skill,” (n = 219, 58.7%) of nurses had high “respectful deference to others,” and (n = 230, 61.7%) of nurses had high “positive Connectedness” (Figure 2).

Out of 373 respondents, more than half 228 (60.9%) (95% CI: 55.7–65.85) of nurses had a good perception of caring behaviors. This is supported by qualitative findings. For instance:

A 12 years of experience, Male nurse participant state that, “My perception towards nurse care is good because nurses are very happy when we help patients and they get better. One thing that motivates me to have a positive outlook is that when a patient improves from a previous problem.” (P2).

The research's findings indicate that the following variables were found to have a statistically significant association at (p < 0.25) with nurse perceptions of their caring behaviors: work experience (COR = 0.51, 95% CI 0.282–0.954), marital status (COR = 1.89, 95% CI 0.798–5.074), job satisfaction (COR = 3.090 95% CI 2.002–4.769), nurse-staff relationship (COR = 0.668 95% CI 0.440–1.014), workload (COR= 2.060 95% CI 1.337–3.174), and professional satisfaction (COR= 3.246 95% CI 2.099–5.018). However, there was no statistically significant correlation found between the perception of caring behaviors by nurses and age, sex, educational status, income, supervisor conflict, or stressful work environment (Table 5).

All variables which showed statistical significance association with nurses' perception of nurse caring behaviors (P ≤ 0.25) in the bi-variable analysis were entered into a final logistic regression to avoid an excessive number of variables. After adjustment five variables are significantly associated with perception of caring behaviors (Table 6).

In this particular study, Nurses who had single were 3.9 times more likely to perceive good caring behavior than compared to those who were divorced and widowed [AOR 95% CI 3.90 (1.190–12.832)]. Nurses who have had worker longer-duration work experience in their profession were more likely to perceive good caring behaviors as compared to lesser working experience. Nurses who had 1–5 years of experience were 0.43 times less likely to highly perceive good caring behavior than those compared with nurses who had more than 10 years of experience [AOR 95% CI 0.43 (0.195–0.974)].

Among Staff related factors, Nurses who satisfied with their job were 2.4 times more likely to perceive a good perception of caring behaviors compared to those who dissatisfied with their job [AOR 95% CI 2.47 (1.468–4.178)]. This is supported by qualitative findings. For instance:

A participant with 10 years experiences stated that, “I have a good perception because nurses are very happy when they help patients and they get better. One thing that motivates me to have a positive outlook is that when a patient improves from a previous problem and shows positive changes, your heart relaxes.” (P2), (P3).

Nurses who were satisfied with the profession were 3.3 times more likely to perceive good caring behaviors compared to nurses who were unsatisfied [AOR 95% CI 3.38 (1.965–5.844)]. This is confirmed by qualitative findings. For instance:

From participants with 13 years of experiences confirmed that, “What is nursing care for patients, the continuous services provided by the nurse to the sick patient who comes to the health facility, when they are sick, especially at the hospital level patients come and most of them are treated as inpatients.” (P5).

Other participants with 12 years of experiences confirmed that “When you give care, if you prescribe medicine for a patient now, you don't know if he is cured or not, somehow pain accuses you of pain, he says he's wearing it, so at hand, you see the actual thing in your hands. It's something tangible. (P1)”

Nurses who have bad nurse-staff relationship were 0.04 less likely to highly perceive good caring behaviors than compared to nurses who have good relationship with their staff. [AOR, 95% CI, 0.044 (1.210–3.451)].

This is confirmed by qualitative findings. For instance:

A participant with 12 years of experiences stated by sharing his experience that, “The other side of the pressure is there is ignorance, which ignores this profession, why there is ignorance one of the care you give is usually nursing care, they refer you to medical care, from the management, from the doctor you work with.” (P1).

The majority of participants stated that nursing care is the main part of the nursing profession and majority of them have good perception of nurse to caring behavior. An EOPD male nurse with 12 years of experience stated that, “Nursing care is holistic and Nurse profession is focused on care rather than medicine. They look at disease-focused, but nurses look at the patient's physiologic needs based on what the patient going through now, based on what he/she is suffering from now, and giving him/her care.” (P1). Again participants of 29 years old with 6 years of experience confirm that, “The main tasks for the topic are what people come looking for, what people expect from us, it is care.” (P6). The participants of the study reported that, they have better understanding of nurse caring behaviors. A participant of 34 age and 13.5 years of experiences confirm that, “What is nursing care for patients is the continuous services provided by the nurse to the sick patient who comes to the health facility, So I have a good perception towards a better understanding of nursing care behavior.” (P5).

Five main themes emerged under this hospital-Environment related issues and have their own sub-themes. Good Perception of caring behaviors among nurses well, if the Environment of the hospital is safe and good for professionals. If the hospitals environment is not appropriate for health professionals there is no good care for the patients.

Nursing work is complex and involves several aspects of practice that are common to the profession which can generate high workloads. A participants with 10 and 12 years of experience, respectively, stated that, “One of the is due to workload, as the relationship or estimate of the nurse with a patient does not match the ratio and the load on the nurse increases care may decline. As a standard, a nurse has to treat that many patients and it doesn't apply whether it's the FMOH or the WHO who puts it down.” (P1) (P2). From some of our respondents, this high work load affects the perception of nurses during care. Another participant with 2 years of experiences confirmed that, “There is a work load so far although it isn't much it doesn't make an impact either. There is a patient ratio to nurse ration and that is not expected.” (P4).

The nurse-staff relationship has expressed the importance of having an environment in which nursing colleagues co-operated and support one another in clinical situations to achieve the best possible care for patients in need. But there are obstacles between individual nurses and other staff. And this affects Perception of nurses. A participant with 12 years of experiences stated by sharing his experience that, “The other side of the pressure is there is ignorance, which ignores this profession, why there is ignorance one of the care you give is usually nursing care, they refer you to medical care, from the management, from the doctor you work with.” (P1). Another participant with 2 years of experience confirmed that, “Occasionally, there are times when there is occasional pressure from professionals in other fields.” (P4).

Some respondents suggested that a good supervisor or good manager was an important factor in achieving organizational flexibility and handling those health professions. Respondents who were working in clinical units saw significant organizational changes as well as professional changes had been implemented, suggested that the hospital manager, supervisors, and ward manager roles were crucial to the success of these changes. A participant with 12 years of experience stated that, “For example, what kind of impact is created by management there is a misunderstanding through their leadership. Management from top to bottom fails to understand nurses as not a good assistant to help physicians.” (P1).

Other respondents suggested, however, that the lack of a manager and supervisor had failed to change the organization as well as the perception of caring behavior of the nurse professionals. As 25 years old and 2 years of working experiences confirmed that, “The occasional aspect of leadership is nothing. Occasionally, sometimes people come to training and gather us together and give us little bits of information. Other than that, there is pressure in that regard.” (P4).

Some of our participants display their ideas, a participant with 13 years of experiences stated that, “It causes a lot of pressure, for example when we talk about security issues when different parties clash, there can be mass-quality between the parties or the most injured person can be hit, then with all the people who came injured to reach you are just.” (P5).

From some participants these also affects caring behaviors. As participant with 10 and 12 years of experience says respectively, “Yes, it does affect. For example, if you take it as an emergency when a problem occurs, if the patient is injured, displaced, and comes with various problems, the load will increase and the care he provides may decrease, why because personal protective equipment is not enough in our country.” (P2) (P1).

When nurses are satisfied with their jobs, they tend to display more caring behaviors, thereby contributing to the achievement of organizational goals related to the provision of quality healthcare services. This suggests that the nurses had been providing quality care and acting in the best interests of their patients. A participant with 10 years experiences stated that, “I have a good perception because nurses are very happy when we help patients and they get better, your heart relaxes and it makes me have a positive outlook.” (P2). A Participant with 6 years of experience confirmed “We can give various care, we can raise vital signs, give prescribed medication…it is our role to follow the prescribed medication legally. Not only that, rolling patients from time to time, checking patients from time to time, even removing bedridden patients from time to time, giving various oral care mouth care are great jobs.” (P6).

“When you give care, if you prescribe medicine for a patient now, you don't know if he is cured or not, you take him home, but when you give care, someone comes bleeding you, you lose blood. so at hand, you see the actual thing in your hands. It's something tangible (Participant 1, aged 37, male, year 12)” From participants with 13 years of experiences confirmed that, “What is nursing care for patients, the continuous services provided by the nurse to the sick patient who comes to the health facility, when they are sick, especially at the hospital level patients come and most of them are treated as inpatients, which is continuous nursing they want that care.” (P5).

Working during a pandemic or endemic is a unique situation and it is imperative to be aware of its special characteristics. There is also work overload and stress related to this during sudden problems. It is known nurses are concerned with their health and personal safety, their families' health, and the need to communicate with team members and family rather than having good care behaviors. This affects the quality of care also the perception of having good caring behaviors among nurse professionals. A participant with 6 years of experiences stated that, “Yes, it can have a huge impact. If any disease arises, one may overburden by disease, the workload may also occur and if a professional is sick if I am infected the person I treated may be affected for example he may stop getting treatment, which can cause various pressures.” (P6).