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Associate degree nursing students' perceptions of caring ability, parental care and nursing school climate: A quantitative and qualitative study of caring links among first semester nursing stud...
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Associate degree nursing students' perceptions of caring ability, parental care and nursing school climate: A quantitative and qualitative study of caring links among first semester nursing stud...
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Content
ASSOCIATE DEGREE NURSING STUDENTS’ PERCEPTIONS OF CARING
ABILITY, PARENTAL CARE AND NURSING SCHOOL CLIMATE: A
QUANTITATIVE AND QUALITATIVE STUDY OF CARING LINKS AMONG
FIRST SEMESTER NURSING STUDENTS AND THEIR RELATIONSHIP TO
SEMESTER COMPLETION
by
Diane Marie Restelli
A Dissertation Presented to the
FACULTY OF THE ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION
August 2004
Copyright 2004 Diane Marie Restelli
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UMI Number: 3145269
Copyright 2004 by
Restelli, Diane Marie
All rights reserved.
INFORMATION TO USERS
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®
UMI
UMI Microform 3145269
Copyright 2004 by ProQuest Information and Learning Company.
All rights reserved. This microform edition is protected against
unauthorized copying under Title 17, United States Code.
ProQuest Information and Learning Company
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P.O. Box 1346
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DEDICATIONS
To my husband, Tom, whose unconditional love tirelessly supported me in this
educational adventure.
To my sons, Paul, Matt, and Mark, who first hand experienced the commitment
it takes for Mom to be an educator in pursuit of advanced knowledge; their
support, understanding and love is indelibly marked in the mother-sons’ bond.
To my late parents, Adrian and Lorena, who gave me the spirit to strive for more.
To my sister, Donna Kay, whose humble life and acceptance of self led me to
demonstrate that intelligence is a gift not to be taken for granted.
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ACKNOWLEDGEMENTS
With much appreciation and thanks to:
Linda Serra Hagedom Ph.D. (Dissertation Chair)
Maurice Hitchcock Ed.D. (Committee member)
Hiromi Masunaga Ph.D. (Former committee member)
Melora Sundt Ph.D. (Committee member)
Dwayne Thompson B.A., M.A.
Marcia Swanson Ph.D., M.S.N., R.N.
Mary Kay Keegan M.S.N., R.N.
Helen Norton M.S.N., R.N.
Thomas Paul Restelli, Jr. B.A.
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iv
TABLE OF CONTENTS
Dedications ........................................................................................ ii
Acknowledgments ............................................................................. iii
List of Tables .................................................................................... viii
List of Figures .................................................................................... ix
Abstract ................................................................................................. x
Chapter I ................................................................................................ 1
The Problem ....................................................................................... 1
Introduction ............................................................................ 1
Problem Area and Need for the Study ................................ 14
Caring as a Concept ................................................. 14
Evolution of Caring ................................................ 19
Nursing School Climate as a Promoter
of Socialization ..................................................... 24
Research Questions .............................................................. 29
Secondary Aims ................................................................... 30
Hypotheses ............................................................................ 30
Definition and Clarification of Terms ................................ 31
Assumptions .......................................................................... 33
Significance of the Study ..................................................... 34
The Nurse’s Commitment to the Profession ......... 34
Effective Nurse Caring and Its Impact on
Patient Outcomes .................................................. 35
The Fiscal Effects of Caring ..................................... 37
Nursing School Climate ........................................... 38
Summary Note ...................................................................... 39
Chapter II .............................................................................................41
Review of the Literature .................................................................... 41
Conceptual Framework ......................................................... 41
Attachment and Bonding Theory ............................ 41
Social Learning and Social Cognitive Theories .........48
Professional Socialization and Modeling Caring ... 52
Cohen’s Professional Socialization Theory ........... 54
Organizational Climate Theory .............................. 57
Perception Theory .................................................... 60
Review of Theoretical Literature and Research Findings ... 62
Caring Theory and Nursing ..................................... 62
Relationship Between Helping and Caring ............. 69
Links Between Prosocial Behavior, Altruism
and Caring ............................................................. 70
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V
Heritage of Caring ................................................... 72
Nurturance, Empathy and Altruism ....................... 75
Further Notes on Empathy ...................................... 77
Association Between Parental Bonds
and Social Bonds .................................................. 80
Caring in Nursing Education ................................... 83
Role Modeling and Nursing Education ....................103
School Climate as an Composite of Factors ............106
The Research Model .............................................................. 108
Summary Note ........................................................................109
Chapter III ..................................................................................... I l l
Method ............................................................................................... I l l
Instrumentation Parts ........................................................... 113
Caring Ability Inventory ........................................ 114
Parental Bonding Instrument .................................. 116
Charles F. Kettering Ltd. School Climate Profile ... 118
Copyrights ............................................................................ 122
Qualitative Portion of the Study ......................................... 123
Population and Sample ........................................................ 125
Data Collection Procedures ................................................ 127
Data Entry Changes ............................................................ 128
Data Analysis ...................................................................... 128
Methodological Assumptions ............................................. 130
Study Limitations ................................................................ 132
Study Delimitations ............................................................ 132
Summary Note ................................................................... 133
Chapter IV......................................................................................... 134
Results of Quantitative Data and Qualitative Inquiry .................. 134
Quantitative Data ................................................................ 134
Data Reliability and Comparisons of Descriptive
Statistics and Measures of Central Tendency .... 134
Caring Ability Inventory (CAI) ................. 134
Parental Bonding Instrument (PBI) ........... 135
Charles F. Kettering Ltd. School Climate
Profile (CFK) ........................................... 136
Shapes of Frequency Distribution and
Frequency Statistics ............................................. 137
Descriptive Statistics and Frequencies for Study
Data Demographics ............................................ 139
Hypotheses Statistical Results ............................. 142
Hypothesis #1 .......................................... 142
Hypothesis # 2 .......................................... 144
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Hypothesis #3 .......................................... 146
Hypothesis # 4 .......................................... 149
Hypothesis #5 .......................................... 150
Associations Between Caring Ability and
Demographic Variables ...................................... 151
Associations Between School Climate and
Demographic Variables ....................................... 154
Further Findings ..................................................... 156
Maternal Care, Paternal Care, School
Climate and Caring Ability .................... 156
Summary of Key Findings from Quantitative
Data Analysis ................................................................... 158
Qualitative Inquiry Data .................................................................. 160
Overview .............................................................................. 160
Data Reliability and Validity ............................................. 161
Respondent Descriptives ................................................... 162
Study Findings ................................................................... 164
Question #1 ............................................................ 164
Question # 2 ............................................................ 166
Question #3 ............................................................ 169
Question # 4 ............................................................ 171
Question # 5 ............................................................ 175
Additional Findings ............................................................ 179
Peer-to-Peer Student Relationship(s) ................... 179
Teacher/RN Caring Role Models ......................... 181
Student Semester Status ......................................... 182
Overall Emerging Themes/Summary of
Qualitative Inquiry ........................................................... 182
Chapter V ...................................................................................... 185
Summary, Discussion, Implications, Recommendations,
and Conclusions .......................................................................... 185
Summary ............................................................................. 185
Study Background ................................................. 186
Study Purpose ......................................................... 187
Research Questions ............................................... 188
Theoretical Support ............................................... 189
Method and Procedures ......................................... 194
Sample ........................................................ 194
Model and Instruments .......................................... 195
Data Analysis .......................................................... 195
Summary of Selected Findings and Discussion .... 196
Quantitative Summary ............................... 196
Hypothesis #1 ................................ 199
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Hypothesis # 2 ................................ 200
Hypothesis #3 ............................... 201
Hypothesis # 4 .............................. 202
Hypothesis # 5 .............................. 203
Selected Demographic Variables with
Selected Criterion Variables and
Discussion ............................................. 203
Selective Qualitative Inquiry Summary
and Discussion ...................................... 206
Question #1 .................................. 207
Question #2 .................................. 207
Question #3 .................................. 208
Question # 4 .................................. 208
Question #5 .................................. 210
Additional Summaries ................. 210
Discussion of Current Research to Related Subjects and
Implications for Nursing Education and Practice ......... 212
Beginning Phase ..................................................... 213
Working Phase ........................................................ 220
Acquiring Phase ..................................................... 233
Summary of Phases................................................. 237
Policy Implications for Nursing Education ....................... 237
Research Recommendations .............................................. 240
Conclusions ......................................................................... 242
References ....................................................................................... 245
Appendices
A. Consent to Participate in Research ......................................... 272
B. Questionnaire ............................................................................ 277
C. Study Focus of Caring Ability Development........................... 288
D. Simmons’s Model of Teacher Caring
Based on Mayeroff (1971) ................................................... 289
E. Model of Caring Competent Nurse Development
Phases and Factors................................................................... 290
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LIST OF TABLES
1. Comparison Descriptive Statistics and Measures
of Central Tendency .................................................................. 135
2. Comparison of Measures of Central Tendency ...................... 136
3. Association Between Caring Ability and
Demographic Variables............................................................... 153
4. Association Between School Climate and
Demographic Variables............................................................... 154
5. Student Caring Definitions from Question # 1 ....................... 165
6. Caring Constituents and Percentages of Use .............................166
7. Constituent List of Changes or Additions Noted
From Question # 2 ..................................................................... 168
8. Constituent List of Events, Relationships or
Situations Noted From Question # 3 ......................................... 170
9. List of Situation Constituents and Percentages of
Use Noted From Question # 4 .................................................. 173
10. List of Category and Subcategory Change Constituents
Noted From Question # 5 .......................................................... 178
11. Peer-to-Peer Relationship(s) .................................................... 180
12. Teacher and RN Caring Role Models ...................................... 181
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ix
LIST OF FIGURES
1. Curvilinear Relationship of Maternal Care with Caring Ability ..
2. Curvilinear Relationship of Paternal Care with Caring Ability ...
3. Curvilinear Relationship of School Climate with Caring Ability .
. 141
. 146
. 149
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ABSTRACT
A sample of 124 first semester students from three Southern California
Associate Degree Nursing Programs provided descriptive information on caring
ability, parental care and school climate. Nkongho’s (1990) Caring Ability
Instrument, Parker, Tupling and Brown’s (1979) Parental Bonding Instrument, and
Howard, Howell, and Brainard’s (1987) Charles F. Kettering Ltd. School Climate
Profile were quantitative instruments used to extract information after the students’
first weeks in a nursing program. Following this process a sample of 12 students was
interviewed using a semi-structured format. The results provided additional
information on the phenomena of caring ability and its development in the student.
Results of the quantitative study were significant for a relationship between maternal
care and caring ability, and between school climate and caring ability. A caring ability
variance of 12.6 percent was explained by school climate and maternal care. Other
demographic characteristics were noted as significant with caring ability including
students with lower ages and higher incomes. Each noted a higher caring ability than
its opposing groupings. School climate was rated significantly higher among students
who passed the semester, had a greater income, first career choice students, and
students with a semester completion grade of A. No difference was found among
students who passed or failed the semester with caring ability, maternal care, paternal
care and school climate scores. The qualitative inquiry results expanded explanations
of the phenomena of caring among nursing students. Five open-ended questions
ranging from the students’ definition of caring ability to a change in their caring
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ability since entering nursing school provided copious amounts of information.
The most significant is the varied responses, but overall concern for the patient in their
care, effective communication, and change in their caring ability since entering
nursing school were key responses. The interviewed respondents also provided
extensive listings of teacher/RN caring attributes and supportive teacher/RN
interactions which they enjoyed and felt empowered when practiced. As a result of
the combined study on caring ability, policy implications for nursing education and
further research recommendations are included.
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1
Chapter 1
THE PROBLEM
Introduction
The American consumer is carefully watching the healthcare industry. When
negative healthcare press hits the consumer hotline, a furry of emotions is unleashed.
Consumers believe they deserve better healthcare and they are demanding change.
Healthcare and nursing care quality become the major focus of debate between
consumers and healthcare providers. Consumers want quality care and they count on
it when in time of need.
Several studies linked consumer quality indicators with healthcare delivery. In
two telephone surveys sponsored by the Kaiser Family Foundation, adult participants
(over 40 percent in each study) rated the quality of healthcare as their biggest concern
(Kaiser Family Foundation, 1996, 2000a). Oermann (1999) interviewed healthcare
consumers in a community setting regarding their perspectives of healthcare and
nursing care quality. Oermann (1999) found that participates defined high-quality
health care was reported as having: access to care, competent and skilled providers,
and receiving proper treatment. Additionally, high-quality nursing care was defined as
having nurses who were concerned about the client, demonstrated caring behaviors,
were competent and skilled, communicated effectively, and taught clients about their
care (Oermann, 1999). Further, in a quantitative study by Oermann and Templin
(2000), consumers reported that the most important indicators of high-quality nursing
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care were: being cared for by an up-to-date nurse who is well informed and
communicates effectively, receiving sufficient time and not feeling rushed, being
taught by the nurse, and having the nurse assist the client in coping with illness and
health maintenance.
These types of studies are important because the closer the congruency of
healthcare perception between provider and receiver, then more effective healthcare
can be provided. Healthcare consumers’ opinions of the care they receive are a direct
indicator of how well healthcare professionals perform their roles, and provide quality
care. However, there are specific indicators from which these opinions are derived.
Hoggard-Green (1995) reported that hospitalized clients perceive quality care as
receiving caring attentiveness and compassion from the nurse. Clients are looking for
a caring relationship with the nurse built upon confidence, trust, and mutual respect
(Turkel, 2001). Trust and confidence in the nurse are created through nurse-patient
interactions. When the nurse is skillful, competent, caring, and knowledgeable in
performing professional nursing then the client perceives he/she is receiving quality
care. These views are similar to Roach’s (1987) conceptualization of professional
caring. Roach (1987) emphasized that knowledge, skills, and the nurse’s experience
are manifested in the five characteristics of caring: confidence, conscience,
compassion, commitment, and competence. The characteristics may be used as
indicators of quality in nurse caring. Whether the client or the nurse is judging quality
care, each can perceive quality from his or her own perspective. It is important for the
nurse to be aware of these indicators regardless of whose perception is expressed.
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3
Incongruities from either side or lack of attention in performing such indicators in a
positive manner can result in a decrease in perception of quality care and nurse caring.
Nursing education must be cognizant of these perceptions, and incorporate an
understanding in nursing curriculum in order to promote nurse caring and quality
nursing care.
Changes are on going in healthcare delivery systems. These changes have
a direct and dramatic effect on the education of nurses both emotionally, and
academically. Nursing education must continue to be ever vigilant in recognizing the
need for change in the nursing practice without compromising the quality of nursing
provided to consumers. Together nurses and consumers have expressed the need for
quality in healthcare practice.
There are other issues pressing nursing care delivery. Sigma Theta Tau
International (1999) reported several issues on nursing employment that will have a
direct impact on nursing healthcare’s future. The two most pressing are the aging
population of nurses who will be retiring just as the swelling population of baby
boomers will need health care, and increased patient acuity bringing more incidents of
work related stress on nurses caused by an increased patient work load. Additionally,
the nursing profession does not attract as many potential student candidates as before,
since there are many other workforce opportunities outside of nursing that do not
demand so much personal commitment. Further, the financial package offered by
alternative careers may be leading to a further nursing shortage. Besides these noted
facts, Ruiz (2000) reported several other factors affecting the shortage of nurses:
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4
declining birth rates, negative media coverage of nursing, cultural objections to
nursing as a profession, and the lack of experienced quality nurses in the ranks to
mentor their own.
The mentoring issue further blemishes student nurse recruitment. Nursing
(2000) documented a survey of practicing registered nurses who were asked whether
or not they would promote the profession to a potential recruit to nursing. The data
reported 60 percent as no or maybe, and only 40 percent said yes (Nursing, 2000).
This is a sad state of affairs when practicing nurses are not satisfied enough to promote
their own career.
A true nursing professional is personally devoted and possesses a strong desire
to deliver quality care. However, the practice workload and other factors are affecting
the registered nurse’s ability to administer quality care, and leading to further career
dissatisfaction. Reformation in the practice of nursing from basic nursing education to
delivery of quality care needs to keep abreast with current times and healthcare
delivery systems. Therefore, a realistic vision for future practice is a must.
Additionally, institutional support must modify itself in order for nurses to effectively
practice and meet the demands of such a vital, yet poignant profession.
With the creation of managed care, many changes have occurred in how
healthcare is delivered and perceived by its recipients. As a result of these changes,
healthcare consumers are continuing to voice concern about the quality of managed
care (Kaiser Family Foundation, 1996, 2000a). Perceived emphasis of managed care
has been on cost-effectiveness (Chang, Price, & Pfoutz, 2001). The National
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5
Coalition on Healthcare (1999) national poll further elucidated the loss of American
confidence in the current health-care system as evidenced by: eight out of ten believe
that there is something wrong with the healthcare system, seven out of ten believe the
system is compromising quality in order to save money. Further, consumers are more
concerned about mistakes made in healthcare practice than mistakes made while they
are passengers in an airplane (Kaiser Family Foundation, 2000b). The Kaiser Family
Foundation (2000a) noted definitively the consumers concern for both cost and quality
in healthcare.
Healthcare cost directly affects the delivery of healthcare and nursing care.
Inappropriate cuts and cost containment can adversely affect the quality of healthcare
including nursing care. American consumers are concerned with the quality of
healthcare they receive. They are identifying the loss of services and deficits in
national polls, and discharged patient mailed surveys. Today’s nursing needs the
support of all healthcare delivery systems to continue providing quality nursing care to
regain and retain the confidence of the consumer, and to redirect the focus of
healthcare to instill quality back into the system.
Effective recruitment of candidates into nursing is crucial for future quality
health care delivery. One way to recruit is to promote and improve the image of
nursing. Nursing continues to operate mostly in the shadows of healthcare. Sussman
(2000) noted Pesut’s (Department Chair, Indiana University School of Nursing,
Indianapolis) comment that reflects nursing practice and caring as in the background
of healthcare media coverage. Under-recognition of the nursing profession
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6
affects nursing recruitment, and undermines the importance of nursing practice. Also,
negative criticism of nursing practice including patients’ perceptions and satisfaction
can have a strong impact on the image of nursing.
Human care is associated with caring and the nursing profession. Nurse
caring, patient satisfaction and positive patient outcomes are linked (Turkel, 2001). In
a study by Turkel (2001) patients reported that being in a relationship with the nurse
enabled the client to open-up and share personal feelings and experiences. This
personal exchange demonstrated the trust of a caring nurse-patient relationship. The
client’s interpretation of caring included: being there, treating with compassion,
helping, staying with the client, teaching, empathy and knowing what to say (Turkel,
2001). The clients reported that the nurse-patient relationship made a difference in
four outcomes of their care: speeded up the client healing process, increased the
client’s well being, enhanced client learning, and reflected quality in nursing care
(Turkel, 2001). Clients recognized and verbalized the acts as quality care by the
nurse.
The recipients of healthcare feel threatened by the rapid changes in the today’s
healthcare and cost-containment (Turkel, 2001). They see the chaos of the nursing
units, and the frustration of nurses to meet client demands for timely and professional
nursing care. Visiting family and friends are affected by what they see and experience
as well. This high-impact personal involvement with forefront nursing in a healthcare
setting can both promote and deter future candidates to nursing. From a positive
experience hopefully come potential nurses. Consumers of healthcare who are
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satisfied and have witnessed nurse caring firsthand become the best recruits for
nursing, and as a result of this connection, they are personally connected. Personal
connection promotes commitment and desire. Conversely, it is possible for negative
healthcare experiences to recruit for nursing as well-meaning persons who are
dissatisfied may enter the profession to improve client care and to change the
undesirable.
Client satisfaction remains an important key to quality healthcare. In a study
by Evans, Martin, and Winslow (1998), nursing care was the primary determinant of
overall inpatient and outpatient satisfaction. Attree (2001) noted the fact that quality
care is related to patient satisfaction and both are used as factors in measurement of
quality care. Patient satisfaction is coalesced with quality nursing care. A decrease in
quality of care and caring for patients has led to “fatal distraction” from the real
business of healthcare (Schiff, 2000). Shindul-Rothchild, Berry, and Long-Middleton
(1997) reported from a national sample of registered nurses (N = 1016) the ten major
factors that can cause quality to deteriorate in a healthcare facility. Two of these
factors related to the process of providing care: (1) lack of time to provide basic
nursing care, and (2) maintenance of professional standards in an arduous
environment. Three of these factors related to outcomes: (1) patient and family
complaints, (2) patient skin integrity issues, and (3) injuries and medication errors.
The other factors related to structure (i.e. reduction in nursing staff) and again to
outcomes (i.e. patient complications, and likelihood of respondent leaving nursing).
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8
These negative factors reflect registered nurse (RN) opinions and dissatisfaction in the
quality of nursing care.
Another element affecting the healthcare consumers’ view of nursing is the
entertainment industry. Rasmussen (2001) reviewed nurses in films and television
shows and the image of the nurse often remains the same: “a warped image of real-
life RNs” (p. 18). Stereotypes of Nurse Ratched from the movie One Flew Over the
Cuckoos Nest and Major Margaret “Hot Lips” Houlihan from the long-running hit
TV series MASH, TV “soap opera” nurses, and the TV show The Nightingales
portrayed nurses as seductive, scantly clad, and ignorant. These images are long
remembered in the public’s vision of nurses. Negative images such as these most
certainly affect recruitment into the nursing profession.
The type of student entering nursing schools presents another dimension of
quality and challenges. Sigma Theta Tau (2000) reported comments by editor
Gray of WebRN. The editor noted that the brightest men and women are not
considering nursing as a career choice. This means that students with less academic
ability are applying and entering nursing programs. Further, the current workforce of
national RNs reflects only 12.3 percent racial/ethnic minority groups (Health
Resources and Services Administration, 2000). This fact notes the incongruity of
working professionals within the national population it serves.
Nursing academe recognizes several factors affecting future student enrollment
and retention. Some of these include: students who are not academically prepared,
students who do not have an adequate grasp of the English language, and other reasons
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9
some of which are not well documented in the literature. Additionally, parity of
minorities and gender (specifically the male student) nursing enrollments is under
represented as compared to the communities being served. With these facts in mind,
nursing academe continues to assess enrollment needs and student academic
differences. However, some students may find that their unique qualities may hinder
their success.
Several authors furnished insight into student difficulties with college success.
Tinto (1975), Bean and Metzner (1985), Pascarella and Terenzini (1980), and
Bean (1980) provided information related to the student attrition process. These
theorists noted student variables that can influence student attrition. Factors such as
gender, race, academic ability, secondary school performance, family status, social
status and goal commitment are important background characteristics of entering
college students which influence the quality of how students become integrated into
the college social and educational process (Tinto, 1975). Bean and Metzner (1985)
proposed variables that influence dropout decisions for nontraditional students: poor
academic preparation, interaction of psychological and academic variables, secondary
school performance and educational goals, and environmental factors. All of these
factors play a role in the attrition or success of nursing students.
An increase in diversity, ethnicity, age, gender differences, and inadequate
academic preparation have increased in the American student body. Unfortunately,
there is an increase in the loss of these diverse students in the general population of
college students and nursing students as well. Overall, at-risk students have increased
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10
in the colleges, and this same occurrence applies to the nursing student population.
These factors have impacted the pool of graduating nurses into the healthcare arena
adding to the nursing shortage.
Although the literature presented views of the nursing shortage, there is
no simple answer to halt the decline of nurses in the workforce, but in the education of
nurses certain facts are known. The Tri-Council, which includes the American
Association of Colleges of Nursing (AACN), American Nurses Association (ANA),
American Organization of Nurse Executives (AONE) and National League for
Nursing (NLN) substantiated the nursing workforce shortage (NLN Update, January
31, 2001). In a policy statement on the nursing shortage, the Tri-Council for Nursing
all agreed that the shortage is very real, fewer nurses are entering the workforce, and
that the supply of appropriately prepared nurses is inadequate (NLN Update, January
31, 2001). The Tri-Council also noted that the shortfall would grow more serious over
the next 20 years (NLN Update, January 31, 2001). Further, the Tri-Council reported
that the number of graduates taking the national nursing license exam each year has
declined since 1994, and the enrollment in all basic RN nursing programs has declined
for the last five consecutive years (NLN Update, January 31, 2001).
The facts are clear. Qualified nurses are needed to meet the baby boomer and
aging populations’ needs. With fewer incentives to become a nurse, those who choose
nursing must have an intrinsic desire, be driven by an extrinsic need, or both. Those
who do choose to be a nurse must be highly skilled, competent, and caring. Without
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11
a caring nature the working nurse may become dissatisfied and client care could
become compromised.
High-quality nursing care remains the most important issue to consumers.
With over 2.6 million RNs in the United States, nurses are the main purveyor of health
care professionals (NLN Update, May 7, 2001). According to Sechrist (Project
Investigator for California Strategic Planning Committee for Nursing) there is a 20
percent RN vacancy rate in hospitals (Lindsay, 2001). Further, Sechrist reported that
California relies on other countries and states to fulfill the nursing workforce demand
(Lindsay, 2001). California is reported as having the highest population growth in the
nation with fifty percent of this growth from foreign migration (Lindsay, 2001). More
practicing RNs will be needed to meet this increasing demand for healthcare. The
implementation of this request is focused on nursing educational institutions. Further,
noting that 70 percent of the nation’s RNs are educated at the associate degree level
(Berens, 2000), and California is the same percentage (California Board of Registered
Nursing Sunset Review Report, 2002).
Nurses are finding it difficult to practice their profession— the profession of
caring, in light of changing healthcare concerns such as the nursing shortage, cost-
containment, high-tech focus, increased patient acuity, low pay, negative stereotypical
image, and variety of other concerns. Nurses have become overwhelmed by increased
duties, the chaos of the healthcare setting, and rapid changes in technology and
healthcare practice. These facts have challenged nursing education to provide
competent and safe practicing nurses in light of these changes. Additionally, Berens
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12
(2000) noted that 70 percent of all nursing graduates come from associate degree
nursing programs. With this fact in mind associate degree nursing programs carry a
large responsibility. They must be mindful of the reductions in key nursing
components (i.e. patient safety, monitoring, assessment, appropriate nursing action,
and skill), which can have serious consequences to the consumer, even death. Nursing
programs have the responsibility to teach students to navigate the difficult terrain of
healthcare practice in order to provide safe, quality care.
It is important for nurses to plan for the future and not lose sight of their
purpose in health care delivery. Nurses are taught the ideal of nursing care in their
primary school of nursing education. They are also expected to adapt this ideal to the
rapid shifts and realities of today’s health care. Nursing education must continue to
play a big part in the re-educating nurses to meet healthcare changes. Singleton
(2000) stated that “caring is one of the most valuable attributes nursing has to offer
humanity; through caring, nurses enhance human dignity” (p. 54). However, the
presence of nurse caring is being seriously challenged in today’s healthcare.
Nurses are finding it difficult to perform their caring role within the limits of
economics and time constraints. Consumers are recognizing this gap and they are
voicing dissatisfaction. Limiting caring or competency from nursing practice does not
lead to patient satisfaction. Therefore, infusing a caring nursing curriculum is
validated and complementary to establishing competency. Nursing educational
institutions must continue their primary responsibility to recognize, initiate, infuse and
nurture the caring quality of nursing in educating students— all the while preparing
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graduates for the many challenges they will face. Caring and competency are both
necessary to a successful nursing student.
Nurse educators report that caring is taught in nursing curriculum, but very
little validation is seen in practical research. There is still no definitive list of caring
behaviors, and there is difficulty in defining what constitutes caring. Literature
supports that caring is the essence of nursing and unifying domain of nursing (Cohen,
1991), but no one knows how or if this transformation of providing nurse caring really
occurs as a result of formal nursing education.
Further research on caring would benefit the education of future nurses. It is
nursing education’s purpose to educate competent, skillful, and caring nurses into the
healthcare workforce. Studying the basics of nursing education can provide insight
into understanding how this process of student transformation to a graduate nurse
unfolds.
The purposes of this study are twofold. One is to investigate potential
predictors of caring ability among freshmen groups of associate degree nursing
students, and the other is to explore caring ability development and the impact of
formal nursing education on first semester nursing students. The potential predictors
to be investigated by the quantitative study are:
• Maternal care received by the participant’s mother during the first sixteen
years o f life.
• Paternal care received by the participant’s father during the first sixteen years
of life.
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• The climate of caring in the school of nursing in which the participant is
enrolled.
• The semester grade received by the participant.
Additionally, the first three predictors are used to explore and expand the
qualitative portion of this study. Information received from all predictors in both
the quantitative and qualitative study portions establishes a baseline of information
from which nurse educators can provide, revise, and emphasize nursing curriculum to
increase professional caring thereby affecting student success both in education and
clinical practice.
Students are entering nursing from a variety of familial, social, cultural,
ethnical, and economical backgrounds. These affect the development of students’
caring ability, which varies among students prior to nursing school admission. After
students enter a nursing education program, it becomes the nurse educators’
responsibility to present a curriculum that develops their basic caring ability to a
professional level. Additionally, a caring school climate encourages student success,
and a successful student graduates from a nursing program, therefore increasing the
RN count in the healthcare workforce.
Problem Area and Need for the Study
Caring as a Concept
Caring is considered a central concept within nursing. McCance and
McKenna (1999) presented an overview of the four main theories on caring using
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some of the same literary sources which support the non-observable construct of
caring: Leininger’s (1988e, 1991, 1995) theory of culture care, Watson’s (1979, 1985)
theory of human care, Roach’s (1984, 1987, 1992) conceptualizations of caring, and
Boykin and Schoenhofer’s (1993) theory of nursing as caring. These four authors
are the major contributors to caring theory and conceptualization in nursing.
They provide the foundation of support for caring in this study.
In Leininger’s (1988e) culture care theory, care is the “essence of nursing” (p.
152). It is the “central, dominant and unifying focus of nursing” (Leininger, 1988e, p.
152). Leininger (1991) defined nursing care as actions and activities directed toward
assisting, supporting or enabling an individual or group with clear and anticipated
needs to ameliorate or improve a human condition or lifeway, or to face death. In
Leininger’s (1991) theory care is inextricably linked with culture. Further, Leininger
(1991) defined culture as the learned, shared, and transmitted values, beliefs, norms
and lifeways of a particular group that guides the groups thinking, decisions, and
actions in modeled ways. The purpose of culture care is to provide culturally
congruent care to different cultures while maintaining or regaining their well-being,
health or face death in a culturally appropriate way (Leininger, 1991). The goal of
Leininger’s (1991) theory is to provide care that is culturally congruent for the health,
well-being of individuals, families, communities, and sociocultural institutional
environments. Leininger’s (1988b) transcultural approach noted, “human caring is a
universal phenomenon, but the expressions, processes and patterns vary among
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cultures” (p. 11). Finally, Leininger (1988b) viewed caring as also having
“biophysical, psychological, cultural, social and environmental dimensions” (p. 11).
In Watson’s (1985) theory of human care, nursing is presented as a human
science, with the process of human care for individuals, families, and groups being the
major focus for nursing. Watson (1985) noted that quality nursing and health care
demand a humanistic respect of the human being. It is dynamic human-to-human
transaction that requires knowledge, commitment, human values, and personal, social
and moral engagement of the nurse’s time and space (Watson, 1985)). Human caring
is viewed by Watson (1985) and Gadow (1985) as not just an emotion, concern,
attitude or benevolent desire, but as a moral ideal whereby the end is protection,
enhancement, and preservation of human dignity.
Watson’s (1985) proposed goal of nursing “is to help people gain a higher
degree of harmony within the mind, body, and soul which generates self-knowledge,
self-reverence, self-healing, and self-care processes while allowing increasing
diversity” (p. 49). Watson (1985) purported that this goal is achieved through human-
to-human caring transactions in which the nurse responds to the individual’s
subjective inner world. Central to Watson’s (1985) theory is transpersonal caring.
Transpersonal caring is a special kind of human care relationship, which holds high
regard for the whole person and their being-in-the-world (Watson, 1985).
Transpersonal caring “allows humanity to move towards greater harmony, spiritual
evolution, and perfection” (Watson, 1985, p. 70). It promotes kinder and more helpful
feelings for humans the more it advances (Watson, 1985).
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Interventions proposed by Watson (1979, 1985) in this caring theory are
referred to as Watson’s 10 “carative factors.” These “carative factors” are actualized
in the interaction process between the nurse and recipient of care. The more human
care is actualized, the more potential for human health goals being fulfilled (Watson,
1985).
Watson’s (1985) human care theory contributes to the preservation of the
individual, in society, and fosters the spiritual evolution of humankind. Transpersonal
caring requires carative interventions, interventions which require an intention, a will,
a relationship, a commitment to caring as a moral ideal, and actions (Watson, 1985).
As Watson (1985) and Gaut (1983) noted, human care has received less and less
emphasis in the (healthcare) system, making it difficult for nursing to sustain its caring
ideology in practice. The increasing technological and bureaucratic demands in the
system has changed the focus of nursing care making professional human caring
submerged (Watson, 1985).
In Roach’s (1984) conceptualization of caring in nursing, a particular set of
values and beliefs about caring as a human mode of being provided the main premise
of Roach’s writings. Roach (1984) presented caring not as unique to nursing, but as
unique in nursing. Further, as it relates to nursing, Roach’s (1984) idea of the caring
concept is essential to nursing as a helping discipline. Roach (1987) believed that
caring is “the most common, authentic criterion of humanness” (p. 2).
The “five Cs” of Roach’s (1987) theory provided a suggested broad framework
of categories for expressing human professional behavior. The attributes or “five C’s”
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of professional caring are: confidence, conscience, compassion, commitment, and
competence (Roach, 1987). Roach (1987) suggested that professional caring was to
be expressed within these attributes or categories of human care. The ultimate
conclusion of Roach’s years of study and reflection presented “caring as the human
mode of being,” and nursing as the professional actualization of caring (Roach, 1984).
Further, Roach (1987) underscored the need for nursing education to professionalize
the human capacity to care.
Boykin and Schoenhofer’s (1993) theory of nursing as caring was an attempt
to establish nursing as an academic discipline, and to create a nursing curriculum
grounded in caring. The theorists postulated that the unique focus of nursing is
suggested in nurturing persons living caring and growing in caring. The philosophical
origins of this model are based in part from the works of Mayeroff (1971) and Roach
(1984, 1987, 1992) promoting the view that caring is a human mode of being.
A basic tenet of Boykin and Schoenhofer’s (1993) theory is that all persons are
caring. This entails a commitment to know self and the other as caring (Boykin &
Schoenhofer, 1993). Caring involves being genuinely humble; being ready and
willing to know more about self and others (Boykin & Schoenhofer, 1993).
Caring in nursing is a lived experience, communicated intentionally, in
authentic presence through person-with person interconnectedness, a sense of oneness
with self and other (Boykin & Schoenhofer, 1993). A personal expression of caring
answers the call for nurturance, and nurturance is directed toward a common purpose
to enhance personhood (Boykin & Schoenhofer, 1993). Boykin and Schoenhofer
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(1993) noted, “personhood is the process of living grounded in caring” (p. 8).
Additionally, Boykin and Schoenhofer (1993) believed that nursing is a response to a
human need that in its living practice, caring develops; the more one has to practice
caring, the easier it becomes to allow oneself to further develop caring. The caring
theorists also believe that caring is not unique to nursing, but is uniquely expressed in
nursing (Boykin & Schoenhofer, 1993). Further, all of the four major caring authors
or theorists presented in this concept section agreed that caring is unique in nursing
but not unique to nursing.
Evolution o f Caring
Caring is a nebulous concept, making it difficult to study. It is not just simply
a series of actions, but a way of acting that is both contextually dependent and value
bond (Fealy, 1995). Using numerous nursing literary sources Morse, Bottorff,
Neander, and Solberg, (1991) presented a comparative analysis of nursing
conceptualizations and theories on caring. The five conceptualizations/perspectives
of caring included: caring as a human trait, caring as a moral imperative, caring as an
affect, caring as an interpersonal relationship, and caring as a therapeutic intervention
(Morse et al., 1991). These are used as categories from which caring nursing literature
can be identified.
An early source of caring philosophy came from Mayeroff (1971). Several
nursing theorist used Mayeroff s writing to derive a caring theory for nursing.
Mayeroff (1971) referred to as the act of caring for another person as helping him/her
to grow and actualize himself/herself; caring was viewed as a way of ordering one’s
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values and activities (Mayeroff, 1971). It provided comprehensive meaning to one’s
life (Mayeroff, 1971). The major ingredients in the development of caring are
knowing, alternating rhythms, patience, honesty, trust, humility, hope and courage
(Mayeroff, 1971). Mayeroff s (1971) work proved to be a valuable resource in the
development of caring theory among nursing theorists.
Noddings (1984) reviewed caring from a feminine perspective. It was noted
that mothering and caring were deeply related. Several authors noted by Noddings
(1984) viewed women as more interested in caring, supporting, and cooperating.
Additionally, Noddings (1984) recognized men as bringing their best human and
masculine qualities to the experience of parenting which involved caring; their ways
remain different, but more deeply and appreciatively complementary. Caring attends
to the uniqueness of the individual being cared for, and it is present only in personal
relationships (Noddings, 1984).
The feminists’ perspective of caring and nursing brings new thought on gender
care. However, in a qualitative study by Boughn (2001), using baccalaureate nursing
students, found that no differences emerged between men and women and their desire
to care for others. Because of the small numbers of males in nursing it has been
difficult to statistically compare males and females. Some studies such as Simmons
(1994), Simmons and Cavanaugh (1996), and Kosowski, (1995) de-selected
males or no males were included in their studies while others such as Watson, Deary
and Lea (1999), Grams, Kosowski and Wilson (1997), Hanson and Smith (1996), and
Beck (1991, 1992, 1993) included male responses in their studies.
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The uniqueness of the individual is developed through a complex proceeding
involving genetic, social, and interactive learning processes. Parents are the driving
force in the development of childhood personal characteristics (Cutrona, Cole,
Colangelo, Assouline, & Russell, 1994). Close relationships with parents enable the
child to develop more self-confidence and independence than those with greater
emotional distance (Maccoby & Martin, 1983). It is this early responsiveness and
nurturant parenting response that provides a secure base for the child to explore the
environment without anxiety (Ainsworth, 1982). Exploration, discovery, skill
acquisition, and the development of self-confidence are facilitated by a secure
relationship with one or both parents (Ainsworth, 1982). These actions may enhance
child learning, and development. In addition, parent-child bonds are presumed to be
broadly influenced by characteristics of the child, actual care-taking relationship
between the child, and by characteristics of the reciprocal, dynamic, evolving
relationship between the child and parent (Parker, Tupling & Brown, 1979).
Acknowledging this, Parker et al. (1979) were able to established a parental bond with
contrasting poles between affection, emotional warmth, empathy, and closeness on
one end, and emotional coldness, indifference and neglect on the other.
Additional factors have influenced bonding (parental attachment) and
development of caring. Family life has changed dramatically since the 1950’s. Later
research provides information that both parents are involved in the child
rearing/bonding process— not just the mother as previously documented by Bowlby
(1951, 1969), Ainsworth (1967), Ainsworth, Blehar, Waters, and Wall (1978), and
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Klaus and Kennell (1976). Seven out of ten mothers work in the “paid” labor force,
dual-eamer households comprise now the majority of two-parent families, and three of
ten households are single-parent households (Hochschild, 1997, U.S. Bureau of the
Census, 1995). Despite these changes, childrearing remains primarily the
responsibility of mothers. Ishii-Kuntz and Coltrane (1992) noted that in dual-eamer
families’ mothers still are responsible for 74 percent of the total parental hours spent
in direct child care.
There is an underlying assumption in bonding research that a single caregiver
is crucial to child development. Yet in many cases someone gives caregiving
other than the mother (perhaps a relative, friend or spouse). Hays (1998) noted that
caregiving notions have been historically specific, socially constructed and culturally
prescripted. Further, child-rearing prescriptions and practices of any given society are
the economic, political and cultural fabrics of that society (Hays, 1998). Hays (1998)
reported that these factors are recognized and must be taken into account when fully
understanding the changes in household parenting practices, bonding, and positive
childhood developmental characteristics.
From a different perspective on caring, Watson, Deary and Lea (1999) in a
longitudinal survey, traced perceptions of nursing and caring among student nurses
as they progressed through their nursing education. This relationship was investigated
by means of two inventory scales: Nursing Dimensions Inventory (NDI), and Caring
Dimensions Inventory (CDI). Significant changes in the scales were reported as
nursing students’ progressed in their education— especially after 12 months of
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education. Around this time there was a loss of idealism about nursing and caring.
However, it is important to note that nursing and caring became more synonymous to
the nursing student after 12 months in nursing education (Watson et al., 1999).
Watson et al. (1999) hypothesized that conceptualization of nursing action and caring
was not as readily evident to the neophytes in early nursing education as those who
have undergone nursing education or became employed in practice.
Many questions still remain unanswered in nursing educational practices: how
does one develop caring, learn about caring, and why is there a loss of caring around
a specific time frame in nursing education? Perhaps the phenomenon of nurse burnout
extends to not only practicing nurses, but student nurses as well. Using this approach,
it is possible for student nurses who burnout early in their education do not graduate.
Further, Garrett and McDaniel (2001) noted that nurses are affected by their healthcare
work environment, and a negative environment can lead to emotional exhaustion,
depersonalization and even nurse burnout. This information leads to additional
unanswered questions: can a nurse care too much, how does a nurse develop a
professional caring distance, and what coping mechanisms does the professional nurse
use in order to practice intense nurse caring, and maintain career development? Each
of these questions may apply to the student nurse as well.
Caring is seen as an area for further study in many areas, but especially in
nursing education. Caring is perceived as synonymous with nursing care especially
after twelve months of nursing education (Watson et al., 1999). This study focuses on
acquiring information on caring among nursing students from several perspectives.
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Factors such as parental bonding, age, gender, religion, previous healthcare
experience, school climate, peer study groups, semester completion, semester grade,
and other demographics can add to the body of caring theory knowledge. Results of
these factors may provide potential predictors of first semester nursing student
(freshman) caring ability, and student success. Also, this information may enable
nursing faculty to discover new understanding of basic caring abilities with which first
semester nursing students enter into nursing education. Knowledge of these facts may
give nurse educators information necessary to provide, revise, and emphasize in
nursing curriculum. These factors are necessary for students to survive the demands
of today’s nursing education and practice.
Nursing School Climate as a Promoter o f Professional Socialization
The nursing school environment has a significant impact in developing the
nursing student. Students are exposed to the professional socialization process when
in contact with academic instruction. Windsor (1987) reported that students
progressed in professional socialization through observation of nurses in practice and
participation in nursing functions. The two main settings responsible for nurse
socialization are the educational setting, and the clinical practice setting. Also, it is
within these settings that professionalism is developed.
In becoming a nurse, the student is able to perform occupational duties in the
role of a nurse. The practice of this role over a set period of time enables the student
to practice activities in order to assume the future role of nurse (Holland, 1999).
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Through practice, the student nurse gains the skills and knowledge to become an
effective caregiver to the most vulnerable group in society— the ill.
There is a hierarchy of nursing knowledge and care. Holland (1999) reported
the three steps as: (1) basic nursing care, (2) nursing care, and (3) technical nursing
care. Nursing requires inclusion of these steps as separate learning and socialization
opportunities. The process of caring is both physical and emotional that is inculcated
within the profession.
In 1990 the National League for Nursing, a nursing program accreditation
body, mandated that caring be included in nursing curricula (Dillon & Stines, 1996).
Since this time nursing literature has attempted to document the inclusion of caring in
nursing curricula. Several recent literary sources provided documentation of how
caring is viewed in nursing education today.
Simonson (1996) reported on a phenomenological study designed to discover
how caring was taught in a nursing education program. The implications from this
study revealed the need for faculty and administrators to exhibit caring as a way of
being. It was not just a matter of teaching a caring curriculum, but the manner of how
the faculty interacted with one another and the students (Simonson, 1996). The caring
climate of the nursing school provided a practicum for nursing students to visualize
and experience caring personally. The faculty and administrators commitment to the
values congruent with caring demonstrated to the nursing students the kind of nurses
they wanted their students to become (Simonson, 1996). The faculty was instrumental
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in the development and demonstration of a caring professional role and personal
lifestyle.
It is clear that student nurses leam about the nursing profession through
experience and close association with expert practitioners. The expert practitioners
coach students to realize their full potential (Grealish, 2000). Without this coaching,
nursing students would resort back to familiar ways of solving nursing dilemmas.
Nursing students need socialization support to maintain interest, gain confidence and
improve in nursing performance, thus striving towards student success and excellence
in nursing.
Lindeman (1993) reported that there has been little real innovation in nursing’s
clinical teaching model for over 30 years. Students are enculturated through nursing
education in various ways. However, the core for clinical learning is expressed
through the student-teacher relationship (Evans, 2000). Nurse educators who role-
model compassionate, holistic care for their clients, and caring ways in treatment of
colleagues, students and other health care personnel, provide a way of being in nursing
(Evans, 2000). This behavior sends a powerful message to students in the
socialization process of the nursing professional role. The result of this may provide a
positive educational environment and may influence students’ professional attitudes,
confidence, compassion, caring, and competence.
There is growing concern that caring is being displaced in nursing with a turn
towards the work akin to medicine (Horton, 1997). Bradshaw (1998) reported that
nurses have wanted to become more like doctors, and Fletcher (2000) noted that
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doctors have become more caring than nurses. Rapid changes in technology and new
treatments forced nurses to gain extended competencies, and as a result this has
challenged the traditional role of the nurse. In the process of trying to meet the
practical and educational demands of a high-tech nursing field, caring appears to fall
short. As a result, caring seems to be viewed as subordinate or not important at all
(Fletcher, 2000).
Nursing is seen as losing its fundamental values in particular concern for
patients, focusing more on acquisition of knowledge and skills to further status than on
patients (Fletcher, 2000). Some fear that a community of nurse “robots” is being
created in the midst of nursing education without caring. It is believed that a caring
ethic and nursing professionalism can be reborn again, and the best hope is to re
educate nurses to care again. The setting for this caring re-birth is supposed to take
place through formal education in nursing schools, and enhanced by a climate of
caring and professionalism among the participants. This re-birth in nursing
educational practice must reflect the contemporary changes of healthcare delivery.
Changes such as increased acuity, increased workload, less nurse-patient interaction
time, decreased patient stays, minimally prepared nurses working in difficult and
stressful environments, economic restraints, and other healthcare issues must be
reflected and dealt with in nursing curriculum so nurses can be prepared to practice in
an ever-changing ambience. Healthcare workers and professionals are finding it
difficult to work safely because of these changes, and as a result mistakes are being
made. Additionally, economic restraints are forcing change. Healthcare professionals
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must be cognizant of this fact on-going, strategize ways to practice safely, efficiently,
and with a caring focus.
Hanson and Smith (1996) studied junior-year baccalaureate (N = 32) nursing
students’ perspectives on experiences of caring and not-so-caring interactions with
faculty in a baccalaureate program. The not-so-caring teacher-student interactions
may lead the student to feel lost, scared, rejected, discouraged, powerless, cheated,
looked down upon, and not understood (Hanson & Smith, 1996). The student’s voice
is not heard; feelings are not understood; respect for the teacher is lost; the student
looses interest in class and contribution during class, and the student worries about
future student-teacher interactions (Hanson & Smith, 1996). In addition, the study
noted that the student’s self-esteem is eroded, learning is disrupted and the student
feels minified as a human being (Hanson & Smith, 1996).
As a result of this negative encounter, Hanson and Smith (1996) reported that
the student begins to doubt their ability to become a nurse. The many caring teacher-
student interactions noted in this study led the student in feeling comfort, confidence,
competence, and motivation to strive more, to keep on, and to study harder (Hanson &
Smith, 1996). This resulting feeling from the teacher-student caring interaction is seen
as affirming the chosen profession of nursing, and that the teacher truly cares about the
student (Hanson & Smith, 1996). This affirming action encourages the student and
promotes the student as being important to the nursing program and to the profession.
Over the decades, nursing education found its way from hospitals and was
taken into colleges and universities. In an on-going manner, the knowledge base for
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nurses has become extensive, and skills more expansive thus making nursing
education formalized with exams, and registration for competence. The process is
expansive and nurse educators have found less time to devote to one-to-one student
instruction, let alone to practice caring in every circumstance.
It is documented that a caring learning environment may enhance students
positive feelings, self-confidence, and empowerment (Hughes, 1992). These feelings
encourage and motivate the student to study and learn. Faculty members that convey a
caring interaction with students are affirming their belief in the humanistic caring
touch of the nursing profession. It is much like treating others, as you want to be
treated. It is not possible to separate the caring role of the nurse and caring educator
who is a nurse.
Caring in academe is carried over into clinical practice as well. Students
emulate what they see from their role models— nurse educators, and a lack of caring in
the school climate does not demonstrate caring and nursing professionalism. There
must be a match between caring curriculum, and caring actions from which students
can learn, model and practice. From this venue students may learn to develop a caring
connection with patients they encounter.
Research Questions
1. What are the relationships among maternal care, paternal care, nursing school
climate, academic success, and caring ability in first semester associate degree nursing
students?
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2. What role does maternal care, paternal care, nursing school climate, academic
success, and caring ability in first semester associate degree nursing students play in
prediction of academic retention/success?
Secondary Aims
In addition to studying caring ability as the criterion variable and maternal
care, paternal care, and nursing school climate as the predictor variables, the effects of
demographics are explored. The main demographic variables included in this
study are age, religion, marital status, socioeconomic status, number of children,
nursing as a career change, years of nursing-related experience, semester grade, and
others.
Hypotheses
1. First semester nursing students who experienced affectionate and warm
are from their mothers in early life will show a greater caring ability than
those who experienced detached and cold care from their mothers in early
life.
2. First semester nursing students who experienced affectionate and warm
care from their fathers in early life will show a greater caring ability than
those who experienced detached and cold care from their fathers in early
life.
3. First semester nursing students who are educated in a nursing school
climate perceived as considerate, warm, and supportive will show greater
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caring ability than nursing students who are educated in a climate
perceived as inconsiderate, cool, and non-supportive.
4. Maternal care will account for more variance in first semester student
caring ability than paternal care or the climate in which the nursing student
is educated.
5. First semester nursing students who pass the first semester of nursing will
have a higher caring ability than those who fail the first semester.
Definition and Clarification of Terms
Caring ability is the ability to help another grow, and actualize himself/herself,
a process, a way of relating to someone and requires development (Mayeroff, 1971).
Caring for an individual involves cognitive, affective, and psychomotor involvement.
Caring involves determining what care to provide which is the cognitive component;
giving care or “doing for” the client which is the physical component; and the
emotional commitment which is the affective side of caring. For purposes of this
study, caring ability was measured on the Caring Ability Inventory (Nkongho,
1990).
Maternal/paternal care is defined as “affection, emotional warmth, empathy
and closeness... .(in contrast to) emotional coldness, indifference and neglect”
(Parker, Tupling, & Brown, 1979, p. 8). For the purposes of this study,
maternal/paternal care was measured by using the “care” subscale of the Parental
Bonding Instrument (Parker et al., 1979). Respondents rated their perception of the
nature of both maternal and paternal care during the first sixteen years of life.
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School climate is the collective personality of the environment in which the
nursing school functions. School climate is considered the atmosphere or personality
sketch of the school. Climate defines the nature of the institution, and provides a
personality profile of sort much like the personality of an individual. For the purposes
of this study, respondents rated their perception of caring within the school climate
using the Charles F. Kettering School Climate Inventory (Howard, Howell, &
Brainerd, 1987) and as adapted from Simmons (1994).
Caring is an elusive phenomenon for which there is no universal agreement
about its relationship to nursing (Lea & Watson, 1996). Regardless of how caring is
used in nursing; all agree that nursing and caring are enhanced by one another.
Several terms are often associated with or used interchangeably with caring: empathy,
altruism, nurturing, compassion, and prosocial behavior/attitude.
Compassion is the core of caring; it can be composed of love, feeling, concern
and friendship; it can be actualized (Wilkes & Wallis, 1998). It is a perception that is
emotionally felt.
Empathy is an affective response organizing perceptions. Empathy facilitates
awareness of self and others therefore increasing sensitivity which promotes shared
respect, mutual goals, social awareness and understanding of individuals within a
historical and social context (Alligood & May, 2000).
Altruism is “doing something for another person at some cost to oneself’
(Ozinga, 1999, p. 5). It is associated as an instinct for survival, supporting a
continuance for existence (Ozinga, 1999). Altruism involves togetherness,
relationships, bonding, connectedness and community (Ozinga, 1999).
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Nurturance is the fusing and integrating of cognitive, physiological, and
affective processes with the aim of assisting a person to move towards a holistic health
(Tomey & Alligood, 1998). It is associated with rearing practices, and development.
A nurturing person gives physical or emotional care to another perceived to be in need
or desire (Edwards, 1986)
Prosocial behavior is “behavior that benefits another person” (Eisenberg, 1982,
p. 199). It is a helping behavior that may be performed as a result of different motives
(feelings of obligation, indebtedness, conformity with others’ expectations,
expectations of external rewards) or altruism (Eisenberg, 1982).
Self-efficacy is the judgment of one’s capability to recognize his or her
capability to organize, execute a course of action, and accomplish a certain level of
performance (Bandura, 1986).
Self-transcendence is an inherent human characteristic to reach out beyond
oneself, to achieve a wider perspective and behaviors to help discover oneself, and to
make meaning of one’s life (Coward, 1996).
Hardiness is an optimistic orientation to life, which accredits individuals to
transform or eliminate stressful situations (Kobassa, Maddi, & Kahn, 1982).
Resilience is a personality characteristic that manages the negative effects of
stress and promotes self adaptation (Wagnild & Young, 1993).
Assumptions
1. The potential to care exists within all individuals (Nkongho, 1990).
2. Caring ability is multidimensional (Nkongho, 1990).
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3. Caring includes cognitive, affective and psychomotor elements.
4. Caring can be learned (Nkongho, 1990).
5. Caring ability can be measured (Nkongho, 1990).
6. The influences of caring ability can be assessed by measuring dimensions
such as caring, respect, trust, and morale within the school of nursing
(Simmons, 1994).
7. The nursing student’s ability to care can be assessed by measuring other
dimensions of caring behavior such as knowing, courage, and patience
(Simmons, 1994).
8. Respondents to the study will provide answers that are truthful and
endearing to their intrinsic beliefs.
Significance of the Study
The Nurse’ s Commitment to the Profession
Nursing schools have a commitment to the nursing profession to provide
competent, caring individuals into the healthcare workforce. At the core of nursing
practice is the moral and ethical treatment of humankind with dignity and integrity
through quality healthcare practices. Caring nursing practices may be considered as
“artful” (Benner, 2000, p. 101), and less tangible to describe, but the outcome of
caring practices can be seen as lifesaving, and empowering to the clients involved. In
1990’s version of the American Nurses Association Code for Nurses, nursing
responsibilities to the client and profession are delineated (Ellis & Hartley, 1995). The
Code for Nurses provides a clear framework upon which the profession functions. At
the core of this code is for nurses to provide services with respect to human dignity
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(Ellis & Hartley, 1995). In addition, competence in nursing and high quality nursing
care is required.
Caring may be the way in which all humans respond to the ill, distressed and
vulnerable to society, but nurses have a professional responsibility and obligation to
provide safe, high-quality care. A loss of this ethic of caring in nursing education can
have a detrimental effect on the quality of care provided. The knowledge obtained
from this study is important to the quality control of nursing education. It is necessary
to take review of the basic tenet of the nursing profession— mainly caring because
caring is the core of the nursing profession.
Effective Nurse Caring and its Impact on Patient Outcomes
Caring by nurses is not individually accounted for in economic value. Because
of this, caring seems to be not valued as much as technological procedures. Nurse
caring costs are not explicit yet caring is a minute-by-minute, day-by-day activity in a
nurse’s role. However, nursing authors have begun to document the impact of caring
by nurses on patient/client outcomes.
Kitson (1996) reported findings from several sources that the attentive caring
nurse can make a patient feel better, and get better more quickly. For example, by
using Watson’s (1985) carative factor, “instillation of faith-hope,” a nurse can exert a
powerful influence for health change. This belief in the client by the nurse fosters
strength, and potential in the individual, thus motivating the client to make a life
change toward wellness. Hinshaw (2000) reiterated the importance of caring in
nursing by identifying the major research priorities as noted in published articles.
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“Quality of care outcomes and their management” was reported as one of the top five
American nursing research priorities (Hinshaw, 2000, p. 118).
The result of implemented quality nursing care is to optimize health outcomes
of people and their families. Aronovitz (2000) noted that preliminary information
exists to show a difference in client outcomes when care is provided by a
baccalaureate prepared nurse, but recognized that some of these nurses may have
begun their education in a community college setting. Also, Staden (1998) explained
that caring has come under increasing pressure from a market driven healthcare
economy, but recognized that nurses need to create alliances with service users and
advocacy groups, and demonstrate that caring with emotion does make a difference in
patient outcomes.
Caring actions by the nurse provide comfort for the patient. Kolcaba (1994)
noted that enhanced comfort readies the patient for subsequent desirable outcomes
(health seeking behaviors). Further, Bush and Barr (1997) researched critical care
nurses and found that nurse caring actions (administering physical care,
communicating— speaking, listening, touching, supporting, teaching, mediating,
advocating, making decisions, and taking responsibility for their actions) made the
patients feel better and look better as reported by the nurses. Bush and Barr (1997)
also reported from a least six authors that caring produced positive outcomes for
patients.
Halldorsdottir and Hamrin (1997) studied the caring and uncaring encounters
with nurses and other healthcare professionals from the perspective of cancer patients
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receiving care. Their results indicated that the perceived effect of a caring encounter
provided a sense of solidarity, empowerment, well-being and healing for the patient.
It is therefore documented by several sources in this section that quality nursing care
has affected patient outcomes in a positive way.
The Fiscal Effects o f Caring
Consumers of health care have long been interested in the quality of care they
receive. Oermann (1999) described high-quality nursing healthcare from the
consumers’ perspective. The researcher noted that consumers described high-quality
nursing care as having nurses who were concerned about them, communicated
effectively, demonstrated caring behaviors, taught them about their care, were
competent, skilled, and acted as liasons (Oermann, 1999). Consumers feel satisfied
when they receive quality nursing care.
In today’s healthcare economy, healthcare providers are competing for their
share of the healthcare market. It is more likely that consumers of healthcare will
return in the future if they perceive their care as being “good.” Nurses are at the
forefront of care being provided in a variety of healthcare settings. They provide a
definitive link between the healthcare facility, patient care, and the economic survival
of the institution through the caring services they provide.
Gordon (2000) reported that the American Hospital Association in 1996 sent
its members a confidential report entitled Reality Check: Public Perceptions o f
Health Care and Hospitals. The report summarized the opinions of patients, and the
key indicator referred to as a measure of quality in their hospital care was the nurse
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(Gordon, 2000). In addition, Gordon (2000) noted from several studies that when
hospitals employ educated nurses and give them ample time with patients, the patients
have ablated urinary tract infections, falls, pneumonias, bedsores, and are less likely to
die. The impact of nursing care is apparent in reducing the cost of healthcare, and
preventing complications to the patients.
Nursing School Climate
School climate was reported to have a significant effect on nursing student
development. Subsequently, in 1989 the National League for Nursing passed a
resolution for nursing educators to include caring as a core value in nursing curricula
(Tanner, 1990). The resolution called for the inclusion of enhanced caring practices
among faculty-student and faculty-faculty relationships that are egalitarian.
Several nursing authors commented on this practice. Tanner (1990) noted that
caring practice is possible only when the culture of the school is supportive of caring
practice. Higgins (1996) reported on a project that implemented caring as a nursing
therapeutic with associate degree nursing students. It is generally believed that caring
outcomes in practice occur because a caring, teaching-learning process in nursing
school was implemented (Higgins, 1996). Two assumptions of this project related to
nurse educators: (1) nurse educators are primarily responsible for establishing a
climate for learning that is non-threatening, warm and caring, and (2) students learn to
value, choose and integrate caring behaviors into practice mainly through modeled
behavior by caring nurse educators and practitioners (Higgins, 1996). The outcome of
this project gave credence to teaching-learning as a human process, and a caring
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climate can foster thinking and practice that is congruent with today’s healthcare
system’s need.
Simonson (1996) reported on a phenomenological study of associate degree
students. The researcher found that students learn caring from faculty and
administrators, and therefore it is imperative that they exhibit a caring way of being in
order for students to learn caring as the essence of nursing (Simonson, 1996). Finally,
nurse educators are supposed to know how to care for students since similar qualities
are used to care for patients (Paterson & Crawford, 1994). Therefore, this study has
merit in determining the first semester associate degree nursing students’ perceptions
of caring, and nursing school climate. The results of this study may promote
curriculum revisions and recognize the need for future educational strategies that
result in a nursing program which focuses on caring as the essence of nursing.
Summary Note
This chapter presented an overview of caring, its theory and its application to
professional nurse caring. The evidence is strong in presenting caring as an important
factor in nursing education and practice. Even though caring is seen as a nebulous
concept, theorists continue to define and perfect its place in nursing.
Healthcare economics continues to drive changes in healthcare delivery. These
changes provide impetus for nursing education to re-look at how caring is
implemented in nursing curricula, and practiced in a managed business. There is an
obvious need to continue further study of caring in nursing to refine, and further define
its place in today’s education of nurses. Next, Chapter II presents a review of
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theories and research related to caring ability and practice, and the research model
used in this study.
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Chapter II
REVIEW OF THE LITERATURE
This chapter reviews the relevant theory and research that are the foundation of
this study. There are several theories that support the conceptual framework in
connecting caring to nursing education. Each provides a unique display of theory and
research where applicable. The literature review begins with the development of
bonding and attachment theory and proceeds to related concepts in creating a caring
connection. Finally, the chapter presents a review of both quantitative and
qualitative caring studies in the nursing realm.
Conceptual Framework
Attachment/Bonding Theory
The earliest recollections of caring encounters come from a parental bonding
influence. It is believed that a person develops caring ability from the significant
people in his/her life— mainly parents (caregivers). Parental relationships provides
the foundation of caring development that is transcended through the child’s growth,
development and beyond. The intimate caring relationship that is developed in the
child’s formation years is considered the attachment or bond with the caregiver.
Several researchers and authors provided information explaining the attachment
process and its effect on the recipient.
Attachment theory is based on the work of John Bowlby from the 1950s and it
has expanded since. Bowlby (1973) described the bonding process that occurs
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between an infant and caregiver. Much of the early work on attachment theory comes
from mother-child studies (Eyer, 1997 & Hays, 1998). Bowlby (1951, 1969)
presented in his works that an intense, constant mother-child attachment was an
essential foundation for proper child rearing, and for social development. Further,
Bowlby (1980) stated that attachment behavior comes from any form of behavior that
results in a person attaining or retaining closeness to some other significant individual.
Attachment behavior and caregiving are complementary (Bowlby, 1980). In the
course of healthy development attachment behavior leads to development of
affectionate bonds or attachments, first between child and parent and later between
adult and adult (Bowlby, 1980). This attachment development can be utilized
throughout life encounters especially in times of illness, stress and old age.
Ainsworth, Blehar, Waters, and Wall (1978) further developed the works of
Bowlby. The Strange Situation experiments by these researchers concluded that
securely attached infants who have a secure base will explore their surroundings and
learn from their environment. This separation from the parent allows the infant to
become more confident. On the other side, insecure infants can be avoidant and
anxious-ambivalent, showing signs of protest, anxiety, and anger (Anisworth et al.,
1978; Feeney & Noller, 1996).
Pfaller and Kiselica (1996) stated that an individual’s attachment experience is
believed to influence his/her future interactions with others. A securely attached child
is said to have had a comforted childrearing experience, and he/she is reported as
having a more secure relationship with the attached caregiver; they are less anxious as
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a result of the secure base relationship (Pfaller & Kiselica, 1996). Securely attached
children are seen as more competent with peers, have greater ego-resilience, and
demonstrate greater empathy (Pfaller & Kiselica, 1996). Further, a confident
individual develops from the caregiver attachment, and this person is less prone to
intense fear or apprehension, and he/she is more likely to partake in exploratory
behavior than an individual who lacks such confidence (Lopez, 1995).
Bowlby (1988) proposed that attachment models are especially active during
periods of stress. During a stressful event, the person organizes personal and inter
personal behavior to achieve a level of closeness or distance with others in a similar
way that was used in the person’s earlier development (Bowlby, 1988). Further,
related to the work of Ainsworth et al. (1978), a person’s sense of self-worth,
confidence, motivation for exploration and mastery are related to the presence, support
and approval of significant important attachment figures in one’s life.
Attachment behaviors are seen to be stable over time, but attachment styles are
changeable (Pfaller, Kiselica, 1996). Ricks (1985) and Egeland, Jacobvitz, and Sroufe
(1988) researched abused children who as adults did not abuse their own children.
The results of these studies indicated that attachment styles could be changed
especially if the abused were able to use formal operational thought in adolescence to
reevaluate their past or if support is given from an adult caregiver outside o f the family
of origin.
Early development of attachment behavior is created through a homeostatic
system. This is a process whereby the child creates behavior by means of a feedback
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loop with the significant person(s) in developing the attachment. The goal of
attachment behavior is to maintain a certain degree of proximity and communication
with the designated attached figure (Bowlby, 1980). There is a degree to attachment,
and attachment is mediated as the need arises (Bowlby, 1980). Bowlby (1980) stated
that attachment behavior becomes organized within one’s personality so as to be used
throughout life when needed.
The history of attachment research has been criticized for poor designs of non
human animal experiments, studies of institutionalized children, culturally bound
conceptions, small samples, and a failure to find consistent evidence of maternal and
child behavior that is a direct result of bonding (Eyer, 1992). This has encouraged
future researchers to expand attachment theory further than the maternal side of
research. However, Hays (1998) argued that the central reason for mother-child
attachment theory is grounded in extant cultural beliefs that the proper maternal role is
for the mother to stay at home with her children to keep the mother in her place.
Additionally, Hays (1998) noted that current literature suggests the mother role has
changed; mothers participate in the paid labor force. This has promoted revolutionary
changes in contemporary society and in the functions of family life since Bowlby
(1951), and the extent of change in attachment theory stemming from this finding is
not fully understood (Hays, 1998).
Parents rather than mothers are now seen as the paramount focus of attachment
theory (Hays, 1998). In the past, 90 percent of attachment research focused on
mothers (Eyer, 1997). Bradley, Whiteside-Mansell, Brisby & Caldwell (1997) and
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Hays (1998) agreed in using the term “parental” attachment rather than maternal
attachment as it once had been in Bowlby’s early years. However, the maternal-child
bond still remains important to early bonding theory, but to state that this is the main
or only means to develop attachment is unfounded in the literature.
Attachment theory asserts that it still remains necessary to have a single
primary caregiver, but in today’s complex parenting society, primary caregivers are
not only mothers, but also relatives, friends, step-parents, single-parents, spouses, and
friends. This fact has added a new perspective to attachment theory. Egalitarian
parenting seems to be a new area in parenting, but it is not yet fully substantiated by
research.
Appropriate caregiving is a part of the human cultural model (Hays, 1998).
Attachment/bonding theory is associated with caregiving. Caregiving is bound with
social and moral trends that shape roles of mothers, fathers, children, and family
(Hays, 1998). Although past attachment research has been gender specific, and
culturally bound, attachment can be non-traditional, and a healthy, happy child can
still be raised (Hays, 1998). The research still leaves open to question the differences
in parenting due to class, race, nationality, sexual orientation and employment.
Attachment theory has two underlying assumptions: (1) humans are social
beings and require social contact, and (2) human children at birth are absolutely
dependent on others for their care (Hays, 1998). However, other factors are
considered in caregiving as well. Parker, Tupling and Brown (1979) agreed that
mothers are perceived as significantly more caring than fathers, but Hays (1998)
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pointed out that childrearing practices and prescriptions of any given society are
affected by economic, political, and cultural structures of that society. These factors
affect those who provide care. Further, it is noted by Hays (1998) that many children
of non-Westem cultures are not raised exclusively by individual mothers. In fact,
other women including older siblings share childrearing. The claim that the West’s
way of raising children is best is not necessarily true especially since attachment
theory research has neither proved nor disproved the postulated causal relationship
between parent-child attachment and the development of socially and psychologically
“healthy” children-tumed adults on the other (Hays, 1998). It is not possible to
separate the caregiver relationship from the child’s life experiences both inside and
outside the family circle (Hays, 1998). There are many actions and events that impact
a child’s development of attachment.
Attachment theory in its basic state is simple-minded, and shallow because it
fails to recognize the deep complexity of child development (Eyer, 1992). Hays
(1998) stated that attachment theorists need to address the gender issues of
childrearing and take a more balanced approach between needs of children and needs
of the caregiver, and recognize the impact devaluation of nurturing in the larger world
of economic and political life has on childrearing practices. It is projected that a
realistic portrait o f today’s family life includes any significant primary caregiver
in a child’s life who promotes caring practice and security in the child. Further
research is recommended on the impact of significant caregivers and child
development.
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Ainsworth (1989) stressed the importance of extending attachment theory
to surrogate figures and affectionate bonds throughout the life cycle including
caregiving systems. This would include caregiving in the pedagogical domain.
Correspondingly, Pfaller and Kiselica (1996) noted that measures of school
achievement or behaviors may be correlated with a measure of the level of attachment
that children have to certain school personnel. They recommended this area for
further research.
Several investigators established significant links between the nature of an
adult’s current attachment style and their earlier accounts of relationships with parents
(Hazan & Shaver, 1994a, 1994b; Brennan, Shaver & Tobey, 1991; Collins & Reed,
1990; Feeney & Noller, 1990). It was disclosed that secure individuals were found to
have parents who provided adequate personal care and encouraged personal autonomy
(Lopez, 1995). In addition, secure adults reported less anxiety, hostility, depression,
higher self-esteem, less shyness, higher levels of interpersonal trust (Lopez, 1995).
Insecure individuals may be predisposed to be less likely to express personal needs
directly for fear of provoking disengagement from the person involved thus adding to
negative self-attributions (Lopez, 1995). However, Lopez (1995) recommended that
the links to the assumptions about the continuity of attachment-related characteristics
from infancy to adulthood needs to be established through prospective and
longitudinal research. Lyddon (1995) noted that attachment theorists are constantly
revising attachment models to accommodate new social experiences, but these models
have become more complex and differentiated. Lyddon (1995) further reported that
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attachment research has recently focused on testing predictive relationships between
persons’ attachment security and their adjustment in a variety of interpersonal domains
such as college, work, and romantic relationships.
Cutrona, Cole, Colangelo, Assouline, and Russel (1994) reported research by
Maccoby and Martin, (1983) that individuals who maintain a close relationship with
parents throughout adolescence demonstrate more self-confidence and independence
than those with greater emotional distance. This equates to a secure relationship,
which fosters exploration, discovery, skill acquisition and the development of self-
confidence (Ainsworth, 1982). It is noted by Cutrona et al. (1994) that a secure
relationship with parents throughout childhood contributes to the development of
positive self-schemata such as high self-worth and self-efficacy. Adding to this,
Giblin (1994) noted that the human family exists beyond just one generation. It is
influenced by past generations and the extended family network. This sets the course
of involvement from the family emotional field, and allows for greater explanation of
sibling differences and behaviors not yet explained by conventional attachment theory
(Giblin, 1994).
Social Learning and Social Cognitive Theories
Social learning theory’s premise is that human behavior is motivated, and
regulated to some degree using the framework of social structure (Frisch & Frisch,
2002). It is a process in which human behavior is replicated and practiced upon
knowledge and interaction within a social environment. Social learning emphasizes
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the tendency for human beings to model or imitate behavior, which is observed from
others. In this process, the individual learns behavior that is socially acceptable and
desirable. Behavior is part of a socialization process that is a learned response. It is
learned through modeling or observational learning and considers both self-rewards,
negative consequences and relative rewards (Gilbert, Fiske, & Lindzey, 1998). Social
learning theory recognizes the noticeable roles played by imaginative experience,
symbolic, and self-regulatory processes in psychological functioning (Bandura,
1977b). Human thought, affect, and behavior are influenced by observation, and
direct experience (Bandura, 1977b). Humans use symbols to represent events, to
analyze, to communicate, to plan, to create, to imagine, and to engage in discrete
action (Bandura, 1977b).
Social learning theory is central in human self-regulatory process (Bandura,
1977b). Within this process people select, organize, and transform to a stimuli
resulting in action (Bandura, 1977b). As a result of social learning, humans are
capable of self-directing to self-regulate their own change. Social learning theory
explains human behavior through reciprocal interaction between cognitive, behavioral,
and environmental determinants (Bandura, 1977b). In this process people can
influence their own destiny and self-direction; they are not powerless, but reciprocal
determinants of themselves and their environment (Bandura, 1977b).
Social cognitive theory is much broader and more comprehensive than
behaviorism and social learning (Stadjkovic & Luthans, 1998). It includes cognitive
constructs, which extend beyond issues of learning or modifying behavior (Stadjkovic
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& Luthans, 1998). There is agreement among theorists that human development is
influenced by society therefore reflecting social learning.
Bandura (1986) stated that social cognitive theory views people as neither
driven by internal factors nor controlled by external factors. Instead human
functioning is derived from a “model of triadic reciprocality” in which behavior,
cognitive, personal factors, and environmental events all operate as interacting
determinants of one another (Bandura, 1986, p. 18). There is a mutual action assumed
between these factors (Bandura, 1986).
Stadjkovic and Luthans (1998) further explained that social cognitive theory
has two main parts. The first part is social which acknowledges the social origins of
much of human thought and action that individuals learn by being part of society. The
other is the cognitive portion, which recognizes the influential contribution of thought
processes to human motivation, attitudes, and action (Stadjkovic & Luthans, 1998).
There are several factors that interplay in social cognitive theory as explained
by Bandura (1986). These are the basic human capabilities: (1) symbolizing
capability— people process visual symbols into cognitive information that is used as a
guide for action, (2) forethought capability— people use their immediate action in the
environments to self-regulate future behaviors, (3) vicarious capability— people use
observation of others and learn from this experience, (4) self-regulatory capability—
people regulate their own internal self-set standards, and self-evaluative reactions to
exerted behaviors, (5) self-reflective capability— people are able to think and
analyze their experiences and thought processes specific to their environment and
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about themselves (Bandura, 1986). Persons use these basic capabilities to initiate,
regulate, and maintain their own behavior. These perceptions are also referred to as
self-efficacy beliefs (Stadjkovic & Luthans, 1998). Perceived self efficacy is defined
as a person being able to make a judgment of his/her own capability, to organize and
execute a course of action to attain the designated performance; it is concerned with
the judgment of what one can do with whatever skills one holds (Bandura, 1986).
Self-efficacy is a central concept in Bandura’s (1977a, 1986, 1997) theory
development.
The process of social cognitive theory is more expansive in understanding
human social learning. It is a multifaceted social transmission model rather than
familial transmission model (Bussey & Bandura, 1999). Social cognitive theory
provides a life-course perspective in human social development (Bussey & Bandura,
1999). All forces are considered in human development including cognitive, social,
affective and motivational processes (Bussey & Bandura, 1999). In addition, social
cognitive theory acknowledges the influential role of evolutionary factors in human
adaptation, and rejects any one-sided evolutionary view (Bussey & Bandura, 1999). It
recognizes that learning is not equipotential, but that some things are more easily
learned than others because of events that are facilitative or impediment in style
(Bussey & Bandura, 1999).
Social cognitive theory supports prosocial behavior. Prosocial behavior is
desirable in society. Behaviors such as sharing, helping, and cooperating encourage
prosocial behavior. It is the end result of social adaptation which is supportive of
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society’s goals. Prosocial behavior is associated with parental attachment (Giblin,
1994). However, social cognitive theory does provide the best explanation for social
learning. A person learns from a cumulative life-time of experiences, and these
experiences guide the person’s actions and thoughts in future interactions.
Professional Socialization and Modeling Caring
According to Quinn and Smith (1987), a profession is defined as requiring a
complex knowledge base, commitment which benefits humans, minimal societal
control exercised over practice, and membership organization which guides for
effective control of itself in practice. Nursing meets this criteria. Although
there is disagreement among many authors as to what constitute these precise criteria
necessary to be named a profession, Huber (2000) delineated nursing as a profession.
Huber (2000) similarly agreed with Quinn and Smith’s definition adding a profession
is “a calling, vocation, or form of employment that provides a needed service to
society and possesses characteristics of expertise, autonomy, long academic
preparation, commitment, and responsibility” (p. 34).
Nursing is taught through an organizational system known as higher education.
In this academic setting, people with specific responsibilities act together for a specific
purpose to educate nurses. All organizational systems are known to have a unique
social system. Nursing academe is no different, and it utilizes a unique socialization
process in the development of the professional nurse.
Getzels (1958) reported on Getzels and Guba’s social system model, which has
two dimensions. One part is the organizational environment in which the institution
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has certain role expectations, culture, ethos, and values. The other part is the
individual person who has a personality and certain needs. This individual’s
personality and needs disposition interacts with the institution’s need for goal
achievement (Huber, 1996, 2000). This process is recognized as socialization into an
organization.
Nursing students construct from learning experiences the professional
socialization process. Experiences whether they are successes or failures have an
indelible effect on an impressionable nursing neophyte. Regardless, nursing students
are socialized into the profession of nursing practice— its ideals and its norms. The
socialization process begins when the new recruit brings to their course of study
personal qualities, ideals, values, and beliefs about the profession. Through the course
of studies and interactions with professionals, peers, and faculty, their ideals and
personal beliefs are transformed and re-evaluated. This sum of this process is also
referred to as role development or professional socialization (Doheny, Cook, &
Stopper, 1992).
Role modeling is considered as of extreme importance in development of
professional socialization in nursing (du Toit, 1995). Higgins (1996) presupposed that
student nurses primarily learn caring behaviors through the efforts of the nurse
educator. It is in the non-threatening climate of caring that a student learns to value
and choose caring behaviors (Higgins, 1996). Modeling of caring behaviors by the
instructor provides a rich environment for the student to learn and integrate into
practice caring behaviors.
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In the practice of caring the student perceives that the instructor is supportive
through positive affirmation. Higgins (1996) stated that in the development of a
helping-trusting relationship with the student, a respect for the humanity and dignity of
the student is recognized. This relationship can have a significant effect on how the
nursing student reflects the same caring behaviors in nursing practice.
Through the teaching-learning human process a transformation takes place that
is philosophically and morally consistent with human caring (Watson, 1989a, 1989b,
1990). A caring teaching/learning process and caring/modeling fosters a caring
outcome in practice (Higgins, 1996). Nursing educators must role model
compassionate, holistic and caring ways (Evans, 2000). This way of being in the
teacher-student relationship is seen as providing an empowering message to nursing
students, and this can have a lifelong effect on how they practice nursing (Evans).
Grealish (2000) reported that students learn about the profession through close
association and experience with expert practitioners. Schaffer and Juarez (1996)
postulated that educators who care for their students in the teach-leaming environment
provide the key influence on students’ understanding of caring and their motivation to
care for others. Modeling caring behavior further indoctrinates the student into the
professional socialization role of the nurse.
Cohen’ s Professional Socialization Theory
Nursing students are socialized into the professional role. Role modeling, role
repetition, and interaction with other professional nurses provide a reference for the
nursing student to clarify their professional role (Meleis, 1975). Kelly (1992)
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reviewed studies in which professional socialization is found to have conflicting
messages from nursing faculty. One such study purported that nursing students are
socialized to be subordinate, obedient, respectful of authority, and be loyal to the team
(Buckenham & McGrath, 1983). However, informants in Kelly’s (1992) study
perceived themselves to be caring, but expressed a lack of confidence in nursing skills
(Kelly, 1992). They included family members as role models as well as nursing
faculty, clinical preceptors, and friends (Kelly, 1992). Although the results of this
study reported predominantly positive interactions with teachers as role models,
negative teacher interactions are proposed to have a powerful influence as well (Kelly,
1992). These encounters provided the impetus for inconsistency in role modeling
professional socialization. Self-confidence and self-evaluation were viewed as factors
in professional socialization development, but must be learned (Kelly, 1992).
Empowerment and professional growth were promoted by excellent instructors who
knew the value of self-evaluation as a strategy (Kelly, 1992).
Doheny, Cook and Stopper (1992) stated that professional socialization is a
process whereby the student learns about nursing from experienced professional
nurses, develops a common basis of understanding through nursing curricula. Old
ideas about health, illness, wellness and caring for clients are reevaluated through this
process. It is a socialization process whereby values, attitudes, knowledge and skills
are changed (Doheny et al., 1992).
Professional socialization is the process through which a person gains
occupational identity by acquiring the values, attitudes, interests of a specific
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profession in which one seeks membership (Melia, 1984). Nursing conforms to this
definition. It has its own specific body of knowledge, values, and skills that make it a
unique profession. Students are taught a curriculum that reinforces a nursing identity,
and upon completion of a nursing educational program, a student is perceived to be
socialized into a way of thought and action that is consistent with the professional role.
Cohen (1981) reported a four-stage developmental model for professional
socialization of nurses originally based upon Piaget’s (1928) cognitive development
work. It begins with the novice student nurse who then passes through a series of
cognitive stages. The first stage places the beginning student in a dependency phase
with the student leaning upon the instructor for direction and guidance. This is known
as unilateral dependence. The student does not challenge, criticize or question the new
information received. In addition, the student recognizes that all nursing actions are
carefully observed due to their lack of experience and knowledge.
In the second phase, the student begins to have more freedom to question the
instructor. This phase is called negative/independence. Concepts and facts that were
previously presented by the instructor are no longer taken as gospel truth. The
dependency cord with the instructor is severed and the students are now able to
question and defend their own ideas. This phase may challenge some instructors
especially those students who question too much. Another aspect of this phase is that
most students experience this within a group setting. The group cohesiveness provides
a conduit to challenge professional education, and as a group they experience
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emotional support and collective solutions. The cohesiveness of the group adds
strength to their ideas.
The third phase is called dependence/mutuality. In this phase, the student
thinks more abstractly, and utilizes an empirical approach to problem solving. Facts
and ideas are not just accepted, but tested. Critical thought has begun making students
in this phase more enjoyable and fulfilling. Nursing students are no longer dependent
on the instructor for the basics of nursing. They have the capacity to connect new
knowledge to previous experiences, applying empathy and commitment to others as
needed. Evaluative/critical thinking runs rampant in this stage, and it is the major
practicum.
The last stage is called interdependence. In this phase, the conflict between
dependence from the third stage and on-going attempt for independence is resolved.
Students are able to learn from others and react independently based upon previously
learned theories and concepts. Resolution of contradictions, and synthesizing of
standards are characteristic of this phase. The functional role of the student nurse in
this phase is synonymous with a “full-fledged professional” (Cohen, 1981, p. 18). An
important aspect of this phase is that the new professional maintains flexibility by
incorporating new ideas and theories when old ones become obsolete.
Organizational Climate Theory
The majority of organized education takes place in the school setting. A
school-learning environment is considered a complex organization. Owens (1970)
stated that the two specific characteristics of an organization are the formal and
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informal structure. The formal structure is composed of roles and rules in which the
individual is supposed to behave. In recognizing one’s role, the individual also notes
authority figures and boundaries of administrative units. The informal structure is not
so obvious, but evidence has suggested that informal organizational structure is
essential to the functioning and administration of an organization, and the informal
structure group member can have great power on the organization (Owens, 1970).
Also, the informal organization can have a strong impact on organizational climate.
Tagiuri (1968) defined organizational climate as an enduring quality
of the internal environment that has three components:
• It is experienced by its members.
• It influences the members’ behavior.
• It can be described in terms of the values of a particular set of
characteristics or attributes of the organization.
Organizational climate is sometimes referred to as “atmosphere”, “culture”, “ethos”,
“personality”, “feel” or simply “climate.” Regardless of the term used, organizational
climate is consistently referred to in a psychological context in which organizational
behavior is embedded (Owens, 1981). Owens (1981) noted that organizational climate
has an important role in shaping the behavior of its participants thus noting the notion
o f person-environment interaction. The members o f the organization enforce the
norms or standards of the organization. Individuals are expected to conform, and meet
the obligations of the group norm. This persuasive environment can have a strong
influence on the individual’s perceptions, values and attitudes (Owens, 1981). Further
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affecting an individual’s behavior is the entire situation in which the behavior
occurs— meaning both the person and the environment are reflective (Owens, 1981). It
is an interaction process whereby the person’s behavior is a result of the function
between the person and the environment. The personal characteristics of the
individual provide an abundance of behavior displays. The environment can impose a
great influence in shaping and eliciting new and changed behavior in the individual. It
can impose change demonstrating that the individual now belongs to the environment
and not vice versa. Further, environmental influences can be so great that the
individual tends to overcome many individual differences.
Hemingway and Smith (1999) in a study reiterated a relationship between
occupational stress and organizational climate among practicing nurses (N = 252).
The results indicated that perceived occupational stressors exist (i.e. heavy workload,
work pressure, death of patients, role conflict, role ambiguity, and unacceptable views
of the nurse’s role). However, certain occupational stressors can be removed or
diminished if attention is paid to the cause or antecedents of identified stressors
(Hemingway & Smith, 1999). Identified stressors in the organizational climate (i.e.
perceived work pressure) can affect perceptions of role conflict and role ambiguity
leading to job stress, decrease in job satisfaction and absenteeism (Hemingway &
Smith, 1999). The authors further noted that target interventions for a specific area
producing stress in an organizational climate would work best in reducing the
perceived stress created (Hemingway & Smith, 1999). Further, Johnson and McIntyre
(1998) noted that job satisfaction is strongly related to several factors: organizational
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culture, climate and goals, personal empowerment and involvement, recognition,
communication, creativity and innovation, and decision-making. These authors
recognize the importance of organizational perception in providing employee job
satisfaction. In another study by Eisenberger, Fasolo, and Davis-LaMastro (1990), a
positive relationship was found between employees’ perceptions of being valued and
cared for by the organization. As a result of this feeling, the employees expressed
affective and calculative involvement in the organization, and they were more self-
directed regardless of direct reward or personal recognition (Eisenberger et al., 1990).
A supportive organizational climate connects the employee with the employer
enhancing employee involvement (Shadur & Kienzle, 1999).
Several other studies noted that organizational climate is individually viewed
through the member’s perception (Hershberger, Lichtenstein, Knox, 1994; Johnson &
Mclntye, 1998; Shadur, Kienzle, 1999). It is the person’s perception of the
organizational climate that can have a positive or negative affect on individual
performance. Further, a supportive climate enhances organizational members
involvement and procreates job satisfaction and success. A practice that is relative to
the educational organization of nursing.
Perception Theory
Roy (1999) included perception in the development of the Roy Adaptation
Model. This model is used in nursing education and clinical practicum as a guide in
nursing practice. Roy (1999) defined perception as “the interpretation of a sensory
stimulus and the conscious appreciation of it” (p. 259). Perception is the conscious
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acknowledgement of a sensory stimulation, and cognitive interpretation from the
individual’s perspective. It is what the individual perceives through the primary
senses of seeing, hearing, feeling. Perception involves an interaction-influence
between the person and the environment. This perception is considered a truism by
the preceptee, and this cognitive thought can have a gradient of belief.
Olson (1992) utilized Bern’s (1972) theory of self-perception and applied it to
the domain of emotion. In this study, Olson noted that self-perception theory assigns
more importance to the interpretation of the contextual environment in which the
emotional reaction occurs. Also, self-perception theory assumes that the perceiver’s
inferences may be self-corrected as a result of influencing factors (Olson, 1992).
Perception has meaning for nursing education in that student-teacher
interaction is composed of perceptions. Students and teachers are evaluating in an on
going fashion how they see things, how to do things, and why they think the way they
do. Meaning is ascribed individually depending on the event and contextual
environment in which the perceived event took place. Perceptions can be selectively
driven or distorted. Factors such as love, fear, jealousy, anxiety, and anger can distort
perception. Perception is believed to be in the “eye of the beholder.” Perception does
not require judgment by anyone else, but the individual involved. It is the impact of
the situation on the individual, and the cognitive interpretation that creates the
perception (Campbell, Dunnette, Lawler, & Weick, 1970).
The current investigation relies upon the perceptions of nursing students
during the first sixteen years of life, paternal care during the same time frame, and
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perceptions of nursing school climate. Previous findings noted that perceptions of
parenting reports of children are significantly more accurate than parents. Possibly
because of the social desirability effect that can have an impact on parents’
perceptions (Marquis & Detweiler, 1985). However, perception in the educational
arena regardless of whose it is, the teacher’s, student’s, or administrator’s, has
meaning in understanding education’s purpose and impact.
Review of Theoretical Literature and Research Findings
Caring Theory and Nursing
Caring continues to be the central focus of nursing. It is difficult to define
“caring” and nursing does not have the only hold on the term and its use. Over the
past years, caring emerged as a significant concept that provides the background for
nursing’s professional existence. Leininger (1988e) described caring as the “essence
of nursing and the central, dominant and unifying feature of nursing” (p. 152).
Theorists argue that caring is not unique to nursing and that it is not possible to
distinguish nursing from other caring professions. Regardless, nursing has continued
to develop a caring science providing proof of caring practices and accumulating a
specific body of knowledge.
Five conceptualization of caring have been identified by Morse, Bottorff,
Neander and Solberg (1991). In the first conceptualization, caring is seen “as a human
trait.” It is a part of human nature that is common and inherent in all people. Human
survival depends upon this basic constant characteristic. It is an essential part of being
human (Morse et al. 1991) Several theorists are integrated in Morse et al.’s (1991)
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conceptualization. Leininger (1988e) added to this theory by recognizing differences
in cultural expressions, noting that caring should be culturally congruent with one’s
culture in order to be therapeutic. Ray (1989) reported that caring could be described
according to a bureaucratic frame. In this frame caring is differentiated by roles and
positions of people within an organization and within areas of the organization, and
each area defined caring using unique descriptors. Authors Griffin (1980, 1983), and
Roach (1987) describe caring as an “essential way of being.” Caring is viewed as a
complementary action using activities, attitudes and feelings mediated through a
nurse-patient relationship (Griffin, 1983). Griffin (1983) also wrote that the nurse as
the giver of care also accrues benefits of increased powers of perception and sense of
increased personal worth. Roach (1987) added that “caring is the most common,
authentic criterion of humanness” (p. 2) and labeled the five “C’s” of caring in
nursing: compassion, competence, confidence, conscious, and commitment that make
caring unique in nursing.
Second, caring is considered to be a “moral virtue” (Morse, Bottorff, Neander
& Solberg, 1991). Theorists in this category are concerned about patient good and
maintaining the dignity and respect of patients as people (Morse et al., 1991). Watson
(1985, 1988b, 1988d) noted caring as a moral ideal. In the action of caring,
improvements in the well being of another can take place. The change in the person
receiving the care can affect the caregiver both mentally and spiritually. This event is
described as “finding meaning in one’s own existence and experiences, discovering
inner power, control and potentiating instances of transcendence and self-healing”
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(Watson, 1985, p. 74). Further, Fry (1989) conceptualized caring as a common value
for the profession with the goal of enhancing human dignity.
Caring embraces the moral component (Morse et al., 1991). Griffin (1983)
noted that the moral undertones of caring, and stressed the need for a moral
component along with cognitive and emotional components of caring. Gadow (1985)
regarded caring as a moral ideal, which involves commitment to protect, and enhance
human dignity. In addition, Fry (1988) agreed that caring involves a moral value by
specifying “good” and “right” reasons for care. Caring is not just a human action. It
reflects a moral value and respect for the person through a specific manner of action
(Kyle, 1995). Theorists recognized that moral theory in caring is underdeveloped and
requires more study.
Third, caring is viewed “as an affect” or emotion (Morse et al., 1991) It is a
feeling of compassion or empathy, which motivates the nurse to provide care (Morse
et al., 1991). In this theory, feelings or emotions must be present in order for the nurse
to care. Gendron (1988) reported that the nurse must be sincere and express the
appropriate form of caring that is congruent with the underlying emotion. This is
recognized as a part of the art of nursing in which the nurse puts oneself (mind and
action) into the one receiving the care (Gendron, 1988). McFarlane (1976) noted that
nursing is “virtually synonymous with caring,” but differs with other theorist in
considering caring as acts of “helping and assisting with daily living activities which
may be simple or complex” (p. 187).
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Fourth, caring is viewed “as an interpersonal interaction” or mutual endeavor
between nurse and the patient (Morse et al., 1991). Characteristic of this interpersonal
interaction include that parties must be: communicative, respectful, trusting, and
committed to one another (Morse et al., 1991). This reciprocal interaction enriches
both the receiver and the nurse (Morse et al., 1991). Three theorists agree with this
approach (Homer, 1988; Knowlden, (1991); and Weiss, 1988). They noted that
feelings and actions in a caring encounter are different than a non-caring encounter.
Further, Weiss (1988) included verbal caring, nonverbal caring and technically
competent behaviors in her analysis. It is also noted that caring helps the receiver of
care to cope, and to successfully deal with whatever they find stressful, and to find
meaning in the situation (Benner & Wrubel, 1989). There is a reciprocal nature in
caring between the one cared for and the giver of care that reflects the interpersonal
interaction of caring.
The last conceptualization of caring presented by Morse et al. (1991) is “caring
as a therapeutic intervention.” Theorist is this category view caring as a therapeutic
intervention that is patient centered (Morse et al., 1991). For example the theorists
contend that the patient must demonstrate a need that the nurse can meet in an
intervention regardless of how the nurse feels. The intervention is an “intentional
human enterprise” and explicitly states that “any action may be described as caring if
and only if the carer (S) has identified a need for care and knows what to do for X (the
one cared for); S chooses and implements an action intended to serve as a means for
positive change in X; and the welfare of X or what is generally considered good for X
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is used to justify the choice and implementation of the activities identified as caring”
(Gaut, 1986, p. 78). This category specifies task-oriented behaviors that are discrete
actions. Orem’s (1985) theory of self-care is specific to this category. Self-care is
seen as necessary for the maintenance of life, linking the nurse’s deliberate action as a
helping service (Orem, 1985).
The debate still continues as to whether or not caring is unique to nursing.
Benner and Wrubel (1989), Bevis (1981), Fry (1989), and Homer (1988) do not agree
that caring is unique in nursing. However, Benner and Wmbel (1989) stated that
“caring practices are lived out in this culture primarily in parenting, child care,
nursing, education, counseling, and various forms of community life” (p. 408). Morse
et al. (1991) posited the views of caring. There is no theoretical agreement that caring
is unique to nursing, that caring remains constant between patients, that caring care be
reduced to behavioral tasks, and that the outcome of caring only affects the patient, the
nurse or both (Morse et al., 1991). Further studies are recommended by Morse et al.
(1991).
Lea and Watson (1996) agreed that caring in nursing still remains an elusive
phenomenon. They reported on Watson’s (1988d) existentialist’s viewpoint that
caring cannot be operationalized, but viewed only through qualitative methods of
investigation. Watson (1985, 1988d) further explained her position in terms of ten
carative factors, none of which can be reduced to behavioral tasks. The carative
factors include:
• practicing a humanistic-altruistic value system
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• utilizing faith and hope
• exercising sensitivity to self and others
• developing helping-trust relationships
• expressing both positive and negative feelings
• creating problem-solving caring processes
• advancing the use of transpersonal teaching/learning
• supporting, protecting, and/or correcting the mental,
physical, societal, and spiritual environment
• assisting with human needs
• allowing for existential-phenomenological-spiritual
forces (Watson, 1985, 1988d).
Additionally, Lea and Watson (1996) reported Gaut’s (1983) view that caring
indeed can be reduced to behavioral tasks, therefore it can be operationalized and
quantitatively researched. Gaut investigated caring from a hermeneutic and
phenomenological perspective (Lea and Watson, 1996).
Leininger (1981a,1981b, 1988b,1988f) provided two definitions for caring:
caring is described as assistive, supportive, facilitative acts toward another or group
with evident or anticipated need to alleviate or improve human condition or lifeway
(generic definition), and professional nursing as those cognitively learned humanistic,
and scientific modes of helping or enabling an individual to improve or maintain a
healthy lifestyle. From this stance, Leininger (1981b, 1988b) provided “Major
Taxonomic Caring Constructs.” Some of which on the list are difficult to
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operationalize (i.e. comfort, and tenderness), while others can be reduced to behavioral
tasks (i.e. touching), (Lea & Watson, 1996). Leininger (1988c) viewed nursing as
having both humanistic and scientific caring. Caring is not unique to nursing, but
caring for people in a way that is congruent with their culture, values and way of
living is what nursing provides through a learned humanistic art and science
(Leininger, 1988a).
Boykin and Schoenhofer’s (1993) theory of nursing as caring presented nurses
as nurturing persons living and growing as caring. The philosophical origins of this
model were built on the work of Mayeroff (1971) and Roach (1984, 1987). The basic
premise of this theory considers all persons to be caring (Boykin & Schoenhofer,
1993). They believed that caring involves a commitment to know oneself and the
other as caring (Boykin & Schoenhofer, 1993). Boykin and Schoenhofer (1993)
agreed with Roach (1984) that caring is uniquely expressed in nursing.
Sourial (1997) presented an overview of the concept of caring. The author
identified eight uses of caring: “ethics; instrumental and affective; traits; patients’ and
nurses’ perceptions of caring; holism; humanism; organizational; and quality”
(Sourial, p. 1189). Each use presents further understanding to the concept of caring
which appears to have numerous interpretations. Sourial (1997) noted that caring is a
part of holism— viewing the whole person, and holistic care is more clearly defined,
comprehended and scientifically based.
The concept of caring is still poorly developed, and additional study is
necessary to further encompass its complex nature among society at large and in
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nursing. Perhaps caring cannot be delineated to behavioral tasks, but its relevance to
human caring is unmistakable. There is a need for more precision research in
understanding this complex term “caring.”
Relationship Between Helping and Caring
Nursing is one of many “helping” professions. Caring for another is
considered to be a helping activity (McFarlane, 1976). The two terms caring and
helping are often used interchangeably. Kitson (1987) analyzed lay-caring and
professional (nursing) caring. The two relationships share the same attributes, which
are respect for the person, knowledge and skills, and commitment (Kitson). The main
difference is that nurse-patient caring requires a moral ideal or commitment to protect
and enhance human dignity (Gadow, 1985).
Other authors clarified differences between helping and caring. Carkhuff
(1969) defined helping as a process which “is calculated to help the helpee with
difficulties he might not otherwise be able to handle” (p. 47). Allmark (1998) noted
that “caring is at the heart of all professions” (p. 470). However, nurse caring is
different from other professions in two ways: in what they care about and in the way
they express care (Allmark, 1998). Swanson (1991) defined nurse caring as those
practices that are person focused, protective, physically comforting and includes
practices which go beyond routine care. In the practice of caring a marked difference
is noted between client and nurse perceived caring. Nurses perceive caring through
psychosocial skills, and clients focus on skills that demonstrate professional
competency (Swanson, 1991). Further, Mayeroff (1971) explained that caring is
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helping another person to grow and actualize himself. It is a process that involves
development much like a parent caring for a child or teacher caring for a pupil
(Mayeroff, 1971).
Reilly and Oermann (1999) listed teaching as a helping field. Teaching has its
own diagnostic and intervention process much like the nursing process (Reilly &
Oermann, 1999). It is noted by Reilly and Oermann (1991) that all helping
professions desire caring as a transcendental quality. Caring in nursing requires
commitment, contextual, relational and subjective (Reilly & Oermann, 1991). It is the
nurse’s perception of his/her actions, not the action itself, nor the client (Reilly &
Oermann, 1991). Caring implies action (Reilly & Oermann, 1991).
Links Between Prosocial Behavior, Altruism, and Caring
Prosocial responsibility and nurturance are complementary behavior systems
(Whiting & Whiting, 1975). Nurturance revolves around the rational moral
considerations of harm-doing and welfare, and prosocial responsibility revolves
around conventional moral considerations (Edwards, 1986). Nurturance is the
offering and giving of physical comfort or emotional resources by one person to
another who is perceived to be in a state of need or desire (Edwards, 1986). Prosocial
responsibility “occurs when one person attempts to influence another to conform to
the rules of family or society, either for the other’s own good or for the good of the
group as a whole” (Edwards, 1986, p. 100).
Bar-Tal (1976) presented prosocial behavior as acts of positive forms of social
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behavior. It is defined as a “voluntary behavior that is carried out to benefit another
without anticipation of external rewards” (Bar-Tal, 1976, p. 4). It is performed under
two circumstances: (1) the behavior is done for its own end, and (2) the behavior is
done as an act of restitution (Bar-Tal, 1976). Prosocial behavior must be carried out
voluntarily, however, it is recognized that the individual might feel an internal
pressure or obligation that can lead to prosocial behavior (Bar-Tal, 1976). Prosocial
acts might carry with it the individual’s anticipation of external rewards such as social
approval from friends or strangers (Bar-Tal, 1976).
Prosocial behavior has two ranges of behavior. One is called altruism, and the
other is called restitution (Bar-Tal, 1976). Altruistic behavior has three components:
(1) it must be carried out voluntarily, (2) it must aim to benefit another, and (3) it must
be carried out without expectation of a reward (Berkowitz, 1972 & Krebs, 1970).
There is some disagreement with the specific conditions of altruism above, although
all agree that an act of altruism requires no expectation of reward.
Bar-Tal (1976) discussed that self-reward may indeed be an outcome or
consequence of an altruistic act. Altruistic behavior is not conducted as a result of
obligation or expectations of something in return (Bar-Tal, 1976). Actions that are
carried out as a result of previously received help or because harm was done performs
compensation or restitution. Restitution is a voluntary act for the sake of paying back
or reducing the harm done; these actions are not considered an altruistic act.
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Prosocial behaviors steadily increase with age during the first ten years of life
(Bar-Tal, 1976). Positive social behavior is easily reinforced, and the degree of the
reinforcement determines whether the behavior will be repeated (Bar-Tal, 1976). Bar-
Tal (1976) recognized that the behavior of children is affected by social agents such as
adults and peers. The author further noted that this interaction has an important role in
creating prosocial behavior using reinforcement and other methods of learning
behavior (i.e. modeling or learning through observation). Additionally, individuals
may behave in a given way just because it is advantageous to do so.
Regardless of which behavior is used Bar-Tal (1976) identified four different
explanations of altruistic action. First, the normative approach suggests that
individuals behave according to the norms prescribed by a particular situation.
Second, the developmental approach maintains that altruism is acquired across social
learning; therefore, altruism may differ among individuals for this reason. Third, the
cultural approach presents a social evolution of altruism, and the fourth approach
whereby there is an expectation of social reward. This explanation perceives that
human beings are by nature utilitarian, and on rare occasions behave altruistically. In
summary, each of the authors in this section added to the connection of prosocial
behavior, altruism and caring.
Heritage o f Caring
Bottorff (1991) presented caring in a practical science sense. Using the
writings of Orem (1988), Bottorff (1991) proposed the practical science of caring
knowledge development in four stages: general conceptualizations and theories,
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midrange theories and concepts, models and principles of caring for practice and
actual descriptions of nurse caring cases. These stages represent nursing as the
practical science of caring and reflects the knowledge foundation for this science
(Bottorff, 1991).
The science of caring is not unique to nursing. Caring remains a difficult
concept to define and no one single author claims its discovery. The term caring is
connected to a human response which reflects a moral or outward emotional
expression. For some this emotional response evokes a caring action or care.
Care or caring is seen in early nursing writings. The term “care” has its roots
from the times of Florence Nightingale (post 1865). From this time nursing has
claimed, “care” and “caring” as its domain. Often caring and nursing are used
interchangeably (Kyle, 1995). Many theorists furthered the knowledge of caring,
but a debate remains as to what it fully entails. McFarlane (1976) contended that
caring is a series of helping activities and Griffin (1980, 1983) emphasized the
undertones of attitudes and feelings in caring out helping activities.
Since nursing has staked a claim to caring as a nursing intervention, many
nursing theorists have furthered the development of a caring theory. Leininger (1991),
Watson (1985), Roach (1884) and Boykin & Schoenhofer (1993) have led the way in
caring theory. Heidegger (1962) influenced the works of Roach, Boykin and
Schoenhofer, which all used caring as “being in the world.” Some nursing theorists
used the works of philosopher Mayeroff (1971) who had a significant impact in the
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development of caring theory using his notion of caring as selfless, devotional, being,
and growth promoting.
McCance, McKenna, Boore (1997) reviewed several studies and listed the
major themes using Walker and Avant’s (1995) method of concept analysis. Themes
were categorized from the patients’ and nurses’ perspectives through accounts of
good/bad caring, and an overview of caring. A list of defining or critical attributes
emerged from this review. Terms such as seriously attentive, concern, providing for a
person, regard, respect or liking, time involved and getting to know the person were
the emerging themes for caring characteristics gleaned from the literature (McCance et
al., 1997). Although this method of concept analysis proved to be valuable, the author
recognized that caring remains a nebulous concept that benefits from qualitative study
(McCance et al.).
Caring involves as a moral or ethical view in the literature. Smerke
(1990), Watson (1988d) and Morse et al. (1990, 1991) take this position. Sourial
(1997) viewed these theorists as recognizing caring as a moral virtue. Patient good,
respect, and dignity of the patient are major themes of these theorists (Sourial, 1997).
Further, Fry (1991) and Jolley and Brykczynska (1992) acknowledged that
competence is coupled with caring. Caring and competence are assumed in nursing
practice. One without the other leads to a decrease in quality nursing practice.
Pepin (1992) reported two dimensions have caring: (1) instrumental and (2)
affective. The author explained that instrumental caring involves activities, and
affective caring involves attitudes, feelings. It is currently emphasized that nursing
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must encompass a balance of both psychological care (affective aspects) and bodily
care (physiological aspects).
In summary, caring is viewed in terms of patient and nurse outcomes. It is
defined and theorized to span the gamete from its beginning, development and on
going practice. Theorists reported that caring is inherent in human life, and without
caring there would be no society. Caring has no specific ownership, except that it is a
human attribute that is practiced in a variety of settings, cultures and practices. Even
though caring has its history from a variety of historical perspectives, it still remains
elusive and complex.
Nurturance, Empathy and Altruism
Fogel, Melson and Mistry (1986) noted that despite the majority of female
caregivers, both sexes possess the ability to nurture. A difference between
competence and performance in terms of ability may be present, and this may occur
because one sex may have had the opportunity to perform tasks more often (Fogel et
al., 1986). Also, it was noted that one may have the ability to perform a task, but lack
the competence to adequately carry out the task (Fogel et al., 1986). In this case, the
act is then seen as lacking competence and is therefore less in quality (Fogel et al.).
Nurturance can be seen throughout the lifespan. Fogel, Melson and Mistry
(1986) defined nurturance as “the provision of guidance, protection and care for the
purpose of fostering development change congruent with the expected potential for
change of the object of nurturance” (p. 55). An individual’s awareness of an affective
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state or need to be nurtured or another is referred to as “empathy for nurturance”
(Fogel et al., 1986, p. 59).
Empathy is related to the ability of one individual to infer or to experience the
thoughts or feelings of another individual (Eisenberg & Lennon, 1983). Empathy does
not involve an action component, but it is often inferred from behavioral acts
subsequent to one’s empathetic perception of another person (Fogel, Melson, &
Mistry, 1986). Empathy is viewed as an affective response to another emotional
experience, and it is composed of a cognitive component.
Altruism relates to giving assistance, comfort or resources to another
individual without apparent reward or reciprocation, and often at great personal
sacrifice (Fogel et al., 1986). Altruism’s definition comes from the socio-biological
concept of altruism relating to parenting behavior (Wilson, 1975). Altruism acts can
be from the simplest form requiring no cognitive or emotional reaction to the recipient
of altruistic behavior. It can be activated by a simple stimulus response, and it is often
an unconditioned response (Fogel et al., 1986). The act may be performed by an
altruistic drive, a sense of obligation or duty, feelings of later reciprocity, or doing
one’s part for society, (Krebs, 1978, Mussen & Eisenberg-Berg, 1977). Regardless,
the act may involve personal sacrifice and gain to another. Altruism does not require
empathetic motivation and empathy although they may co-exist (Fogel et al., 1986).
Fogel et al. (1986) explained that nurturant behavior could occur without an
altruistic and empathetic component. For example, a parent could foster development
of a child that was contrary to the needs of the child. The parents own personal and
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77
cultural goals for the child define the process of making parental decisions. Altruism
would not be appropriate in this case, since the nurturant behavior fosters maintenance
of the parent’s own goals.
Nurturing does not apply only to humans (Fogel et al., 1986). Inanimate,
insubstantial things can be nurtured. The only requirement for nurturing to occur lies
in the definition of the term: nurturing fosters developmental change within the
potential of the nurturant object; personal satisfaction is attained, and without the need
for empathy (Fogel et al., 1986).
Further Notes on Empathy
Rogers (1961) defined empathy as an accurate perception of the internal world
of private, personal meanings and emotions of another. Empathy involves
understanding the unique situation and personal preferences of the person to be
understood. Davis (1996) noted that empathy is composed of four related constructs.
First, antecedents are the characteristics of the observer, target, or situation. Second,
processes are the particular mechanisms by which empathetic outcomes are produced.
This includes noncognitive, simple cognitive, and advanced cognitive responses.
Third, intrapersonal outcomes are the affective and non-affective responses produced
in the observer, and fourth interpersonal outcomes which behavioral responses
directed toward the target can include helping, aggression and social behavior.
Empathy involves relationships between the constructs, and it is seen as a complex
perception.
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Empathy has an important place in nursing care. Nursing most commonly
defines empathy as the ability to perceive the feelings and meanings of a person and to
communicate that feeling to the specified person (Gagan, 1983). Nursing exists in
order to help other people, and it is crucial to the aim and goals of nursing (Reynolds
& Scott, 2000). Empathy encourages development of a trusting relationship, state of
readiness to talk, reduction in physiological distress, improved self-concept, reduction
in anxiety and depression; the achievement of outcomes is dependent on how high
levels of empathy was applied in the relationship (Reynolds, & Scott, 2000).
Empathic expression is viewed as important in developing a professional
relationship, and communicates an attitude of caring that can affect client outcomes.
Reynolds and Scott (2000) noted that low levels of empathy could have a negative
influence on client (patient) outcomes as well. However, the use of empathy in a
caring nurse-patient relationship is most commonly noted to make a positive
difference in client outcomes. The ground-work for this response occurs among the
client and nurse. Hospital patients (clients) want a caring relationship constructed
upon trust, confidence, and mutual respect with their nurses (Turkel, 2001). This type
of relationship development requires empathetic concern by the nurse which goes to
the core of caring. Knowledge of the client at this level promotes decisive nursing
care, which ultimately results in promoting positive client outcomes and quality care-
giving. This is the “value-added” component that professional nursing provides in
using empathetic communication. In another study, nurses who used high empathy
among institutionalized elderly were found to have a significant increase in self
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concept of the elderly adults (Williams, 1979). Further, an adequate self-concept acts
as an anti-anxiety device, and results in more satisfactory relationships with significant
others (Peplau, 1990).
Accurate perception through the effective use of empathy is recognized to
improve the outcome of the nurse-client interaction (Orlando, 1961). Olson and
Hanchette’s (1997) study supported that a relationship exists between accurate
perceptions of patients’ needs (nurse-expressed empathy and patient perceived
empathy) and patient distress. These results demonstrated a negative relationship
between nurse-expressed empathy and patient distress (r = -.71, p < .001), and a
positive relationship between nurse-expressed empathy and patient-perceived empathy
(r = .35 to .47, p < .05). Thus, in the process of caring, empathy is expressed
which becomes an important factor in executing quality nursing care.
Empathy is composed of warmth and genuineness. An empathetic nurse
demonstrates commitment therefore providing a positive effect of emotional support
to the one receiving empathy. Bennett (1995) noted that there is little research to date
that supports the view that clinical empathy affects healthcare outcomes, but the
cumulative research across helping professions remains a reasonable proposition
otherwise. Empathy implies that the nurse uses one’s personal understanding
(empathy) to understand another personal experience. MacKay, Hughes, Carver
(1990) agreed with this point. This study found that the quality of client self
disclosure was associated with levels of empathy used by nurses. Self-disclosure
allows the nurse to further understand client needs.
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Several studies provided support for inclusion of empathetic concern and
effective communication skills among student nurses (Peitchinis, 1972; Layton, 1979;
Wheeler & Barrett, 1994, Reynolds, 1998). Nurse educators have the responsibility to
educate students in factors of empathy. Deficiency in communication skills relates to
a deficiency in empathy. Empathy instruction is not seen as a clinical course in itself,
but as a skill to be acquired perhaps through role modeling. A couple of factors
involved in the lack of empathy development may be the lack of time, and
unsympathetic support from colleagues. Additionally, a nurse with a low level of
empathy may miss-read a client which could result in a client who does not feel
understood. The impact of this nurse mis-communication could delay a client’s ability
to meet an expected healthcare outcome.
The goal of nursing care is to provide quality nursing care. An essential
ingredient of quality care as evidenced by the literature is the provision of professional
empathy in communication. Without clear and concise communication, it is difficult
to understand how quality care can be achieved. Professional empathy is an emotional
engagement that is deliberate and in response to specific learning (Forsyth, 1980). It
is seen as a tool for the professional practitioner (Thomas, 1996). It is a skill that can
be learned (Yates, Hart, Clinton, McGrath, Gartry, 1998).
Association Between Parental Bonds and Social Bonds
There is an identified link between parental bonding and social networking.
The authors of attachment theory Ainsworth and Bowlby (1991) are credited with
providing the basic tenets that can be applied to a social connection in human
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interaction. Bowlby’s theory of a child’s tie to the mother and its disruption through
separation, and Ainsworth’s theory on the secure base from which a child can explore
unfamiliar situations and return are developmental relationships that can expand to
social interactions.
Attachment theory has been applied to a variety of core relationships
including: professor-student (Lopez, 1997), child- parent (Hazan & Shaver, 1994a,
1994b), violent relationships (McClellan & Killeen, 2000), higher education student
success and perceived parental social support (Cutrona, Cole, Colangelo, Assouline, &
Russell, 1994), caregiving in counseling (Pistole, 1999), and nursing students and
caring (Cavanaugh & Simmons, 1997; Simmons, 1994; Simmons & Cavanaugh, 1996,
2000). Each of these relationship areas involved social interaction at some level, and
relate to early attachment theory. Bretherton (1992) and Pistole (1999) noted that the
quality of the social interaction is not dependent only on the early bond of a parent, but
environmental or contextual, social networking, economics, and cultural values impact
the link between parental bond and the child’s ability for social interaction.
Pistole (1999) stated that early attachment relationships influence later
relationships, and these relationships are more resistant to change across time because
environmental and child-rearing conditions remain fairly stable. In times of anxiety
and distress the attachment system is activated and the affected person seeks proximity
to and care from someone who is stronger and wiser (Pistole, 1999). Additionally, a
secure attachment style promotes effective problem solving and adjustment (Hazen &
Shaver, 1994a, 1994b). From this stance, it is believed that the experiences of early
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attachments influence a person’s future interactions with others (Pfaller & Kiselica,
1996).
Ricks (1985) and Egeland, Jacobvitz and Sroufe (1988) studied adult women.
The results of their studies indicated that adult women who were abused as children
can choose to correct the emotional experiences from childhood in adolescence
through the use of formal operational thought, outside supportive adult caregivers, or
individual therapy. The final result on both studies indicated that negative attachment
behaviors are changeable. In another study of medical residents by Hojat, Glaser, and
Veloski (1996), satisfactory relationships with their mothers were significantly linked
to higher clinical competency ratings on physician’s interpersonal relationships
and attitudes. No link was found with early relationships with fathers (Hojat et al.,
1996).
Hojat (1998) further studied the relationships with parents and psychosocial
attributes in adulthood. The author found that perceived satisfaction with the mother
in childhood was significantly associated with less intensity and chronicity of
loneliness, less depression, less anxiety, less negative view of stressful life events,
higher self-esteem, and more satisfaction with peer relationships (Hojat, 1998). The
father was not found to be significant in the perceived satisfaction and development of
these personality measures (Hojat, 1998).
Hays (1998) on the other hand presented a different view of attachment. The
author noted that the dramatic changes in family life over the last fifty years has
changed child-rearing practices. Dual-income families and single-parent households
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necessitate a new look on how children are being raised. Hays reflected that
standards used to evaluate the parent-child bond in the past are not sufficient for future
understanding of the changed parent-child practice. The author proposed a fresh look
at the role of fathers, needs of children, needs of caregivers, and single-parent
households in child-rearing practice, and its affect on attachment theory.
Caring in Nursing Education
Little is known about clinical teaching strategies for a caring curriculum. In
teaching about caring it is believed that a caring nurse educator has a particular
epistemological ethical stance that evokes a caring enculturation to students.
Therefore, nursing students are enculturated into an alien environment through
opportunities in a safe environment of learning through classroom theory and clinical
practice. Several authors related caring in nursing education and clinical practice
through literary report and/or research.
Nursing is human science that requires the intervention of an effective teacher
practicing in a humanistic climate with the student. Reilly and Oermann (1999) stated
that “the teacher is a vital link in the dynamics of teacher-learning” (p. 46). It is the
teacher who brings the human qualities that make the total experience stimulating,
developmental, and fulfilling for both the teacher and the student (Reilly & Oermann,
1999). The three domains of learning still remain dynamic during the learning
interaction: cognitive, affective, and psychomotor. The affective competencies are
seen as “essential elements in skilled nursing practice” (Reilly & Oermann, 1999, p.
291). Meeting these competencies require a commitment to personal beliefs, cognitive
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skills, decision-making, and a pattern of behavior of commitment to the choice made
(Reilly & Oermann, 1999).
In a study by Bowen and Young (2000), they noted that a decrease in the
quality of patient care as one of the top negative effects occurring in the health care
system. There can be many reasons for the decline in patient care external from the
basic nursing education component, but some do believe that the nursing educational
system must over-ride the external forces and prepare graduates to manage the
changes being made universally in healthcare (Bowen & Young, 2000). The literature
supports that the quality of care reported by patients is related to the affective
component of caring. Reilly and Oermann (1999) reflected that if affective learning in
nursing education remains an essential ingredient to quality nursing care then the real
world of nursing care application should reflect the same.
In an interpretive study, Evans (2000) noted the student-teacher relationship
creates the core for clinical learning. Cognitive, ethical development and student life
experiences with teacher interactions are a part of this process (Evans, 2000). Role
modeling by the teacher using compassionate, caring, holistic ways sends an
empowering message to the student (Evans, 2000). Efficacious clinical learning is
promoted by the caring nurse educator’s epistemological ethical maturity and practice
that could result in influencing the students’ professional attitudes, confidence,
compassion, and competence (Evans, 2000). Evans (2000) recommended further
research to understand the enculturation process and lived experiences of student
caring through gender, nontraditional learners, and students of color.
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Grealish (2000) posited that role modeling or coaching by expert practitioners
encouraged student learning. Students are able to develop confidence in psychomotor
skills, and coherent theoretical thinking using the information gathered. Additionally,
Grealish (2000) reported that cognitive coaching and psychomotor coaching together
provide the student with the motivation to improve performance and strive for
excellence.
In an enthnographic study by Holland (1999), English student nurses from a
Diploma Level Project 2000 Adult Branch Studies were used to track their transition
through nursing studies. Eight themes emerged from the open-ended approach, and
three themes were relevant to caring: theme one included reasons for becoming a
nurse included caring and helping, theme three included giving care through basic,
nursing and technical care, and theme six included performance and manner such as
caring and doing, knowing and knowledge, and being able to do. It is presumed in
nursing that there is a hierarchy of care from novice to expert with the expert being the
coach or role model (Benner, 1984). Nursing education acknowledges that the caring
nature of the nurse is not usually visible and may be accrued through the culture of
nursing rather than the educational experience (Holland, 1999). Further research is
needed to determine the exact nature of a student’s contribution to care both as
students and as healthcare workers (Holland, 1999).
Greenhalgh, Vanhanen, and Kyngas (1998) examined caring behaviors of
nurses in a general and psychiatric hospital (n =118). Using the Care-Q instrument
physical based caring behaviors were ranked higher than affective behaviors;
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monitoring and comforting behaviors were paid more attention than anticipatory
behaviors. Gender had the greatest influence on the value caring behaviors
(Greenhalgh et al., 1998). Additionally, male nurses were less likely to form trusting
relationships, be accessible or perform comforting behaviors (Greenhalgh et al., 1998).
The results of this study challenged nurse educators to increase the importance of
caring behaviors in nursing curriculum. Previously substantiating this finding
Paterson and Crawford (1994) noted that caring behaviors are not conceptualized and
unclear in their transmission to nursing students.
Wilkes, and Wallis (1998) performed a qualitative study using a questionnaire
and semi-structured interviews. Students (n = 120) from two pre-registration nursing
programs in Sydney, Australia tertiary institutions were used for the study. The
authors found compassion as the core of caring. They believe it is actualized by
communicating, providing comfort, being competent, being committed, having
conscience, being confident and being courageous. Wilkes and Wallis (1998) also
noted that communication is considered an important medium for the expression of
caring actions, and confirmed the components of caring as a student moves from year
to year in nursing education. Besides educational student differences, individual
differences may occur as a result of student relationships and acts of client caring to
influence the development of professional nurse caring in the student (Wilkes &
Wallis, 1998). The study proposed that professional nurse caring be followed from the
first year to the next and beyond to further understand the development and actions of
professional caring.
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Welch (1999) studied baccalaureate nursing students’ (n = 205) attitudes as
they progressed in a nursing program. The sample included sophomores and senior
nursing students who were tested at the beginning and end of their final semester. The
bulk of the results indicated in the sophomore category were: personality
characteristics, component of medical care, communication, teaching, knowledge and
education, health promotion, emotional and physical caring, and meeting needs. The
results of the senior category included: health promotion for family and community,
knowledge, communication, teaching, professionalism, moral conduct and caring
for the whole person. Welch (1999) reported that the sophomores focused on the task-
oriented role of the nurse, while the seniors revealed a deeper understanding of the
interrelationships of nursing care, knowledge, ethics, professionalism, independence
and accountability, which included values, espoused by the nursing program. In
addition, the seniors presented a depth and richness in their descriptions of the themes
of caring as an intentional and informed act, the perceptions of their values in practice
and understanding of professional standards, expectations of practice and conduct,
knowledge and independent thinking (Welch, 1999).
In a longitudinal study by Simmons and Cavanaugh (2000), baccalaureate
nurses (n = 189) were followed over a three-year period. The study was a
correlational study to investigate potential predictors of caring ability in nascent
nursing professionals who have entered professional practice. The study was
originally developed by Simmons (1994) and reported by Simmons & Cavanaugh
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(1996). It was extended further in preparation for a longitudinal study by Simmons &
Cavanaugh (1997) and reported by Simmons & Cavanaugh (2000).
The predictors used in the original study were maternal and paternal care
during the first sixteen years of life, the caring climate of the nursing school, and the
effects of demographics on caring ability. Simmons and Cavanaugh (2000) noted the
theories of Leininger (1981b) and Gaut (1983) as proponents of caring in nursing
curriculum. In addition, they noted several authors (Brookover, Wilbur, Beady, Flood,
Schweitzer & Wisenbaker, 1979), who implicated the school climate as an important
influence on role definitions, norms expectations, values, and beliefs that students
internalize, such that socialization affects student achievement, academic self-concepts
and other affective responses. The authors further enlisted support from additional
sources, who acknowledge that nursing students favor relationships with positive role
modeling teachers who are caring, warm, supportive, and empathetic (Beck, 1991;
Boykin, 1994; Halldorsdottir, 1990; Nelms, Jones, & Gray, 1993). Junior and senior
students (n = 495) responded to the phase one questionnaire (completed in two data
collections), and n = 189 were available for follow up three years later in phase two.
The results indicated no change in the parental bonding scores from the initial
Simmons (1994) study in nursing school. However, caring ability scores significantly
increased after entry into practice (paired t-test, p < .001). Simmons and Cavanaugh
(2000) noted that the student’s caring ability in nursing school was the strongest
predictor of postgraduate caring ability (r = .58, p < .001). School climate scores were
the next strongest predictor of caring ability after caring ability scores were excluded
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from stepwise multiple regression analysis (r = .17, p < .05). The results of this study
suggests that the development of professional caring ability is related to a caring
school environment, and caring ability in nursing school predicts caring ability after
entry into practice.
Watson, Deary, and Lea (1999) performed a longitudinal study with nursing
students at entry into nursing practice and 12 months later. The theoretical
support for their study included the caring theorists of Watson (1988d), and Larson
(1984). Students (n = 168) participated in phase one, and 124 participated in phase
two of the study. The purpose of the study was to investigate the perceptions of caring
among student nurses as they progress through their education. The Caring
Dimensions Inventory (CDI) and Nursing Dimensions Inventory (NDI) were used in
this study. Watson and Lea (1997) previously tested the CDI (35 item) for validity
and reliability, and reported the findings. For this study, the 35 item NDI was created
from the CDI to investigate if nurses differentiate between nursing and caring. Further
studies were performed to compare the two inventories in this study.
The results indicated that nursing students after 12 months of education loose
some of their idealism. Watson, Deary, and Lea (1999) proposed that this loss of
idealism should be investigated, and it may be related to a negative development in the
student nurse as they progress through the program, burnout, or recognitions o f
professional limitations. They also reported that nursing and caring is not perceived as
synonymous at entry into education, but after twelve months of education nursing and
caring is perceived more synonymously. Watson et al. (1999) presented several
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possible explanations for this response as those students who enter nursing have
different perceptions than those who spend several years in nursing employment.
Also, perceptions may be altered after students undergo a program of nursing
education. Regardless, Watson et al. (1999) postulated that the high ideals could be
fostered, and the reasons for the loss of idealism or change investigated as to academic
or clinical components of nursing education. In addition, they acknowledged that
further analysis of the change in perception might provide insight into recruitment,
retention, and success in nursing education.
Hughes, Kosowski, Grams, and Wilson (1998) compared two Georgia
associate degree nursing programs in terms of the level of caring reported by students
during informal interactions with peers. Leininger and Watson (1990) were used as
the caring theorists support for the study. First and second year students (n = 88)
participated in the study between the two schools. The scale used to measure the level
caring was the Peer Group Caring Interaction Scale (PGCIS). The internal
consistency reliability of the PGCIS was performed before answering the research
question using the Cronbach’s alpha. The results indicated an alpha of .88 for the two
PGCIS subscales for a total reliability measure of .92.
The findings of the study documented the level of peer group caring according
to their school of enrollment. This study acknowledged that the academic setting can
play a role in the ability of students to experience caring within the context of peer
group relationships. It was noted that faculty involvement may have made the
difference in caring level scores because their level of participation may have been the
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only way faculty expressed their commitment to the creation of an academic
environment that was caring, and perceived by the student peer group (Hughes,
Kosowski, Grams, & Wilson, 1998). Also, it was noted by the authors that the student
peer group who scored higher might be from a more caring environment in addition to
the peer group participation. The results of this study have implications to nursing
education. Hughes et al. (1998) recognized that students needed to be socialized into
caring as a professional value. Student interactions and interactions with faculty lend
support to creating a caring value. Also, the authors agree that further studies are
needed to investigate experiential learning strategies in nursing education that promote
caring in students.
Manninen (1998) used a sample of Finnish nursing students (n = 158) from 6
specialties and 26 institutes. The purpose of this longitudinal study was to examine
the students’ perceptions of nursing after 6, 18, and 30 months, and at the end of the
educational program. No caring theorist is recognized in this study. A Likert style
questionnaire was mailed which included 90 questions developed from nursing
literature. The study focused on three areas: nursing as a medical-technical activity,
nursing as promoting human well-being and health, and nursing as professional
activity.
The results of the study indicated that Finnish nursing students assimilate the
primary goal of nursing to take care of patient’s well-being and needs. Manninen
(1998) noted that the constant remaining throughout their education was the human
scientific approach to nursing. Manninen (1998) documented as others that students
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still felt the need to help people. This remained as a motive for some students aspiring
to become a nurse. Further, Manninen (1998) noted that helping, caring, and other
human-oriented needs and features may be what drives a person to view nursing as
attractive and fulfilling.
Manninen’s (1998) study results indicated that students since their first year of
education were convinced that professionalism existed in nursing, and that
professionalism was noted to increase as the student progressed in education, and as a
result of a curriculum focus. Additionally, Manninen (1998) postulated that teachers,
tutors, and clinical settings might facilitate student awareness of his/her perceptions of
nursing and the nurse’s role. The author believed that student perceptions and
reflections of their nursing educational experience are individually derived, and
analysis of these would be of benefit for understanding roots and consequences for
nursing activities and practice.
Simmons and Cavanaugh (1996) reported on the relationship of parental care,
professional school climate and caring ability among senior baccalaureate-nursing
students (n = 350) who were members of the National Student Nurse Association
(NSNA). Some of the caring theorists used in this study’s background were Leininger
(1988e), Watson (1988a), and Mayeroff (1971), a philosopher for his original theory
building work on caring. The premise of the study was that students model their
behavior after significant people in their lives. The most influential people proposed
were parents and nurse educators. Three reliable and valid questionnaires were
combined into one and used to obtain the necessary data. The questionnaire included
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the following instruments: Caring Ability Inventor (CAI) by Nkongho (1990),
Parental Bonding Instrument (PBI) by Parker, Tupling, and Brown (1979), and
Charles F. Kettering Ltd. (CFK) School Climate Profile by Howard, Howell and
Brainard (1987).
The results of the study indicated that there was no correlation between the
level of maternal or paternal care and subsequent caring ability (r = -.01 and .01
respectively), but it was acknowledged that a curvilinear relationship did exist.
Students with higher caring ability scored both high and low in levels of maternal care.
However, school climate was found to be the strongest predictor of caring ability (r =
.16, p < .01). The concern noted from this response was that only 52 percent of the
nursing schools had a high rating from the students. Simmons and Cavanaugh (1996)
questioned that if caring is a valued attribute in professional nursing than the quality
must be cultivated within the climate of nursing schools. In addition, the results
indicated that nursing students who are nurtured in a caring school climate are more
inclined to role model the same caring behavior. The nursing school climate served as
a moderating influence on inherent caring ability displayed by nursing students
(Simmons & Cavanaugh, 1996). Also, educators need to recognize the power they
have in modeling caring practices, and identification of student needs in order for
caring to flourish in nursing (Simmons & Cavanaugh, 1996).
In two studies presented in the same year, faculty-student caring interactions
were identified from the students’ perspective. Dillon and Stines (1996) studied
students at the practical nurse (n = 49) and nurses’ aid (n = 32) level. The major
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caring theorist and conceptualization authors that supported their study were Watson
(1979), Leininger (1988d), Benner (1984) and Roach (1987). The authors used the
1990 resolution passed by the National League for Nursing (NLN) as support for their
study (Dillon & Stines, 1996). It included the call for support and enhancement of a
caring climate as a core value in nursing in which faculty care for students, each other,
and students care for peers (Dillon & Stines, 1996).
The authors supported Roach’s (1987) belief that the capacity to care must be
nurtured and valued, and the degree to which one feels cared for is correlated to one’s
capacity to care. Confirmation is again given to nursing as a helping profession, and
those who enter nursing desire to care for another (Dillon & Stines, 1996). Dillon and
Stines (1996) also noted that caring can be enhanced, called forth, or inhibited by the
student’s educational, and most importantly by the absence or presence of caring
models. Support for Dillon and Stines’s stance came from the study by Bush (1988).
In this study, doctoral students were surveyed as to the essential characteristics of a
caring teacher in nursing. The caring characteristics were identified into six
categories: spirituality, presence, mutual respect, sensitivity, communication with
others, organization of teaching and learning (Bush, 1988). The result of Bush’s
(1988) study found that human care knowledge is forwarded when caring is
experience in academic life.
Dillon and Stines (1996) also used Halldorsdottir’s (1990) study to support
research on caring from the student-teacher standpoint. The students in this study
were from baccalaureate and master’s level nursing programs. Halldorsdottir (1990)
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reported the basic elements of caring encounters to be: a sense of acceptance and self-
worth, personal and professional growth, motivation, appreciation of role-modeling,
and long-term gratitude and respect. Beck (1992) furthered Halldorsdottir’s study to
include peer interactions of caring. The results of this study found the main
constituents of a caring experience to be: selfless sharing, enriching effects, fortifying
support, and authentic presencing. The themes of valuing and respectfulness towards
the student emerged in this study.
The findings of Dillon, and Stines’s (1996) study supported the importance of
the caring teacher establishing a climate, which promulgates caring through nurturance
and valuing. Providing time, remembering the little things, listening attentively, and a
nonjudgmental attitude were deemed important by these authors in supporting a caring
educational climate. Dillon and Stines (1996) hypothesized that the student “who is
educated in a humanistic caring environment has the potential to carry this attitude to
his/her practice” (p. 115-116). However, this was not proved in this study. The
researchers were able to provide descriptive lists of theme clusters and descriptions of
faculty-student caring interactions that will be useful in identifying caring interaction.
Caring teachers were viewed as positive role-models when he/she were attentive, took
time, followed-up, remembered the little things, non-judgmental, approachable,
competent, supportive, respectful, honest, calm, confident, and nurturing (Dillon &
Stines, 1996). Positive reinforcement and praise by the instructor were also seen as
interventions that promoted student confidence and value (Dillon & Stines, 1996).
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Dillon and Stines (1996) agreed that caring is an important concept, and that it
needs to be nurtured, fostered, and promoted in all areas of nursing education
including interactions between administration and faculty, between faculty members,
between teacher and students, and between students as well. They noted that further
studies in these areas and other studies of cultural and gender perceptions of caring
would aid in understanding the concept of caring in nursing education. Future studies
of cultural and gender differences in perception and expression of caring behaviors
were suggested by the authors.
Hanson and Smith (1996) completed a similar study to Dillon and Stines’s
using a phenomenological approach. They studied baccalaureate nursing
students (n = 32) from a private liberal arts, and public university. Leininger (1981a,
1988e), Watson (1979), Boykin and Schoenhofer (1991), and concept caring writings
from Gaut (1983), and Noddings (1984) were used as nursing theory and scholarly
support. The purpose of this study was to identify and describe students’ experiences
with caring and not-so-caring faculty interactions. Their literature support included
the same writings of Halldorsdottir’s (1990) four components of a caring encounter
(teacher’s caring in a professional approach, mutual trust, teacher-student working
relationship, and positive responses from the student encounter), and Beck’s (1991)
themes or clusters of caring interactions with teachers (attentive presence, sharing of
selves, and consequences of feeling valued and respected).
The results of Hanson and Smith’s (1996) research noted that in the student-
teacher caring interaction: the student is recognized as an individual and special
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person; the student’s whole life is recognized through an attitude of flexibility,
fairness, warmth and genuineness. These teacher interactions convey directive,
supportive and accepting action (Hanson & Smith, 1996). Hanson and Smith (1996)
stated that a caring, skillful teacher ensures a good classroom experience, and through
this caring connection the student receives a feeling of comfort, confidence,
competence, and motivation to keep on, to strive more, to study harder. In addition,
Hanson and Smith (1996) stated that the student is affirmed in having chosen nursing
as a profession. Also, in seeing the teacher care, the nursing student learns to care for
others (Hanson & Smith, 1996).
Not-so-caring interactions were identified by Hanson and Smith’s (1996)
study. The faculty interactions responses with students included: unavailability,
hurriedness, insensitivity, condescending, dismissive, and disrespectful behaviors
(Hanson & Smith, 1996). These interactions may be accompanied by perfunctory,
detached, unpredictable, and cold teacher behaviors (Hanson & Smith, 1996). The
authors concluded that these teacher behaviors with students may result in the student
feeling lost, scared, rejected, discouraged, powerless, cheated, looked down upon, and
misunderstood (Hanson & Smith, 1996). As a result, the nursing student’s self-esteem
is eroded, learning is disrupted, the student feels diminished, and the student may
doubt the ability and choice to become a nurse (Hanson & Smith, 1996).
The phenomenological approach used in this study proved useful in identifying
nursing student perspectives of caring and not-so-caring interaction. Hanson and
Smith (1996) further reported that a caring environment enhanced students’ positive
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feelings and self-esteem, increased motivation to study and learn while affirming the
student’s choice to become a nurse. From this article nurse educators are reminded to
match their instructional ways with caring actions and provide curricula that do the
same. This interconnectedness can also be promoted in the student interactions with
clients as well.
In another study by Hughes (1992), junior nursing students (n = 10) were
asked to identify faculty behaviors and faculty-student interactional episodes through
which students’ recognized a climate for caring. Caring concept writers were used as
the theoretical support for this study such as Noddings (1984), Bevis (1989), Bauer
(1990).
The results indicated that modeling, dialogue, practice, and confirmation/
affirmation in the faculty-student interactions promoted a climate for caring and
components of a moral education (Hughes, 1992). Modeling was defined as the
enactment of behaviors which show oneself to another as caring (Hughes, 1992).
Hughes (1992) used Noddings’ (1984) explanation that dialogue included reciprocal
and open communication between two people so that ideas, thoughts, and feelings are
mutually exchanged.
Practice was the demonstration of the skill of caring behaviors and
enhancement of the quality of the relationship a student experiences with another
(Hughes, 1992; Noddings, 1984). The students noted that in positive interactional
experiences, they felt empowered as a student and the emerging professional nurse
coalesced (Hughes, 1992). One student reported that “if you don’t have a good
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clinical instructor, you can’t make it........if they don’t give you confidence then you’re
not going to have the confidence” in yourself (Hughes, 1992, p. 67). Hughes (1992)
also reported that students who felt empowered had reduced anxiety, a bolstered self-
confidence, expressed belief in themselves, and engaged in a relationship with the
teacher using collaboration and collegiality.
The last component of a moral education that promoted a climate of caring is
confirmation/affirmation (Hughes, 1992). Teachers enable students to envision their
goals as attainable in a way that otherwise would not be possible (Noddings, 1984,
Hughes, 1992). Students need to experience confirmation/affirmation in their role as a
student nurse and emerging professional (Hughes, 1992).
In a phenomenological study of junior and senior nursing students (n = 47),
Beck (1991) reaffirmed the importance of faculty members as the main resource for
fostering student’s capacity to care. Leininger (1980), and Roach’s (1984) writings
were used as the theoretical support for this study.
Beck (1991) noted that the environment surrounding the student must be
caring. Students must feel nurtured in order to care for others. Through her research
she identified forty-seven written descriptions of a caring nursing student-faculty
interactions. Beck (1991) further reflected that the descriptions fell into the five
characteristics (“Cs”) of caring previously noted by Roach’s (1984) writings:
confidence, conscience, compassion, commitment, and competence. Overall, students
need to feel respected, valued, provided undivided attention, and listening by the
instructor in order to foster a caring climate (Beck, 1991). Beck (1991) reported that
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one of the most precious caring gifts a faculty member can give to a student is their
time.
Further, in a literature search Beck (1999) presented a comprehensive list of
quantitative measurements of caring. Each instrument listed had a particular
measurement focus: caring behaviors, satisfaction with caring behavior, response to
caring behaviors, and ability to care. The analysis included the focus person
completing the quantitative measure (the client receiving care, trained observer, or the
nurse). Also, the number of questions in the instrument, time it took to complete,
underlying definitions of caring in the instrument development, and internal
consistency reliability coefficient, test-retest reliability, and construct validity were
noted in the instruments when available.
The Caring Ability Inventory (CAI) is the only quantitative instrument that
measures ability to care; it is in a Likert form with 37 questions (Beck, 1999). The
CAI developed by Nkongho (1990) measures a person’s ability to care when in a
relationship with others. It is based on the eight critical elements of Mayeroff (1971):
knowing, alternating rhythms, patience, honesty, trust, humility, hope, and courage.
Previous use of the CAI included university students with various majors and nurses.
Beck (1999) reported its one time use after development in the literature by Simmons
and Cavanaugh (1996) with senior baccalaureate nursing students (N = 350). Internal
consistency reliability coefficient, test-retest reliability, and construct validity were
noted in CAI use (Beck, 1999).
Beck (2001) performed a metasynthesis of fourteen qualitative studies of
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caring within nursing education. Only one of these studies used a sample of associate
degree nursing students. The majority of studies came from baccalaureate students,
few faculty, one diploma program and one doctoral program. The studies were broken
down into specific categories: caring among faculty, faculty-student caring, caring
among nursing students, and caring between nursing students and patients. Each of
these categories had additional breakdowns: components of caring and effects of
caring. The final metaphors or themes extracted from the metasynthesis centered on
reciprocal connecting which consisted of supporting, presencing, sharing, competence,
and the lifting effects of caring (Beck, 2001). In addition, the literary data suggested a
trickle-down effect starting with faculty caring, to students, to patients (Beck, 2001).
Beck (2001) noted “caring needs to be nurtured and cultivated in all members of the
academic community” (p. 108). It “must become a way of being for both faculty and
students” (Beck, 2001, p. 108). Also, the author stated that the process of reciprocal
connecting— themes provided a foundation and building blocks to creating a caring
climate in nursing education (Beck, 2001). The author recommended further research
across educational lines and dimensions of caring (Beck, 2001).
Poorman, Webb, and Mastorovich (2002) addressed a different research issue.
The authors specifically researched student experiencing academic difficulties.
Nurses from associate degree, bachelors and diploma programs (n = 26) were the
informants. The informants were out of school less than two years, and they were
interviewed in a nonstructured format. A Heideggarian analysis of the data was
performed. The analysis revealed three themes: expecting, helping and hindering
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(Poorman et al., 2002). The students expressed many expectations of teachers, related
many helping experiences and noted hindering experiences. A helping experience
included being with a student. This was found to be the most powerful in promoting
student success (Poorman et al.). The second helping experience was reviewing
nursing content. This enabled students to identify what was important to study
(Poorman et al.). The third helping theme was approaching. This is reflected when
the teacher reaches out to the student so other possibilities could be seen by the
student. This action enabled the student to tackle and eliminate problems (Poorman et
al.).
Another theme presented by the authors was hindering. Hindering was
composed of uncaring, owning, hovering and favoring. An uncaring action was
demonstrated in two ways: faculty who were uninterested about teaching or
uninterested in students and insensitive faculty interactions (Poorman et al., 2002).
Other hindering actions included running the classroom as if it were a battlefield, and
hovering over a student to the point at which student comfort and learning was
impinged upon (Poorman et al.). Finally, favoring was a hindering action as well.
Paying to much attention or lack of attention to someone affected the students in a
negative way (Poorman et al.). Each of these students’ perceptions as themes
impacted the students’ at-risk (Poorman et al.). The results o f the study fostered the
students’ need to be with faculty, learn what is most important, and open dialogue for
nurse educators to question the assumptions guiding nursing education practice
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(Poorman et al.). The study noted the disparity between students and educators in the
application of nursing education.
Role Modeling and Nursing Education
Role modeling is found to be the key component in learning caring behaviors.
A nurse educator or practitioner who is non-threatening, warm, and caring, establishes
a climate in which caring may be learned (Higgins, 1996). In this environment
students are able to integrate these behaviors and model them because the caring
climate developed a helping-trusting relationship between the student and role model
(Higgins). Evans (2000) explored clinical teaching strategies used by clinical
instructors to create a caring curriculum. Role modeling, using theory and practice
(praxis) to enculturate students into a caring role among other teaching strategies were
noted (Evans, 2000). Evans also affirmed that the facilitation of student
epistemological growth is the student-teacher relationship, which creates the core for
clinical learning. The essential structure of a caring student-teacher encounter
includes four basic elements: teacher’s professional approach, mutual trust, a
professional teacher-student relationship and responsive positive student caring
encounters (Halldorsdottir, 1990). Students learn to emulate these components.
Paterson and Crawford (1994) reiterated that the primary proposed teaching strategy
by which caring is transmitted is the modeling of caring by faculty to students.
Du Toit (1995) studied professional socialization of first and third year
baccalaureate Australian nursing students (n = 173). Role modeling was noted as an
important component, but faculty personality characteristics played an equally
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important role as well (du Toit, 1995). A diversity of teacher personality
characteristics provided the nursing student with an opportunity to select an
appropriate role model that could aid in the student professional socialization process
(du Toit, 1995). Du Toit (1995) also noted that anti-models whose style is to be
avoided were important in student development.
Junior and senior baccalaureate participants (n = 18) in a phenomenological
study by Kosowski (1995) reported that role modeling of caring interactions by
instructors and staff nurses were the most frequent and powerful learning mode in the
clinical setting. Two constitutive patterns were identified: creating caring and
learning caring (Kosowski, 1995). Creating caring contains seven dominant themes:
“connecting, sharing, being holistic, touching, advocating, being competent, and
feeling good” (Kosowski, 1995, p. 238). Learning caring has five modes: “role
modeling, reversing, imaging, sensing and constructing” (Kosowski, 1995, p. 238).
An “embodied caring knowledge” was created from this study (Kosowski, 1995, p.
235). Further research was recommended by this author using cultural, racial, sexual,
and economic backgrounds.
In creating a caring community in nursing education Grams, Kosowski, and
Wilson (1997) used Halldorsdottir (1990), and Nelms, Jones, and Gray (1993) to
support their interpretative qualitative study am ong associate degree nursing
graduates. Role modeling was again seen as a strategy for students to learn caring
from teachers in the classroom and clinical settings. The authors reported from
Halldorsdottir (1990) that a caring teacher-student relationship (role modeling) can
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lead to positive responses of professional caring that includes a sense of acceptance,
self-worth, personal and professional growth, motivation, appreciation, and long-term
gratitude and respect. Further, the results suggested that creating a caring environment
has a potential for empowering students to create an egalitarian relationship among
caring communities (Grams et al., 1997). The authors generated two constitutive
themes from creating a caring community. The first theme included: setting the rules,
participating in activities, establishing trust, seeing faculty as part of the group (Grams
et al.). The second theme included: bonding with each other, self-disclosure, and
helping others to get through (Grams et al.). The participants in the study felt that they
were transformed as a result of the caring group experience in the following ways:
learning to know and care for self, learning to care for others personally and
professionally, seeing others holistically, and becoming more accepting of others
(Grams et al.).
Sanford (2000) noted that “modeling is the responsibility of the teacher” (p. 5).
The purpose of this article was to present a middle-range theory for patient education.
The author reported that students do not receive instructions to care, assignments or
tests, but it is necessary for caring to be demonstrated through the relationship with a
teacher; dialogue among teachers and students is crucial to learn roles of being cared
for and carer (Sanford, 2000).
School Climate as a Composite o f Factors
A school climate is a subcategory of organizational climate theory. The school
environment is complex, and is comprised of formal and informal structure (Owens,
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1970). Each of which play an important role in the development of school climate.
Owens (1981) stated that the climate of an organization plays an important role in
shaping the behavior of its participants thus noting the person-environment interaction.
Three components are a part of the internal organizational climate: it is experienced
by its members, it influences the members’ behavior, and it can be described in
terms of values or attributes of the organization (Owens, 1981).
Organizational climate is the personality of an organization (Huber, 1996). It
is individual specific and reflects the perceived environment of an organization’s
practice culture (Huber, 1996). An organizational culture is defined “as the shared
beliefs, values, and assumptions that exist within an organization” (Huber, 1996, p.
193). An individuals perceptions of various aspects of the organizational environment
is defined as climate (Huber, 1996). Both climate and culture work together either to
improve or degenerate the work of nursing (Huber, 1996). In nursing practice, a
positive culture is related to productivity, high morale, retention, and even decreased
mortality among acute care clients (Shortell, Rousseau, Gillies, Devers, & Simons,
1991; Thomas, Ward, Shorba, & Kumiega, 1990). Further, it is believed by several
authors that a caring climate fosters student personal growth, and learning (Evans,
2000; Dillion & Stines, 1996; Hanson & Smith, 1996; and Hughes, 1992).
It is not possible to isolate one individual that is responsible for school climate,
since school climate is a blend of many factors including school personnel. Several
authors link school climate to nursing education. Patistea (1999) hypothesized that
caring is affected by various personal, organizational, and social factors and to what
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extent and effect the answer is unknown. Bamum (1998), and Meleis (1997) noted
that a nurse’s perceptions of caring are influenced by the philosophy of the educational
institution and the environment in which they provide their services.
Student nurses as members of a community develop their own way of thinking
and acting. Many members of the community including family, and friends (Kelly,
1992), teachers, staff workers, preceptors, and school administrators influence
students. It is perceived that students emulate the one’s they admire most (Kelly,
1992). Paterson and Crawford (1994) concurred that little consideration is paid to
others (patients, peers and staff nurses) in teaching caring to students.
Nelms, Jones and Gray (1993) determined from interviews of nurse educators
that caring as a nurse is learned from faculty role models as well as healthcare staff.
Paterson and Crawford (1994) presented another side of school climate which is in
order to foster communities of care, faculty “must feel cared for and valued by their
colleagues, students, and administrators” (p. 171).
In the nursing educational experience, many relationships have an impact on
the student in the development of caring. No one factor or relationship is responsible
for the development of caring. However, it is recognized that nursing faculty and
climate in which the student is educated does play a key role in its development.
Between clinical practice, classroom peer encounters, family relationships, and past
caring experiences, cognitive and affective development, caring ability development
and practice occurs as a result of an amalgam of all factors that creates the caring
integrative being.
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The Research Model
The research model for this study is comprised of three inventories: Caring
Ability Inventory, Charles F. Kettering School Climate Profile, and Parental Bonding
Instrument. The foundation for this study is based on the theoretical work of Mayeroff
(1971). Eight major ingredients composed this theory: knowing, alternating rhythms,
patience, honesty, trust, humility, hope and courage (Mayeroff). Nkongho (1990)
used Mayeroff s indicators of caring to create the Caring Ability Inventory. After
open-ended interviews, test/re-testing of study participants, and content expert
evaluations, the results revealed knowing, patience and courage to be the constructs
which related significantly to caring ability (Nkongho, 1990).
The Charles F. Kettering (CFK) School Climate Profile developed by Howard,
Howell, and Brainard (1987) has undergone several adaptations. Simmons (1994) is
the original researcher who adapted this instrument to post-secondary nursing
education using the four statistically significant scales of respect, trust, morale
and caring as noted from a previous research study by Johnson & Dixon (1990).
Further, the literature suggests that school climate may have an effect on the student
learning process.
The literature review previously suggested that early infant/childhood caring
experiences by a parental figure(s) may influence the caring ability of the child. This
influence is believed to have an impact throughout one’s personal and social life.
Parker, Tupling, and Brown (1979) developed an instrument (Parental Bonding) to
measure the degree of paternal and maternal bonding. They found care to be a major
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parental dimension noted in the bonding process. The impact of parental bonds on a
nursing student is noted from previous study reports (Simmons, 1994; Simmons &
Cavanaugh, 1996, 2000; Cavanaugh & Simmons, 1997). However, further study is
welcomed to understand nursing student caring ability, and its relationship to the
parental bonding process.
The main ingredients of Mayeroff s (1971) work are reported to have a direct
relationship to teacher-student learning. The application of these ingredients may lead
a nursing student to grow in the spirit of nurse caring. It is the caring components that
are perceived to make a positive difference in the nursing educational process.
However, this student learning opportunity is impacted by attributes the student brings
to this learning opportunity and the environment in which it is nurtured.
Summary Note
This chapter presented attachment/bonding, caring theory, related theory
concepts, caring literature reviews, and studies surrounding the premise of this study.
The amount of caring literature for review is immense. However, the focus was to
bring the important factors of caring to present support for the study’s development.
Caring goes to the core of nursing’s purpose, but caring takes a “back seat” to
competence in the critical healthcare delivery moment. Nursing education seeks to
infuse both professional caring and competence through a definitive academic course.
Competence in nursing practice is of utmost concern. Caring without
competence is not valued; competence without caring does not make a professional
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nurse. The final outcome of nursing education is to provide knowledge, skill, values,
attitudes, and beliefs for a new graduate to begin his or her journey focusing on
the delivery of professional nursing practice.
The researcher further recognizes that caring theory is under constant
development and reconstruction to be inclusive of its many facets in parental, family,
social, and professional application. For this reason, it is necessary to be vigilant of
caring theory support and its relevance to the profession of nursing. Next, Chapter III
presents the methodology used in applying this study to first semester nursing
students.
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Chapter III
METHOD
This chapter includes information regarding the instruments utilized, required
approvals, description of the sample, setting, procedures for the collection of data, data
entry, data statistical analysis, and the study’s methodological assumptions, limitations
and delimitations. The purpose of the study was to quantify and explore caring’s
existence and development among first year nursing students from three nursing
programs in Southern California.
A combination of three instruments provided the data for the quantitative
portion of this study. Each of the instruments generated descriptive and inferential
data that either supported or rejected the research hypotheses. The data assisted in
clarifying, resolving, and supporting previous research findings following similar
conceptual assumptions. Further, the combination of instruments and demographics
served a unique purpose in gathering quantitative data for determining the relationship
between caring ability, parental bond, school climate, and semester success. A model
of the quantitative study focus is presented in Appendix C.
The qualitative portion of this study consisted of semi-structured interviews
performed with approximately 10 percent of the responding quantitative volunteers.
This process clarified the participant’s personal experiences, meanings and
development of caring during the first semester of nursing. Several open-ended
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questions were asked to initiate a more naturalistic approach and to gain information
on the phenomena of caring ability and its development in an individual.
The use of both quantitative and qualitative methodology in this research
design gave methodological triangulation support. This methodological approach
provided a multidimensional perspective in understanding the caring ability
phenomenon. Several research theorists delivered support for combining research
methodology. Dzurec and Abraham (1993) furnished agreement for mixing of
quantitative and qualitative methods, if the objective, scope and nature of the inquiry
in the study are similar, which it is in this study. Field and Morse (1985) affirmed that
the strongest research methods are found in studies that use both quantitative and
qualitative methods. Wilson and Hutchinson (1991) reported that the combined
methodological approach gives breadth and depth required in nursing research. Also,
Hanson (1999) stipulated that positioning the methods as one verses the other
prohibits creativity that a broader interpretation would allow.
The combined methodological approach enhanced the data. Data from the
qualitative method in this study provided a rich resource of unbiased and insightful
data. Such information could not be obtained from the quantitative method alone.
Additionally, quantitative data recognized outliers or unique cases that could be
explored or explained in the qualitative data. This study used multiple sources of
theory, methodology, and their interconnectedness to acquire a more useful approach
in understanding a phenomenon as posited by the research theorists.
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Previously, Simmons (1994), and Simmons and Cavanaugh (1996) noted the
explanation in variance of caring ability to be 13 percent. The combination of
quantitative and qualitative methodologies allowed for more discernment in
understanding other explanations for caring ability development. Therefore the two
methodologies were justified in this study.
Instrumentation Parts
The combined quantitative instrumentation was used successfully in previous
studies (Cavanaugh & Simmons, 1997; Simmons, 1994; Simmons and Cavanaugh,
2000). The three instruments included in this study are the same: Caring Ability
Inventory (Nkongho, 1990), Parental Bonding Instrument (Parker, Tupling, & Brown,
1979), and Charles F. Kettering Ltd. School Climate Profile (Howard, Howell, &
Brainard, 1987). These instruments were identified as parts in the participants’ copy.
Part One of the questionnaire addressed the student’s perception of his or her
caring ability (questions 1-37) from the Caring Ability Inventory (CAI). Parts Two
and Part Three represented the student’s perception of parental caring during the first
16 years of life adapted from the 12 item care subscale of the Parental Bonding
Instrument (PBI). Each of these parts represented either maternal or paternal
perception responses (questions 38-49 & 50-61). Part Four of the instrument collected
data from the student’s perception of the nursing school climate. This part is
comprised of 16 items from the Charles F. Kettering School Climate Profile (CFK).
Questions 67 through 77 of the instrument covered this section. The final part of the
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instrument, Part Five, obtained demographic details used in data analysis (questions
78-100). The instrument took approximately 20 minutes to complete. A copy of the
five part instrument is presented in Appendix B.
Caring Ability Inventory
Nkongho (1990) originally designed the Caring Ability Inventory (CAI) to
measure an individual’s caring ability. It is a 37-item, self-administered, Likert-type
questionnaire with responses varying from one (strongly agree) to seven (strongly
disagree). The total potential range (summation) of scores is between 37 and 259.
Nkongho (1990) developed this questionnaire from the works of Mayeroff
(1971), caring theorists and review of caring literature. Originally there were 61 items
on the inventory. After interviewing 15 adults with 10 open-ended questions, 19
additional items were constructed. A total of 80 items were identified using a 7-point
Likert scale, and subsequently tested using this inventory. Following principal-axis
factor analysis, only 37 items remained consisting of three subscales that were
congruent with Mayeroff s (1971) work on caring. The subscales included: knowing,
courage, and patience. The revised inventory was then administered to two groups of
college students: varied majors (n = 462), and nurses (n = 75) for a total of N = 537
participants. The nurses in the study completed an additional instrument the
Tennessee Self-Concept Scale (Fitts, 1986). The participants in the study were mostly
female (80%), under 33 years of age (61%), and from varied ethnic backgrounds.
Reliability was assessed in two ways: internal consistency using Cronbach’s
alpha and test-retest reliability. Each of the reliabilities was reported within
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acceptable range (Nkongho, 1990). Cronbach’s alpha coefficient for the total score
was .84, and the test-retest reliability total was .75 (Nkongho, 1990).
Validity was confirmed through several measures. Two content experts
analyzed the items for clarity and adequate representation of the caring concept as
described by the developer. Suggestions were made, and the items were revised and
again reviewed for clarity, consistency, and relevancy. The content validity index
(CVI) was computed. The percentage of agreement was .80 (Nkongho, 1990). The
construct validity was reviewed using two approaches: discrimination between
groups, and correlation with the Tennessee Self-Concept Scale.
Since literature suggests that caring is partly learned, it was expected that
caring nurses would exhibit more caring ability than would other college students
(Nkongho, 1990). The t-test was statistically significant (p = < .001, df = 535) for
mean scores on the two groups. Also, a comparison of the mean scores between
females and males was found to be significant. Female students scored significantly
higher than male students. The result was not surprising because the literature
supported women as being socialized to be more expressive and caring than men
(Nkongho, 1990). In addition, the Pearson correlation between self-concept using the
Tennessee Self-Concept Scale and the CAI subscales were moderately high, noting
that persons who were high in self-concept were also high in caring (Nkongho, 1990).
Nkongho justified with evidence the construct validity for the C A I.
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Parental Bonding Instrument
Parker, Tupling, and Brown (1979) developed the Parental Bonding Instrument
(PBI) in Australia. Its purpose is to measure the participant’s perception of bonding
with parents. Two bipolar factors were analyzed. The first factor was affection and
warmth contrasted with coldness and rejection (scale 1). The second factor was
casual demanding contrasted with regulation and intrusiveness with demands for
obedience and high accomplishment (scale 2). It was determined from the original
study that each of these scales could be used independently (Parker et al., 1979).
The original PBI was piloted using medical students. After revision, it was
used with psychiatric nurses, and medical students. Factor analysis and
intercorrelations resulted in leaving 48 items for use in the principal study. It was
noted at this time that the model had a two-dimensional focus with one being a care
dimension and the other being control or overprotection. The principal study used
sixty-five medical students, and forty-three psychiatric nurses, thirteen technical
college students, and twenty-nine parents of children at a local school. There was
almost an even number of female and male respondents with the mean age being 25
years. Validation occurred against responses to a subset of Thematic Appreciation
Test cards and by interview of a 43 percent sample. Factor analysis resulted
in 25 items for the final scale with 12 being the caring component, and 13 being the
overprotection component. The current study used only the items in scale 1 relating to
the caring component.
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Reliability was verified through the addition of identical items in the
questionnaire. The responses to the items were intercorrelated and produced a Pearson
correlation coefficient of .70 (p < .001). In addition, seventeen members of the sample
completed the scale on two occasions three weeks apart to assess test-re-test
reliability. The Pearson correlation coefficient reflected a .76 (p < .001) for the care
scale. A split-half reliability was also performed with the Pearson correlation
coefficient being .88 (p < .001) for the care scale. Using a joint interview with sixty-
five subjects, a care score was assigned for each subject. Inter-rater reliability
coefficient for the care dimension was .85 (p < .001). The Pearson correlation results
for the care measures and care-raters scores were .77 and .78 (p < .001).
Parker et al. (1979) analyzed the scale on four hundred and ten patients from
various social classes and ages attending practices in Sydney, Australia. The results
indicated that there was no clear association between social class and parental care,
and no association was found between age of the respondent and perception of
parental care. In addition, the study found that mothers are perceived as significantly
more caring than fathers (t = 8.28, p = .001), and the sex of the respondent did not
influence the respondent’s perception of the parents’ capacity to care (Parker et al.,
1979). This verification by Parker et al. (1979) using this analysis, found the scale to
be reliable.
The PBI contained 12 items on care that were used specifically in this study. It
required no instructions except that the original scale was not in a Likert form.
Simmons (1994) transformed the scale to a Likert form for respondent use. The scale
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consisted of a range from 1 meaning very unlike to 4 meaning very like. Simmons
(1994) made additional adjustments to respond to negatively worded items, and
identified the final scaling before data input to be 0 to 3. The total potential score in
the PBI (maternal and paternal scores individually) was now from 0 to 36. A score of
36 would be a maximum score suggesting warm maternal or paternal care. The
maternal and paternal scale scores could then each be used to form predictor variables
in future quantitative investigations.
Charles F. Kettering Ltd. School Climate Profile
The Charles F. Kettering Ltd. School Climate Profile (CFK) was originally
developed by Fox, Boies, Brainard, Fletcher, Huge, Martin, Maynard, Monasmith,
Olivero, Schmuck, Shaheen, and Stegman (1973). It was published as part of a book,
entitled School Climate Improvement: A Challenge to School Administrators. Later,
the CFK appeared in another book entitled: Handbook for Conducting School Climate
Improvement Projects by Howard, Howell, and Brainard (1987) making the
instrument available for use.
Four sections compose the CFK: Part A = General Climate Factors (40
questions), Part B = Program Determinants (35 questions), Part C = Process
Determinants (40 questions), Part D = Material Determinants (15 questions), (Howard,
Howell, & Brainard, 1987). These parts represent a total of 130 items. The scaling
technique for the CFK by Howard et al. (1987) involves two discrepancy format
columns: the “What Is” column and “What Should Be” column. The Likert
descriptors are: 1 = almost never, 2 = occasionally, 3 = frequently, 4 = almost always.
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The General Climate Factors section consists of eight subscales: respect (items
1-5), trust (items 6-10), high morale (items 11-15), opportunity for input (items 16-
20), continuous academic and social growth (items 21-25), cohesiveness (items 26-
30), school renewal (items 31-35), and caring (items 36-40). Each of these sections is
comprised of five questions making up the total for 40 items in the General Climate
Factors section.
The purpose of this instrument is to rate students’ perceptions of the teaching-
learning environment using respect, trust, morale, and caring within the professional
school climate. Subsequent psychometric research by Johnson and Dixon (1990) and
Johnson, Ryan, and Dixon (1991) invited the CFK General Climate Factors section to
change from a 40 item to 16 items. The CFK developers (Fox et al., 1973) wrote the
original climate operational definitions, which were re-written in Howard, Howell &
Brainard’s (1987) handbook. These definitions were used in the current abbreviated
scale:
Respect. Students should see themselves as persons of worth whose
ideas are respected in an environment where teachers and administrators feel
the same way. School should be a place where students are appreciated, have
self-esteem, and are considerate of others in an atmosphere where mutual
respect prevails.
Trust. Trust is the perception that others can be counted on to say and
do what they expressed, and have the integrity to carry it through.
High Morale. People feel good about what is happening in their
school, and as a result they are willing to performed assigned tasks in a
cheerful and confident manner. The participants are self-disciplined in
completing tasks without failure.
Caring. All individuals in the school environment are concerned and
interested in each other like in a family-type of aura. Even teachers feel the
caring attitude from administrators. Administrators seek to understand and
assist in minimizing the pressures of teaching. Effective schools operate in an
atmosphere of cooperation and caring. (Howard et al., p. 7-8).
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The Likert 4-point scale response remained the same: 1 = almost never, 2 =
occasionally, 3 = frequently, and 4 = almost always. This instrument was adapted for
use in the nursing educational climate originally by Simmons (1994). Reliability and
validity did not accompany the original development of the 1987 instrument.
Consequently, Simmons used the works of Dennis (1979), unpublished doctoral
dissertation, to support content validity of the CFK. Dennis did not establish criterion-
related validity either. This finding was not surprising because the study used
administrators, teachers, and students who perceive school climate differently-
creating the discrepancy. However, Dennis did provide a .94 reliability of the General
Climate Factors section.
Johnson and Dixon (1990) gave support to establish construct validity. They
used factor and Rasch latent trait analyses in their study. Items clustered and were
found to be distinct from other items. Therefore respect, trust, morale and caring, the
affective experiential features remained. These features reflected the general climate
(20 items). The other twenty items measured cognitive/managerial components i.e.
school renewal, and opportunity for input. Johnson and Dixon (1990) noted that these
items should be assessed separately. These items were not assessed in the current
investigation. Additionally, Johnson and Dixon (1990) noted several misfitting items
(item 3, item 8, item 5, and item 36 from the original 40 item instrument). These were
deleted in the current investigation. Further, the instrument was found to be most
valid when administered to a homogenous group, such a students alone (Johnson and
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121
Dixon, 1990). The first year nursing students in this study provided the homogenous
sample suggested by Johnson and Dixon (1990).
Simmons (1994) used Johnson and Dixon’s (1990) suggestions and
administered the 16 items for the CFK. This instrument proved useful in Simmons
(1994) dissertation study in soliciting reliable data regarding nursing school climate.
Simmons reported a Cronbach’s alpha reliability of .93.
Johnson, Johnson, Kranch and Zimmerman (1999) created a university version
of the CFK. It contained the 40 item General Climate Factors. They revised the
instrument replacing the words school with university and principal with teachers
(Johnson et al., 1999). The scale maintained all the other features including the
subscales, scaling technique and 4-point column descriptors (Johnson et al., 1999).
The authors posited that the CFK could be invaluable in gathering data of present
cognitive managerial and affective-experiential status of a university, and validated
the need for this kind of research (Johnson et al.). This study included cognitive-
managerial and affective-experiential analysis together. This would be considered a
violation in the study, since Johnson and Dixon’s (1990) recommended to test these
areas separately.
Although the original developers of the CFK set up a total of 130 items to be
used in evaluating school ideal conditions, subsequent psychometric research lended
the instrument for abbreviation (Johnson & Dixon, 1990). The tool proved to be
useful in several studies (Cavanaugh & Simmons, 1997; Johnson & Dixon, 1990;
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122
Simmons, 1994; Simmons & Cavanaugh, 1996, 2000). Therefore, the current
research study used the 16 item questionnaire of the CFK.
Simmons (1994) noted that construct validity is never confirmed, but support
is provided by predictions from multiple different studies. Simmons used several
nursing theorists and researchers to support validity. Using this perspective, the caring
theory review in Chapter II provided support for construct validity in the current
study.
There is no other nursing research study except Simmons (1994), Simmons
and Cavanaugh (1996, 2000), Cavanaugh and Simmons (1997) that use the CFK. No
other nursing school climate measurement is available for comparison to establish
criterion-related validity. The CFK is the best instrument to date.
Copyrights
Permission to use the Caring Ability Inventory (Nkongho, 1990) was
obtained from the Behavioral Measurement Database Services. Dr. Evelyn Perloff,
Director, agent for N. O. Nkongho, provided written permission to use this instrument.
Phi Delta Kappa International in Bloomington, Indiana, granted written
permission to use the Charles F. Kettering Ltd. School Climate Profile both in
receiving a copy of the Handbook for Conducting School Climate Improvement
Projects (Howard, Howell & Brainard, 1987), allowing document copy use, and
written permission to use and modify the instrument from David Ruetschlin, Assistant
Editor. The instrument is copyrighted.
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123
Dr. Gordon Parker, Professor of Psychiatry, the University of New South
Wales, Sydney, Australia provided written correspondence granting permission to use
the Parental Bonding Instrument. This instrument is not held in copyright.
Simmons (1994) provided written permission to use the combined tools (CAI,
PBI, CFK, and demographic questions), and Model of Teacher Caring based on
Mayeroff (1971). Simmons authored the 1994 dissertation on the relationship among
caring ability (criterion variable), and other predictor variables using senior
baccalaureate nursing students.
Qualitative Portion of the Study
The target sample of the qualitative portion of the study was 10 percent of first
semester nursing students that included both high and low caring ability scores.
Analysis of the caring ability data noted this fact. The sample contained ethnic, and
gender diversity. After semester completion, success diversity was added. The
diversity of the sample aided in the variety of data complied, analyzed, and discussed.
The potential population sample from the consenting quantitative group was
N = 123. The researcher selected the 10 percent random sample from each
participating nursing program for the interview process. The final count of qualitative
interviewees consisted of twelve students. The students were contacted by phone
individually, and a meeting date and time was mutually agreed upon. The
participating students met the researcher on the student’s campus in a comfortable
setting.
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Prior to the individual semi-structured forty-five minute to one hour
interviews, students were reminded of their consent to participate, and all agreed to
continue with the interview. All individual interviews were conducted during the
months of October and November 2001. The interview consisted of five open-ended
questions:
• Question # 1: How would you define caring?
• Question # 2: Now that you are a nursing student, how has your
definition of caring changed?
• Question # 3: What events, relationships or other situations contributed
to the development of your caring ability?
• Question #4: As a student nurse, describe a situation in which you
were able to practice your caring ability?
• Question #5: What changes in your caring ability have occurred as a
result of your enrollment in the nursing program?
The researcher developed these questions based on the literature review.
They focused on the main aspects of the quantitative research to elicit data that may
not be available through a questionnaire approach. The questions corresponded to the
epistemological premises of this study which were: caring is developed, students
experience caring in their nursing practice, and caring ability may change as a result of
formal nursing education.
An explanation of the context of each question is provided in the following
discussion. Question # 1 asked the first semester nursing student to provide thoughts
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on his/her definition of caring. Question # 2 requested the student to contrast his/her
personal definition of caring to himself/herself as a caring student nurse. Question # 3
probed introspection from the student as to how he/she developed into a caring person.
The quantitative questionnaire focused on the parental role in the development of
caring ability, but the open-ended interview approach can validate what is already
known or shed further insight into caring development. This question provided the
student’s perception of how caring ability is developed. Question # 4 provided an
opportunity for a phenomenological approach to the qualitative data collection using
student stories. This technique allowed the researcher to extract themes or key points
from real-life situations. This method is most preferred by qualitative caring
researchers. Question # 5 gave the student the opportunity to provide insight as to
whether or not the student has changed in his or her caring ability since nursing school
enrollment. Although only a short period of time allowed nursing curriculum to be
presented to the student prior to the interview, the students were able to report
personal perceptions, opinions, and stories.
Population and Sample
The population sample was confined to first semester nursing students from
three Associate Degree Nursing Programs in Southern California. There was no
restriction to gender or ethnicity in obtaining study data. All nursing students enrolled
in the first semester of the selected nursing programs were invited to join in on this
study. The data was not collected until after the first semester students had completed
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126
a minimum of five weeks of the semester. This was planned so there would be
adequate time for the students to develop a perception of their educational experience.
The potential was for approximately 100 to 150 students to be included in the study.
The number was based upon the usual enrollment for a first semester of nursing,
which is approximately 36 to 60 students depending on the college district and state
funding.
Permission to use the community college sites was obtained prior to student
contact. Individual program directors and key first semester nursing faculty and staff
were contacted. Personal meetings were arranged as requested to discuss the
particulars of the proposed study, and obtain permission to proceed for first semester
nursing student contact. Student initial contact dates were set prior to the semester
commencement. During the month of September 2001, the first semester faculty
contact persons were reminded and up-dated on the classroom contact dates and times.
The faculty contacts at each campus were advised to notify the researcher if any
changes were to take place regarding student contact dates, places, and times, so
modifications could be made.
At the fifth to seventh week semester interval (September through October),
the researcher made contact with the possible study recruits during class time at each
proposed study site on the date agreed upon in advance. A brief overview o f the
proposed study, review of the Consent to Participate in Research (Appendix A), and
invitation to participate in the study was provided. Also, a time for questions and
answers was given as classroom time permitted. Students requiring further contact
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with the student researcher were referred to the Consent to Participate in Research
form that contained contact numbers.
Two copies of the Consent to Participate in Research form were provided to
the possible study recruits (one for the student’s file), and one copy of the actual
questionnaire to be completed. A stamped self-addressed envelope in which to return
the completed questionnaire was provided to those who could not complete the
questionnaire during class time or absent (questionnaire packet was given to students
upon return to class by instructor). It was noted that in-class time was sufficient for
most respondents to complete the questionnaire. After which, the students returned
the completed consent and questionnaire during the initial researcher visit. Others
who did not complete the questionnaire during class time were directed to complete
the consent and questionnaire at home, and return it in the stamped self-addressed
envelope. To encourage nursing student participation, a lunch was provided to all
participants when the questionnaire was administered. Students who withdrew for the
program or who were in the process of withdrawing by the fifth week of the semester
were not included in the research population.
Data Collection Procedures
Each of the questionnaires was numerically marked and coded. Student
identification numbers were requested in the questionnaire demographics. This
number was used to track the correct nursing students’ course completion and course
grade at the end of the semester. Course completion and course grade information was
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necessary to carry out correlation data with continuous variables. After the student
grade and completion were documented, information was coded according to the
questionnaire number for the individual student. Student confidentiality was
maintained at all times. The Consent to Participate in Research form (Appendix A)
further defined the student confidentiality process.
Participating first semester students returned all questionnaires within two
weeks after initial student contact. It was not necessary to contact program team
leaders or students for additional participants.
Qualitative data from the interview was audio taped, and the researcher took
annotated notes. The recorded data was transcribed verbatim. Information from this
phase was anatomized. Analysis of this phase is further explained in Data Analyses.
Data Entry Changes
Quantitative missing data was noted and coded accordingly. All necessary
reverse scoring on the CAI data, and PBI data changes in numerical Likert scoring was
noted and computed. All quantitative data was entered for computer analysis.
Data Analyses
Descriptive statistics were first performed. Information such as gender, age,
ethnicity, semester in the nursing program, and others was tabulated. Correlational
statistics for a continuous independent variable (predictor) with a continuous
dependent variable (criterion) were run, and one-way ANOVA was used to isolate
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independent group differences when group numbers were sufficient with the
dependent variables, (i.e. caring ability, paternal bonding and school climate).
Otherwise for those items in the study, which were dichotomous independent
variables, and continuous dependent variables, a t-test was used. Further tests were
delineated as the working data unfolded and data numbers and specifics were
tabulated.
Qualitative data analysis consisted of reducing data into codes or themes.
Commonalities were noted, and unique perceptions tabulated. Interview data was
managed and analyzed using a modified version of Knafl and Webster’s (1988)
approach. A verbatim transcript of each interview was typed and coded to correspond
with each audiotape. The entire written transcript was read in order to obtain the
whole theme of caring ability as described by the students. The transcripts were read
question-by-question, and line-by-line, as many times as it took to extract meaningful
phrases or ideas. Researcher comments were written in the margins to signify
pertinent themes or ideas. These were coded with identifying themes and patterns in
the data noted throughout the individual transcripts. After several readings of the
transcripts and marked codings, categories and subcategories were documented and
noted on each transcript. Information results from this process is reported in
Chapter IV.
Intracoder and intercoder reliability was assessed for stability or consistency of
the original coding used in establishing categories. The researcher reviewed a 25
percent random sample of coded material after a two-week time lapse. In addition,
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two content experts (nursing instructors), one with research experience were invited to
review a 25 percent sample of coded, categorized and subcategorized material.
Credibility of the qualitative data interpretation was inferred since each participant
from the participating nursing schools agreed with the written interpretation, or
summary of his or her verbal response to the interview questions after telephone
contact by the researcher.
Methodological Assumptions
The following are some of the methodological assumptions involved in this
study:
1. The potential to care exists within an individual.
2. A basic innate human desire is to help or care for another.
3. Caring’s roots begins in infancy, develops throughout childhood, and it has the
potential for further development in adult years.
4. Caring ability is multidimensional (Nkongho, 1990).
5. Caring includes cognitive, affective, and psychomotor elements.
6. Caring ability can be measured.
7. The influences of caring ability can be assessed by measuring dimensions such
as caring, respect, trust and morale within the school o f nursing (Simmons,
1994).
8. The nursing student’s ability to care can be assessed by measuring other
dimensions such as knowing, courage, and patience (Simmons, 1994).
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9. Respondents to the quantitative portion of the study will provide answers to the
questionnaire that are truthful and endearing to their intrinsic beliefs.
10. Respondents to the qualitative component of the study will be truthful in
expressing their perceptions of caring ability, factors that promote caring
ability, and changes in caring ability after receiving some curricular instruction
and clinical practice.
11. A level of caring self-perception will be noted in associate degree first year
nursing students.
12. A level of perception regarding school climate and parental bonding will be
present among associate degree first year nursing students.
13. Both cognitive and affective learning is associated with caring ability.
14. The respondents will understand the directions for the questionnaire.
15. The quantitative research design, instrumentation, and data analysis are
appropriate.
16. The qualitative research design will provide data not otherwise obtained
through a quantitative approach.
17. The participants in this study are representative of the general population of
first semester associate degree nursing students from the three community
colleges.
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Study Limitations
The following study limitations are noted:
1. It is recognized that many factors have an influence on caring ability and only
a few of the documented variables are studied at this time.
2. It is acknowledged that the researcher’s affiliation with a study site might
have influenced the respondents’ answer selection.
3. The study was limited to subjects who voluntarily agreed to participate in
the study.
4. The ethnic composition of students may vary according to the school tested.
5. The results of the study may not be generalized to other ethnic groups because
of sample size or semester representation.
6. The study was limited to first semester nursing students in selected Associate
Degree Nursing Programs in Southern California.
7. The study was limited to subjects who voluntarily agreed to participate in
the study.
8. If any of the limitations were not met this would constitute a limitation to this
study.
Study Delimitations
The following study delimitations are noted:
1. It is recognized that it is not possible to control all variables that interplay in
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the development of caring ability among first semester nursing students, and
some factors may play a more influential role on a student.
2. It is acknowledged that the selection of the first semester nursing students may
have an influence on the study results different from any other semester
of nursing student or program degree preparation.
3. The study sample was limited to nursing students in selected Associate Degree
Community College Nursing Programs in Southern California.
4. The study was limited to subjects who voluntarily agreed to participate in the
research study.
5. The participating sample included only students from the first semester classes
from three Associate Degree Nursing Programs.
6. The qualitative portion of the study reflected a small sample (10%) of the
total participants in the study.
Summary Note
Chapter III presented the combined methodologies used in the study.
Quantitative instruments and qualitative technique were described, and the population
sample was defined. Preliminary data analysis strategies were delineated for both
methodologies. Methodological assumptions, study limitations and delimitations were
provided. Next, Chapter IV presents the study’s findings.
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Chapter IV
RESULTS OF QUANTITATIVE DATA AND QUALITATIVE INQUIRY
This chapter begins with discussion of the reliability and internal consistencies
of the quantitative data, followed by a presentation of the quantitative descriptive and
frequency data. Next, hypotheses data are recounted and discussed followed by
reporting of additional relationships among key research variables. In the qualitative
data reporting, interrater agreement is established before qualitative data and captured
themes are presented. Finally, a summary of the key findings is presented after each
data section.
Quantitative Data
Data Reliability and Comparisons o f Descriptive Statistics and Measures o f
Central Tendency
Caring Ability Inventory (CAI)
In the original study of 537 college students with varied majors and
professional nurses, Nkongho (1990) reported a Cronbach’s alpha coefficient of .79,
.75, and .71 for the CAI subscales of knowing, courage, and patience respectively for a
total CAI of .84. Later, a subsample of thirty-eight reported test-retest reliability
coefficients of .80, .64, and .73 for knowing, courage, and patience respectively
resulting in a total CAI test-retest of .75 (Nkongho, 1990). In another study involving
350 senior baccalaureate students, the total Cronbach’s alpha reported was .79
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(Simmons, 1994). Additionally, Nelson, Howell, Larson, & Karpiuk (2001) in a study
of 421 associate degree and bachelor nursing students reported a Cronbach’s alpha
coefficient of .68 to .83 and .83 for a total CAI score. The current study revealed a
Cronbach’s alpha of .77, .73, and .65 for the CAI subscales and .82 for CAI total.
Table 1 exhibits a comparison of descriptive statistics and measures of central
tendency.
Table 1
Comparison Descriptive Statistics & Measures of Central Tendency
RESEARCH GROUP Score Ranges Mean Standard Deviation (sd)
Current Study
ADN First Semester Students 118-240 206.62 18.44
(n = 124)
Postgraduation 3 years
Simmons & Cavanaugh (2000)
(n = 189)
167-247 209.25 15.84
BS Seniors
Simmons (1994), Simmons & 173 - 244 208.20 13.10
Cavanaugh (1996)
(n = 350)
Professional Nurses
Nkongho (1990)
(n = 75)
None reported 211.70 17.20
College Students
Nkongho (1990)
(n = 462)
None reported 196.00 21.40
Parental Bonding Instrument (PBI)
From a principal study comprised of 150 medical students, psychiatric nurses,
technical college students and parents of children, the PBI was developed (Parker et
al., 1979). In subsequent testing by Parker et al. (1979) reliability was established
through two identical item testing and yielded a Pearson correlation coefficient of .70
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136
(p less than .001), and test-retest reliability showed a Pearson correlation coefficient
of .76 (p less than .001). To further establish reliability, a split-half reliability test
produced a Pearson correlation coefficient of .88 (p less than .001) for the care scale
items of the PBI (Parker et al., 1979). The current study revealed a Pearson
correlation coefficient of .93 for maternal care PBI and .90 for the paternal care PBI.
Table 2 exhibits a comparison of descriptive statistics and measures of central
tendency.
Table 2
Comparisons of Measures of Central Tendency
SOURCE GROUP MC Mean / Range MCsd PC Mean / Range PCsd
Current Study
ADN first semester 25.88 8.97 23.65 9.57
(n = 124) (0-36) (1 -3 6)
Postgraduation 3 years
Simmons & Cavanaugh (2000)
(n = 189)
27.42
(0 -3 6)
9.35 23.72
(0 -3 6)
10.38
BS Seniors
Simmons (1994), Simmons & 28.20 8.00 24.00 9.80
Cavanaugh (1996)
(n = 350) (5 -3 6) (0 -3 6)
Charles F. Kettering Ltd. School Climate Profile (CFK)
The original 1970’s developers of the CFK did not publish reliability and
validity findings. It has been suggested that they departed from the conventional
approach to test construction, and the instrument was accepted on face validity
(Johnson & Dixon, 1990). However, several studies thereafter yielded CFK’s overall
capacity to identify areas of need (Johnson & Dixon, 1990). Refinements in the CFK
Profile are on-going, including factor analysis (Johnson, Dixon, & Johnson, 1992;
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137
Johnson & Johnson, 1992; Johnson, Johnson, Kranch, & Zimmerman, 1999). Upon
recommendations made by Johnson and Dixon (1990), Johnson, Ryan and Dixon
(1991) and successful modified instrument use by Simmons (1994), use of the 16-item
adaptation from the original profile seemed logical. Simmons reported an overall
Cronbach’s alpha of .93 for respect, trust, morale, and caring. In subsequent testing of
a university version of the CFK, Cronbach’s alpha coefficient of subscales yielded .65,
.79, .68, and .82 for respect, trust, morale, and caring respectively (Johnson et al.,
1999). The current study found the subscale reliability yielded a Cronbach’s alpha of
.53, .78, .70, and .76. The overall analysis of reliability in the current study figured
the Cronbach’s alpha at .88. Additionally, the range of scores for the entire profile (N
= 123) was 37 - 94 with a mean of 54.8, and a standard deviation of 6.7. The current
study results are comparable to previous studies. Therefore the data are considered
reliable. Further analysis of key variables was the next step in verifying the quality of
the data.
Shapes o f Frequency Distribution and Frequency Statistics
In further analyzing the current study data with frequency statistics and
histogram graphs, several factors were examined to verify normality. Plots of caring
ability scores was similar to a normal distribution with bimodal scores occurring near
the peak. Skewness of the curve was -1.27. This indicated a negative lean towards
lower caring ability with the greater distribution of scores being at the positive end.
Kurtosis reflected a 3.89. This score suggested a leptokurtic peaked distribution as
noted in the frequency statistics mode data.
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138
The maternal caring ability score visually appeared somewhat normal in the
histogram. However, the scores were slightly negatively skewed (-.80) with the bulk
of the scores being positive. A kurtosis of -.28 demonstrated less degree of
peakedness with multiple modes existing at the positive end of the plotted data.
The paternal caring ability score plotted histogram contained several lowered
drops in scores with coverage through most of a normal distribution. Skewness
reflected a -.63, which demonstrated a negative lean in the distribution. Paternal
caring ability kurtosis was -.47 and this was reflected in the drop of scores seen in the
overall distribution.
Finally, the normal distribution of school climate was calculated. The
histogram revealed a resemblance to a normal distribution. Skewness again
demonstrated a negative lean in scores (-.55). A kurtosis in the school climate scores
reflected a -.40.
The results of the data indicated that the normal distribution of maternal caring
ability, paternal caring ability and school climate approximated a normal distribution
especially since skewness and kurtosis were not more than 1 or -1 from 0 (the mean).
Further, the caring ability score distribution was slightly over in skewness (-1.27), and
bimodal peaked in kurtosis. Although a normal distribution is most useful to extract
statistics, a nonnormal distribution can be used especially if it is close enough to a
normal distribution with mean and standard deviation of raw scores being made
available (Harris, 1998). The current study meets this practice. Therefore, the
distribution data is acceptable to continue further analysis of the data.
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139
Descriptive Statistics and Frequencies for Study Data Demographics
Three Southern California associate degree community college nursing
programs participated in the study (N = 124). The population included 110 first
semester females and 14 males. School One provided 36 students with thirty-four
females and two males. School Two provided 54 students with fifty females and four
males. School Three provided 34 students with twenty-six females and eight males.
The mean, mode, and range of ages among the programs were similar. School One’s
mean age was 32, mode was 22, and range was 21-53 years. School Two’s mean
age was 29, mode was 24, and range was 19-47. School Three’s mean age was 31,
mode 26, and range was 21-54 years. The overall sample age mean was 30, median
was 27, and mode was 22 with a standard deviation of 8.4 and spread of 35 years
between range ages of 19 and 54 years.
The majority of study participants was single, never married (n = 68, 54
percent). Ten (8.1 percent) were single-separated or divorced. Forty (32.3 percent)
were married for the first time, and six (4.8 percent) were married more than once.
Sixty-two percent of the students reported having no children with the remaining thirty
eight percent reporting one or more. The sample’s present family annual income
reported 44 percent at $20,000 or less, 14 percent at $20,001 to $30,000, 11 percent at
$30,001 to $40,000, 9 percent at $40,001 to $60,000, and 22 percent at $60,001 or
larger annual income.
The majority (86.3 percent) of students (n - 107) selected their birth mothers
as the maternal figure with whom children lived with, and this maternal figure was
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140
used as the reference in the present study 91.9 percent (n = 114) of the time. The
paternal figure was the birth father with whom they lived as children in 79.8 percent
(n = 99) cases. Most respondents (83.9 percent, n = 104) used this paternal figure
source in answering the sample questionnaire. Students who reported seeing or
talking daily or weekly with their maternal figure was 77 percent (n = 96), and with
the paternal figure included 58.9 percent (n = 73). Six percent of the maternal figures
and 12.9 percent of the paternal figures were no longer living.
Ethnic heritage and religious affiliation statistics were obtained. Asian
Americans represented 23.4 percent (n = 29), Caucasians 57.3 percent (n = 71),
Hispanic 15.3 percent (n = 19), Middle Eastern 2.4 percent (n = 3), South American .8
percent (n = 1), and Filipino .8 percent (n = 1). The majority of the sample (34.7
percent, n = 43) were Catholic, 19.4 percent (n = 240) were Protestant, 14.5 percent
(n = 18) were other Christian, 18.5 percent (n = 23) had no religious affiliation, 4.8
percent (n = 6) were Buddhist, 1.6 percent (n = 2) were Muslim, and 6.5 percent
(n = 8) reported as being spiritual, belonging to a non-traditional, non-Christian or
unusual religious affiliation. Religion was not important to 15.3 percent (n = 19), of
minimal importance 12.1 percent (n = 15), somewhat important to 23.4 percent
(n = 29), and 48.4 percent (n = 60) reported religion as very important.
Several demographics including career choice, degrees and non-degrees
provided additional data. Nursing was a first career choice of 73.4 percent (n = 91) of
the respondents. Nursing was a second career choice of 24.2 percent (n = 30), and
third choice of 2.4 percent (n = 3). Many students obtained previous college degrees
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141
before nursing school admission. A Bachelor of Science (BS) degree was reported by
ten, Bachelor of Arts (BA) degree by twelve, Associate in Science (AS) degree by
one, and Associate in Arts (AA) degree by thirty. A total of 53 degrees were held
before entering the nursing program. Besides degrees some students had other non
degree accomplishments. These non-degrees included pharmacy technician,
emergency medical technician, medical assistant and massage therapist.
Nursing-related experience, National Student Nursing Association (NSNA)
membership, and nursing peer or study group added demographics used to calculate
data. Less than half of the student population (40.3 percent, n = 50) reported less than
six months of nursing-related experience. 10.5 percent (n = 13) reported greater than
six months to one year, and 6.5 percent (n = 8) reported greater than one year. Less
than one half of the students reported two to five years or more of nursing-related
experience (40.4 percent, n = 50). The majority of students reported working with
several instructors since the semester had begun. This was a reasonable response
since students from each school received faculty team instruction.
A small number of students reported membership in NSNA (n = 21), and only
one student reported membership in Phi Beta Kappa. Regarding studying with a
nursing peer for study group, 38.7 percent (n = 48) reported a weekly routine of
meeting. Only 21.8 percent (n = 27) met before an exam, 30.6 percent (n = 38) did not
use a study person or group and 4.8 percent (n = 6) met only to split up theory
objectives for answering and dispensing information. The remaining 4 percent was
insignificant (i.e. rarely met) or responses were missing (n = 5).
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The final outcome of the semester yielded a letter grade and pass/fail data.
Less than one quarter of the students (21.8 percent, n = 27) received an A, 43.5
percent (n = 54) received a B, 17.7 percent (n = 22) received a C, 8.1 percent (n = 10)
received a D, 3.2 percent (n = 4) received an F, and 5.6 percent (n = 7) withdrew.
Overall, 16.9 percent (n = 21) did not complete the semester satisfactorily. The final
count showed 83.1 percent (n = 103) passing, 11.3 percent (n = 14) failing, and 5.6
percent (n = 7) who withdrew by the semester's drop date. The total number of
students who either failed or withdrew from the semester was 16.9 percent (n = 21).
Hypotheses Statistical Results
Hypothesis # 1
The first hypothesis stipulated that first semester nursing students who
experienced affectionate and warm care from their mothers (maternal figure) in early
life would show a greater caring ability than those who experienced detached and cold
care from their mothers (maternal figure) in early life. The histograms and
scattergrams of maternal care and caring ability variables were heteroscedastic.
However, the results focused on the higher end of the scales when graphed. The
relationship between the two variables was significant using the Pearson product-
moment correlation (r = .254, p = .004) for 124 subjects. In order to test the high/low
maternal care hypothesis, a score 26 and below was established as the lower end , and
a score 27 and above was the upper end of maternal care scores. Both Parker (1983)
and Simmons (1994) used the same cut-off mean of 27 in their studies. Even though
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Simmons obtained an original mean of 28, it was comparable to Parker’s. The scores
for the maternal care had a potential range of 0 to 36. Parker explained the scores as
follows: scores below 27 reflected “emotional coldness, indifference, and rejection”
(Parker pp. 95-96), and scores 27 and above revealed maternal care characterized by
“affection, emotional warmth, empathy, and closeness” (Parker, p. 95). The mean
established in the current study was 26, so it was reasonable to apply the same cut-off
point as Parker’s 27 cut-off point to establish theory-based support.
From this detail, data were divided into two groups for analysis. The low
maternal care group of 53 (score less than or equal to 26) displayed a mildly positive,
nonsignificant correlation with caring ability (r = .239, p = .085). The high maternal
care group of 71 (score greater than or equal to 27) showed a mildly positive,
nonsignificant correlation with caring ability (r = .21, p = .084). The direction and
degree of these high/low correlations was almost the same. The results indicated that
the hypothesis was not supported. There was no difference between high and low
maternal caring score groups and caring ability.
Additionally, a linear regression analysis yielded an observable curve view of
maternal care and caring ability relationship (Figure 1). Although heteroscedasticity
existed among the scores, the line-of-best-fit was seen as linear, but weak. Regression
analysis results indicated a linear correlation coefficient o f R2 = .065, p = .004 and
quadratic Rz = .068, p = .014. Overall, higher caring ability scores were associated
with higher maternal scores. Few exceptions were observed. Exceptions were
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students who reported maternal care scores in the lower range, but reflected higher
caring scores than hypothesized.
Figure 1
Curvilinear Relationship of Maternal Care ('MCI with Caring Ability (CA)
D O b s e r v e d
n L in e a r
° Q u a d ra tic
-10 0 10 20 30 40
Maternal Care
Hypothesis # 2
The second hypothesis stipulated that first semester nursing students who
experienced affectionate and warm care from their fathers (paternal figure) in early
life would show a greater caring ability than those who experienced detached and cold
care from their fathers (paternal figure) in early life. The histograms and scattergrams
of paternal care and caring ability variables were heteroscedastic. The results of the
zou
>> 200
O 160
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variables displayed in a scattergram showed a higher concentration of scores moving
towards the middle to upper end. There was no relationship between these variables.
A Pearson product-moment correlation coefficient confirmed this result for 122 (r =
.04, p = .66). In order to test the high/low paternal care hypothesis, a score below 24
was established as the lower end, and a score of 25 and above was the upper end of
paternal scores. The scores for paternal care had a range of 0 to 36. Both Parker
(1983) and Simmons (1994) maintained the same cut-off points. Again, it was
considered that scores below 24 reflected “emotional coldness, indifference, and
rejection,” and scores above 24 revealed “affection, emotional warmth, empathy and
closeness” (Parker, p. 95-96). Also, the mean established in the current study was 24,
the exact mean established by Parker’s (1983) study and used by Simmons (1994). It
was reasonable to apply the same cut-off point in the current study.
From this point the data was divided into two groups for analysis. The low
paternal care group of 54 (score less than or equal to 23) displayed a slightly positive,
non-significant correlation with caring ability (r = .016, p = .906). The high paternal
care group of 68 (score greater than or equal to 24) showed a slightly positive, non
significant correlation with caring ability (r = .167, p = .175). The direction and
degree of these high/low correlations were similar. The results indicated that the
hypothesis was not supported. There was no difference between high/low paternal
care score groups and caring ability.
Regression analysis provided further information regarding the above
hypothesis. The scores were scattered from 0 to 36, revealing heteroscedasticity. The
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146
line-of-best-fit between the variables was nearly a straight line (Figure 2). Regression
analysis results indicated a non-significant correlation coefficient of R2 = .002, p =
.659, and a non-significant quadratic relationship of R2 = .011, p = . 504. Overall,
there was no relationship between paternal care scores and caring ability, and all
scores (plus outliers) were included in the equations and results.
Figure 2
Curvilinear Relationship of Paternal Care (PC) with Caring Ability (CA)
260
240 ■
220
200 ■
- t — »
.Q
« 180-
c
CD
O 160'
140'
D O b s e r v e d
1 2 0 -
° L in e a r
100 D Q u a d ra tic
0 10 20 30 40
Paternal Care
Hypothesis #3
The third hypothesis stipulated that first semester nursing students who are
educated in a nursing school climate perceived as cooperative, caring, and supportive
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will have greater caring ability than nursing students who are educated in a nursing
school climate perceived as non-cooperative, uncaring, and non-supportive. The
scattergram of school climate and caring ability was heteroscedastic and revealed no
obvious relationship. Scores were not at the low end of the scale. The relationship
between the two variables was significant using Pearson product-moment correlation
for 123 (r = .252, p = .005). In order to test the high/low hypothesis in perception of
nursing school climate, a score of less than or equal to 48 was used as the moderate-
lower end of scores, and a score of greater than or equal to 49 was established as the
higher end of scores. This cut-off point was previously used by Simmons (1994) and
it followed the same rationale established by Parker (1983) for maternal and paternal
care. This practice was reasonable based on previous research. The scores for school
climate had a potential range of 4 to 64. The mean established in the current study
was 55 for 123 subjects. Although the school mean was higher than Simmons (1994)
study, it is reasonable to assume that it would be higher because of the students limited
exposure to the nursing school environment. Even with this difference in mind, the
current research used Simmons (1994) cut-off point to lend theory-based support for
the analysis.
From this point data were divided into two groups for analysis. The moderate-
low nursing school climate group o f 24 (score less than or equal to 48) displayed a
mildly negative, non-significant correlation with caring ability (r = -.264, p = .213).
The high nursing school climate group of 99 (score greater than or equal to 49)
showed a mildly positive, significant correlation with caring ability (r = .297, p =
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148
.003). The direction and degree were in opposite fields with only one group showing a
significance. The results supported only one half of the hypothesis. Students who
experienced high caring in school had significantly higher caring ability, but students
perceiving moderate or low caring in their nursing school climate did not show a
significant relationship with caring ability.
Regression analysis was used to view the non-linear relationship of
scores. Heteroscedasticity existed among the plotted scores. A curved line was
the best fit between school climate and caring ability (Figure 3). Higher caring ability
scores seemed to be associated with higher school climate scores, but score outliers
existed, changing the line’s appearance. School climate scores were dipped around
the mean and higher in caring ability scores. Regression analysis results indicated a
linear correlation coefficient of R2 = .064, p = .005, and quadratic R2 = .126, p = .000).
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Figure 3
Curvilinear Relationship of School Climate (SCI with Caring Ability (CA1
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120
100
30 40 50 60 70
School Climate
Hypothesis # 4
The fourth hypothesis stipulated that maternal care would account for more
variance in freshmen caring ability than paternal care or school climate. A stepwise
regression analysis was performed with caring ability as the dependent (criterion)
variable and maternal care, paternal, and school climate care as the independent
(predictor) variables. Regression analysis excluded paternal care from the equation as
non-significant. Therefore, the other variables were entered into the prediction
equation.
° O b s e r v e d
D L in e a r
D Q u a d ra tic
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150
School climate explained 7.2 percent of the variance in caring ability, and
maternal care score explained an additional 5.4 percent of the variance in caring
ability. The regression equation obtained in the analysis was Y1 = 155.50 + .70 (SC) +
.49 (MC). Using these two predictors, 12.6 percent of the variance in caring ability
was accounted for. The hypothesis was not supported. Nursing school climate
accounted for more explanation of variance than maternal care and paternal care.
Paternal care provided no explanation in variance.
Hypothesis # 5
The fifth hypothesis stated that first semester nursing students who pass the
first semester of nursing (independent variable) will have a higher caring ability
(dependent variable) than those who fail the first semester. An independent samples t-
test determined whether or not a difference in caring ability group means existed
among the pass and fail groups. The mean for the pass group (n = 103) was 206.3
with a standard deviation of 18.2, and the fail group (n = 14) mean was 210.3 with a
standard deviation of 17.2. The result of the t-test was not significant (t = -.799, p =
.438, df = 115). There was no difference in caring ability means among pass and fail
groups.
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Associations Between Caring Ability and Demographic Variables
Statistics generated data between caring ability and various demographic
variables. It is noted that even though some groupings (i.e. male gender) contained
low numbers, data analysis was still possible. Further, in referencing age groupings,
the sample population was predominantly between the modes of 21 to 26 years (39.6
percent), and slightly over one half of the participants were less than or equal to 27
years of age (50.8 percent). The overall range of ages was 19 to 54 years with a mean
age of 30. Table 3 presents results of further statistical analyses.
Table 3
Associations Between Caring Ability and Demographic Variables
VARIABLE n Mean sd t Value p Value df
Gender
- Female 110 207.0 18.8
- Male 14 201.0 13.7
- RESULT 1.23 0.220 122
Age (Using approximately 50% in each age groupings as cut-off)
- Less than or equal to 26 57 211.0 15.8
- Greater than or equal to 27 65 203.0 19.9
- RESULT 2.44 0.016 120
Age (Using Simmons (1994) ages as cut-off tor age groupings)
- Less than or equal to 24 41 213.0 13.4
- Greater than or equal to 25 81 204.0 20.0
- RESULT 2.5 0.013 120
National Student Nurses Association
- Member 44 205.0 21.9
- Not a member 79 207.0 16.4
- RESULT -0.544 0.590 121
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Table 3 cort
Associations Between Caring Ability and DemograpNc Variables
VARIABLE n IV fe a n sd t \£lue p \£lue df
IVbrital Status Group 1
- Single 68 206.0 19.8
- Single/Seperated/Divoroed 10 207.0 13.2
- Mhrried for first time 40 206.0 18.4
- IVhrried more than once 6 214.0 8.6
IV brital Status Group 2
-Mbnied for first time 40 206.5 18.4
-^ l others 84 206.7 18.6
-RESULT 0.061 0.952 122
Number of Children
-None 77 208.2 16.8
- One or more 47 204.1 20.8
- RESULT -1.21 0.229 122
Present Income
- Less than or equal to $40,000 85 204.5 19.7
- Greater than $40,000 38 211.1 14.7
-RESULT -1.86 0.650 121
- Less than or equal to $60,000 96 204.7 19.2
- Greater than $60,000 27 213.0 14.2
-RESULT -2.07 0.040 121
Maternal Communication
-Never 2 220.0 5.7
-Daily 61 209.0 20.4
- Once V\feekly 35 204.0 13.7
- IVbnthly 1 1 203.0 20.4
- 2 to 3 times per month/yearly 8 194.0 22.0
- Internal figure deceased 7 212.0 7.7
Paternal Communication
-Never 8 204.0 13.8
-Daily 43 209.0 20.4
- Once V\feekly 30 209.0 14.6
- IVbnthly 17 205.0 21.4
- 2 to 3 times per month/yearly 8 203.0 10.2
- Paternal figure deceased 16 203.0 20.4
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Table 3 cont.
Associations Between Caring Ability and Demographic Variables
VARIABLE n Mean sd t Value p Value df
Ethnic Heritage
-Asian-American 29 201.0 14.1
- Caucasian 71 209.0 20.8
- Hispanic 19 208.0 15.4
- Middle Eastern 3 204.0 13.3
- South American 1 199.0 NA
- Filipino 1 218.0 NA
Religious Affiliation
- Protestant 24 207.0 15.5
- Catholic 43 209.0 14.9
- No religious affiliation 23 210.0 22.2
- Christian 18 207.0 16.6
- Buddhist 6 196.0 14.4
- Muslim 2 209.0 11.3
- Others not listed 8 191.0 31.9
Religion Importance
- Limited importance (not at all, minimal, 63 207.0 21.4
somewhat)
-Very important 60 207.0 14.2
- RESULT -0.242 0.810 121
Career Choice
- First career choice 91 208.0 15.8
- Other than first career choice 33 203.6 24.4
- RESULT 1.11 0.270 122
Nursing-Related Experience
- Less than 6 months to 5 years 95 207.0 18.8
- Greater than 5 years 26 205.0 17.7
- RESULT 0.427 0.670 119
- Less than 6 months to 1 year 63 207.2 17.9
- Greater than 1 year 58 205.0 19.4
- RESULT 0.529 0.598 119
Study Group
- Met rarely/minimally or not at all 73 202.4 21.2
- Met weekly with peer or with study 48 213.1 11.2
group
-RESULT 3.19 0.002 119
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154
Associations Between School Climate and Demographic Variables
Several demographic variables (independent variables) were tested separately
in an independent samples t-test with school climate (dependent variable). One case
was noted that insignificant numbers prevented inferential analysis (i.e. semester
grade). Table 4 presents the results of further statistical analysis.
Table 4
Associations Between School Climate and Demographic Variables
VARIABLE n M ean sd fVhlue pV alue df
Ages
- Less than or equal to 26 57 55.3 6.8
- Greater than or equal to 27 64 54.7 6.6
- RESULT 0.491 0.625 119
- Less than or equal to 24 41 55.7 6.5
- Greater than or equal to 25 80 54.6 6.7
- RESULT 0.835 0.405 119
Income
- Less than or equal to $40,000 84 54.2 6.9
- Greater than or equal to $40,001 38 65.3 6.4
- RESULT -1.662 0.009 120
- Less than or equal to $60,000 95 54.2 7.0
- Greater than or equal to $60,001 27 57.1 5.5
- RESULT -2.03 0.044 120
Seeing or talking with maternal figure
- Dailyweekly 95 55.0 7.0
- All other respondents 28 54.4 5.9
-RESULT 0.434 0.670 121
Seeing or talking with paternal figure
- Dail^weekly 73 54.3 7.3
- All other respondents 49 55.6 5.9
-RESULT -1.05 0.297 120
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Table 4 cont.
Associations Between School Climate and Demographic Variables
VARIABLE n M ean sd t \felue p \felue df
Nursing career choice
- Nursing as a first career choice 90 55.9 6 .1
- All other respondents 33 52.0 7.7
- RESULT 2.95 0.004 121
Nursing-related experience
- Less than or equal to 1 yr. experience 62 54.2 7 .1
-Greater than 1 yr. experience 58 55.7 6 .1
- RESULT -1.21 0.230 118
Nursing peer/group study
- Weekly 47 56.1 6.0
- All other respondents 73 54.4 6.9
- RESULT 1.41 0.160 118
Semester Grade
-F 4 53.5 6.6
-D 10 50.3 6.9
-C 22 54.0 7.4
-B 53 54.9 6.3
-A 27 58.0 5.9
Semester Pass/Fail
- Pass (A 's, B's, C's) 102 55.5 6.6
-Fail (D’s&Fs) 14 51.2 6.7
- RESULT 2.28 0.024 114
Ethnic Heritage
- Asian-American 29 52.6 6.2
- Caucasian 70 56.0 6.5
- Hispanic 19 53.0 7 .1
- Mddle Eastern 3 60.0 4
- South American 1 58.0 NA
- Filipino 1 40.0 NA
Career Choice
- First career choice 90 55.9 6 .1
- Other than first career choice 33 51.9 7.7
- RESULT 2.90 0.004 121
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Further Findings
Maternal Care, Paternal Care, School Climate and Caring Ability
Additional testing was performed to determine if first semester nursing
students who had a perception of high maternal care and high school climate would
have a greater caring ability score than those first semester nursing students who
experienced a perception of high maternal care, but only moderate or low perception
of school climate. Using the Parker (1983) and Simmons (1994) cut-off points, a
maternal score of 27 was considered a high maternal care score, and Simmons (1994)
used less than or equal to 48 as a moderate or low school climate score. These same
cut-off points were used in the current study to establish a theory-based decision for
action.
The groupings were established as follows:
Group 1 MC > 27
(n = 59) SC >49
Group 2 MC > 27
(n= 12) SC <48
The mean caring ability for Group 1 was 210.2, standard deviation 15.7, and Group 2
was 204.3, standard deviation 12.9. There was no significant difference between the
means of the two groups (t = 1.23, p = .225, df = 69).
The data were re-constructed to perform another t-test to determine if first
semester nursing students who perceived moderate or low maternal care and high
school climate would have a greater caring ability than those first semester nursing
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157
students who perceived moderate or low maternal care with moderate or low school
climate. The groupings were established as follows:
Group 1 MC < 26
(n = 40) SC >49
Group 2 MC < 26
(n = 12) SC <48
The mean caring ability for Group 1 was 205.3, standard deviation 18.5, and Group 2
was 195.6, standard deviation 30.19 respectively. There was no significant difference
between the means of the two groups (t = 1.37, p = .177, df = 50).
Next, using a t-test, paternal care and school climate were linked to caring
ability. The test determined whether or not first semester nursing students who held a
perception of high paternal care and high school climate would differ in their caring
ability from those with high paternal care, but moderate or low school climate. The
Parker (1983) and the Simmons (1994) paternal care cut-off point score of greater than
or equal to 24 was used in the testing for high paternal care score and Simmons (1994)
school climate cut-off score of greater than or equal to 49 was again used as a high
score. The groupings were as follows:
Group 1 PC >24
/— \
3
tl
U \
i j \
w -1
SC >49
Group 2 PC >24
(n=12) SC <48
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The mean caring ability score for Group 1 was 208.8, standard deviation 17.6, and
Group 2 was 195.9, standard deviation 28.8 respectively. There was a significant
difference between the means of the two groups (t = 2.02, p = .047, df = 65).
Group 1 had a higher caring ability mean than Group 2.
The data were re-configured to perform another t-test to determine whether or
not first semester nursing students who encountered moderate or low paternal care and
high school climate would differ in caring ability from first semester nursing students
who encountered moderate or low paternal care and moderate or low school climate.
The groupings were as follows:
Group 1 PC <23
(n = 44) SC > 49
Group 2 PC <23
(n = 10) SC <48
The means for the groupings were 207.55, standard deviation 16.3, and 202.9,
standard deviation 17.3 respectively. There was no significant difference between the
means of the two groups (t = .806, p = .42, df = 52).
Summary o f Key Findings from Quantitative Data Analysis
After data analysis 2 of the 5 hypotheses provided either definitive or partially
significant results. Hypothesis # 1 was significant for a relationship between maternal
care and caring ability, but it was not supported for a relationship difference between
high and low maternal care and caring ability. Hypothesis # 2 was not significant for a
relationship between paternal care and caring ability therefore, it was not supported for
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a relationship difference between high and low paternal care and caring ability.
Hypothesis # 3 was significant for a relationship between school climate and caring
ability, and the hypothesis was supported for high school climate perception and
caring ability. Hypothesis # 4 was not supported, and it did not confirm that maternal
care would explain more variance in caring ability. Instead school climate was the
leading factor to explain variance. Only a small amount of the variance was
explained by school climate and maternal care in caring ability (12.6 percent).
Hypothesis # 5 was not supported, and no difference was found in caring ability
between the pass and fail student groups.
Several demographic analyses were found to be significant. The following is a
summary of significant findings:
• a difference was noted between younger (less than or equal to 26) and older
(greater than or equal to 27) age student
groups with the younger group reporting higher caring ability
• perception of caring ability was found to be significantly higher in the income
group greater than or equal to $60,001
• students who passed the semester had a significantly higher perception of
school climate than the group that failed
• perception o f school climate was found to be significantly higher in the income
group greater than or equal to $60,001
• first career choice students had a significantly higher perception of school
climate than any other grouping
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• students with an A grade had a significantly higher perception of school
climate than students who received a grade of D
• student heritage groups perceived school climate differently (no Post hoc tests
were performed because of the small number of group participants)
• a paternal care score greater than or equal to 24 and school climate score
greater than or equal to 49 grouping had a significantly higher score in caring
ability than a paternal score greater than or equal to 24 and school climate of
greater than or equal to 48.
All other findings with the groupings of maternal care, paternal care and school
climate were not significant.
Qualitative Inquiry Data
Overview
Review of the qualitative data includes reliability and validity determination
procedures used in the inquiry process, and follows with descriptive statistics of the
interview participants. Each of the qualitative questions is reported with
accompanying tables and interpretative discussion. Unique characteristics of the data
are included in the discussion text of each section as well as in the Additional
Findings. Finally, a summary o f the key findings is included at the end of
Chapter IV.
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Data Reliability and Validity
Both intracoder and intercoder methods were used to ensure stability or
conformity of the coding decisions. Intracoder methods were used first by the
researcher. After all interviews and verbatim transcribing were completed, coding of
information began. Categories and subcategories were created. After all coding was
completed, a 25 percent random sample was again reviewed from transcribed
respondent data sheets, and all coding categories were re-verified. This procedure
resulted in nearly a 100 percent agreement of coding responses.
Second, intercoder reliability was verified using Cohen’s Kappa analysis. A
25 percent random sample of respondents’ transcripts was reviewed by two expert
nurse educators independently. Both educators held expertise in communication
techniques and interpretation, and one of the educators had previous research
experience. Each educator reviewed the same transcript sample with category and
subcategory data sheets. The sample was presented un-marked to the reviewers to
allow for un-biased review. To encourage consistency of reviewing all sections, the
transcripts were lined and numbered so each reviewer responded to the same sections
of the transcript consistently. This process aided in setting up the Cohen’s Kappa for
later analysis. In addition, the reviewers were encouraged to note questions, coding
concerns, inconsistencies, and omissions on the transcription sheets. The coding data
from the two expert nurse educators yielded a Cohen’s Kappa of K = .95. Thus, the
data were verified as reliable.
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162
The credibility of the qualitative data was inferred. Respondents were
assumed to provide truthful information to the researcher. The respondents were
assured that no consequences would follow as a result of the interview and their
responses prior to the interview process. All respondents were contacted by phone to
verify a summary of their transcription response and pertinent coding categories. All
agreed that the responses were a faithful description of their interview.
Respondent Descriptives
Twelve students were interviewed. This was approximately a 10 percent
sample (n = 12) who agreed to participate in the interview from a possible N = 123.
One student refused to participate in the random interview process. School one
provided four interviewees, school two provided five interviewees, and school three
provided three interviewees. Two of the students interviewed were males.
Ethnicity, student age, and pass/fail rate furnished varied information.
50 percent were Caucasian and the rest were Hispanic, Asian-American, or Filipino.
The students’ ages ranged from 19 to 46 with a mean age of 28. The final pass/fail
rate included 10 passing (83 percent) and 2 (16.6 percent) not passing or withdrawing.
These results were similar to the quantitative data pass/fail rate of 83.1 percent and
16.9 percent failing/withdrawing respectively.
Although the interview sample size was small (n = 12), a saturation point was
reached with this number. A saturation point conveys that no new information was
obtained from the respondents (Nieswiadomy, 2002). Data collection ceased after
noting this observation in the current study.
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Several factors became apparent after the random sample of interviewees was
selected. It was originally proposed by the researcher that a varied sample with
gender, ages, high/low caring ability scores, and ethnicity would make up the random
sample. The results indicated that such a proposal had randomly taken place. The
type of sampling proved to be even more beneficial than was originally expected.
Gall, Borg and Gall (1996) were used as a resource to identify the types of sampling
procured in the current study. The sample contained the extreme of possible grading
(A through F and withdrawals); the intensity remained a first semester nursing student
focus; typical cases were extracted from the first semester interviewees; a stratified
sample included segments from final grades, high/low caring ability categories, single
married, and various age groups; the criterion sample focus obtained information from
first semester nursing students who were not yet set in the ways of professional
nursing; theory-based sample used interview questions on caring as gleaned and
created from the literature; and the purposeful random sample was unbiased.
It became apparent that the interviewees expressed a strong desire to provide
detailed information in answering the questions proposed by the researcher. As each
interview progressed, the respondent became more at ease, and the flow of
information increased. The interviewees provided copious amounts of useable
information in the 45 to 60 minutes o f dialogue. Students seemed relaxed and felt
valued by the researcher in this process. This allowed for difficult and important
expressions of students opinions to be formulated and recorded. This part became a
meaningful component of the current research. The interviews took place in less than
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a two-week time frame within weeks after quantitative data collection was completed.
This added to the consistency of the researcher’s style in performing the interview.
Study Findings
Question # 1: How would you define caring?
Responses to Question # 1 provided definitions using physical, personal,
social, intellectual, and spiritual concerns. A strong emphasis was noted in meeting
someone’s needs in the caring process. The respondents recognized the importance of
interpreting what another person would want in receiving care. Personal individuality,
fairness, appreciating another, and non-reciprocity were key in their definition of
caring. Respondents defined caring from their own personal perspective. Technical
definitions of caring including nursing treatments, and using technical equipment did
not enter their cognitive equation in defining caring. A practical definition with
examples was most prominent in response to this interview question. Table 5 provides
a list of condensed words students associated in the caring definition. The central
constituents derived from these words were personal action, assessment, concern and
evaluation. Table 6 provides a list of constituents and percentages of use among the
respondents. The respondents’ definitions focused mostly on three aspects: personal
concern for another, assessment of the individual, and action.
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Table 5
Student Caring Definitions from Question # 1 ______________________________
Meeting their needs. It involves working with a disease or with difficulties they are
having. Needs may be different and depend on the individual.
Putting others before yourself, thinking what other people would want. Meeting
their needs.
Taking car of people, seeing how people feel and what they need.
The things I do to show that I love or appreciate someone.
Being financially supportive, being there for a person whenever a person has a
problem ... a caring person is someone who sincerely wants to help another
person. I would listen to what you would say. I wouldn't make you feel bad.
It would be similar to treating a patient... Caring shows emotion, how I express my
emotions to others ... accept others as equal to myself... treating them with kindness
gentleness, always being helpful. Treating others as you would want to be treated.
I come out with different answers every time ... The definition of caring would be being
able to provide for someone (broad spectrum) who is in need ... like a cancer patient.
You try to give them the best life possible up to the end ... You're trying to help them
out. Trying to care for the individual, the personal needs, the emotional needs, the
psychological needs, the religious needs, trying to fill all those aspects for them ...
Provide the utomost care for that individual.
Showing consideration for other people, going out of your way to help someone, just
showing kindness.
You see what he needs and then you go from that, not expecting anything back.
Providing like care without, you know, interrupting their personal boundaries ... Like do
unto yourself to others ... Genuineness ... make sure that it's truly caring and
not just a job ...
I guess it's about putting somebody else's needs ahead of your own.
It is using your heart and your mind together, using your feelings and your emotions
and your beliefs and love for this humanity and people. For nursing, often using
that as your skills and your knowledge and your knowledge base and actions ...
understanding individuals, humans and how they are not deciding and how you
would use them.
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Table 6
Caring Constituents and Percentages of Use
CONSTITUENT NUMBER OF STUDENTS PERCENTAGE
Assessment 6/12 50.0%
Action 7/12 58.3%
Concern 10/12 83.3%
Evaluation 2/12 16.7%
Question # 2: Now that you are a nursing student, how has your definition o f caring
changed?
Approximately one-third of the respondents (33 percent, n = 4) stated that their
definition of caring had not changed after becoming a first semester student. The
other respondents suggested several areas in which their definition of caring had
changed. The following is a list of some of the student responses:
• “I have to care in a professional way rather than an emotional way.”
• “[It] is in relation to what you [are] studying].. .you care for the person
... feelings ... its not just physiological ... [ You] ask ... assess... look... at the
whole picture .. .you see more.”
• “I am more cautious .. .wiser doing things.. .1 treat everybody the same
[Recognizing] culture and gender [differences].”
• “ [Learning tasks] like helping the patient bath... change... brush
teeth.. .listening to other’s problems.”
• “I think I am starting to look at people a lot more on all levels when they are
sick.. .focusing more on the nursing stuff instead of just the medical stuff. I
think I am gravitating more towards the emotional side of nursing.. .1 am
focusing on my diagnoses, emotional and behavioral things.”
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• “I have to look at them [patient] individually rather than imposing my opinion
or do things [that are not culturally accepted] therapeutic.”
• “Look[ing] at the whole person.. .family, their needs, their outside life.. .Its
more mental than physical...I like to communicate more, like to explain what’s
going on.”
The four respondents whose personal definition of caring had not changed
recognized several adjustments in thinking about additional areas of caring
development. Their responses included more knowledge about caring, the caring
environment (i.e. hospital), prioritizing care, learning about technical devices,
performing nursing skills, therapeutic communication development, and different
ways people care. The respondents reported an increase in knowledge and skill that
was immediately apparent.
Major areas were identified in respondents who changed in their view of
caring. The categories included: leaming/knowing/seeking/planning (L),
communicating (C), performing (P), personal recognizing/reviewing/growing (R), and
developing as a professional (D). Examples of student responses using the above key
are as follows:
L = “[You] glance at the person.. .look around [and] check vital signs.. .then you
talk to [him]so you know [his] level of consciousness... you see more.”
C = “Learning how to listen to people.. .having them express their feelings. Caring
covers a lot of things, making a client comfortable, and having them build a
trusting relationship with [you] so you can provide comfort for them .. .that’s
what therapeutic communication does, it opens up different areas.. .so you can
provide better care.”
P = “Just doing things for them they can’t do for themselves. Daily care, ADLs
(activities of daily living).. .providing privacy and respecting what they want.”
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R = “Ever since I was little I’ve always.. .wanted to help people. I’ve always
wanted to fix everything and everybody.. .1 am able to see the implications of
emotional stuff.. .the medical stuff.. .how they are combined.. .1 am not looking
at the two separately.”
D = “You have responsibility. [As a nurse] you need to know everything, how to
do good work.”
Table 7 provides a constituent list of the changes or additions in the students’
definitions of caring. It is noted that although some of the responses could be
considered in another category, the context of the dialogue was considered. This
action provided an accurate placement of the change into categories and subcategories.
Also, it became evident that the students’ definitions of caring seemed to become a list
of newly studied material from the semester, self-evaluation, and self-professional
discovery.
Table 7
Constituent List of Changes or Additions Noted From Question # 2
C A RING
PE R SO N A L PR O F E S S IO N A L
A S S E S S M E N T COM M UNICATION N U RSIN G SKILLS IN S IG H T /R E V IE W D EV ELO PM EN T
Information seeking Verbal / non-verbal T asks Personal definition Professional way
A ssessm ent Trust Interventions of caring expanded Follow recom m endations
(Physical) Listen M anage, Monitor, Teach Actions / thoughts More responsibility
Individualism Check personal em otions Equipment Better care Comfort to
W hole (holistic) Expression Commitment Nursing P rocess implication
Emotions Privacy Confidence Routines
Prioritize R espect Comfort self Check-lists
Levels Tim e constraints C orrectness
Focused S am e technique - Nursing Diagnosis
Culture specifics different abilities Cautious (Safety)
G ender specifics Family vs. Hospital caring
R an Disease implications
Goal Knowledge
Knowledge / Theory Rules
Policies
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Question # 3: What events, relationships or other situations contributed to the
development o f your caring ability?
The respondents reported 18 events, relationships or other situation that
contributed to their development of caring. Table 8 presents the constituents.
Seventy-five percent of the respondents (n = 9) mentioned parents as the main persons
who assisted in their caring development. The other 3 respondents reported an
uncaring or negative parental relationship that did not promote an atmosphere for
learning about caring virtues. Thirty-three percent (n = 4) mentioned grandparents or
being a family member encouraged caring development. Seven respondents reported
an accident or illness of a parent, grandparent or self. These events brought out new
insights in the development of a caring personal nature or practice. Two respondents
reported that religious belief, healthcare employment, and natural instinct provided
development of caring ability. There was only one mention in all the other categories
that aided in the respondent’s development of caring ability. An example of some of
the student responses were as follows:
• “Now I think looking at.. .parents, how loving they are, how they care
about other people, I think that influences you a lot. My dad passed away
with.. .cancer, my mom took care of him. My mom took care of him
well.. .1 don’t exactly know what made me care about other people, but I
think all that influences me.”
• “Well from growing up I noticed caring from my parents, from my elders,
like my grandmother, my grandfathers, family members. I learned how to
care from my religious ways.. .Like I followed [in] my mother’s steps as
well.”
• “I think definitely my parents [had] a big, huge impact. The way they
treated me and the way I saw them treat others is how I am [now].. .My dad
was in a car accident.. .and just the way my mom was towards my
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dad.. .doing everything.. .to see her do that like it was nothing.. .it was a
normal thing. She never complained, she always did it whole
heartedly. . .My grandmother is so patient.. .and so giving. Giving so much
of [herself].. .not really expecting anything in return.”
• “.. .family is important. Family.. .instilled good values in me. My mom
and dad are a big part.. .So [is my] relationship with God, the church.. .1
think it is just a natural thing. I don’t know [if it is] something you can
learn. It is kind of instinctual I think.”
• “I’ve been a patient.. .I’ve seen the good and the bad. It may be
something... with me wanting to become a nurse, and provide care for
somebody else. I have a good relationship.. .with my family...showing
care for me...[the] doctors, [and] all [the] healthcare professional [s too].”
• “My grandmother...she was very caring...she was a good person...she
helped a lot in her town.. .she was very involved in the community.. .she
was a good listener and I think that made me the way I see caring.”
Table 8
Constituent List of Events, Relationships or Situations Noted From Question # 3
Parent(s) Mom, Dad
Parent(s) accident / illness
Brother(s), Sister(s)
Family
Grandparent(s)
Grandparent(s) illness
Healthcare employment
Religious belief(s)
Community involvement
Current event(s)
Previous event(s)
Natural/instinctual
Self (accident / illness)
Student nurse experience(s)
Teacher(s)
Other healthcare worker(s)
Motherhood
Fatherhood
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Question # 4: As a student nurse, describe a situation in which you were able to
practice your caring ability?
The respondents to Question # 4 provided information to create four situation
categories. The categories included: gaining information in order to care,
intercommunicating in the process of caring, providing actual physical care, and
personal transforming as a result of the caring encounter. Table 9 contains a list of
situation constituents, and the percentage of recognition by the respondents. The most
prominent responses were intercommunicating, providing physical care and
transforming of the students in greater than or equal to 75 percent of the respondents.
Respondents with just weeks of nursing education furnished stories to complete this
constituent category. The following are examples of the subcategory of situation
constituents:
Category Data Example
Gaining information “You learn skills.. .doing assessments and that is what
we are practicing now. We learn [at] school and then
we actually go out and do it.”
Intercommunicating “.. .therapeutic communication.. .1 asked her if she was
O.K... she lost it [I sat with her]... I haven’t had that kind
of interaction with any client yet so far.. .it felt good to
be useful. Just that some of his hard work is paying
off.. .she gave me feedback later that it helped her.. .1
really didn’t do a lot. It was mostly about listening.
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Providing care
Transforming
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There was a lot of paraphrasing.”
“I do what I think I can for her .. .she likes that. [The
lady says that she has] been here for five days now [and
that she has] not had a bath.. .then I gave her a comfort
bath.”
“.. .1 felt th a t.. .just giving her attention... [showed] that
I care about her needs.. .1 just felt good. I remember
even.. .1 took her to be discharged downstairs. There
was a taxi cab coming to pick her up. I just remember
as she [was] getting into the taxi, she kept thanking me
the whole time. ‘You really made a difference.’ It made
me feel good to know that I did something to make her
feel a little bit better.”
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Table 9
List of Constituents & Percentage of Use Noted From Question # 4
CARING CARING CARING PHYSICAL CARING
FOUNDATION (25%) INTERCOMMUNICATION (91.6%) EXPRESSION (75%) TRANSFORMATION (83.3%)
A s s e s s in g R e s p o n d in g H elping C h a n g in g (self)
K now ing C o n n ec tin g D oing C o m p e ta n c e
Prioritizing T ru stin g Dgiving E n c o u ra g in g
R eco g n izin g F eelin g Intervening P o sitiv e feelin g
R eg a rd in g A dv o catin g E m otional c o n g ru e n c e
U n d e rstan d in g T rea tin g R ew ard in g
A tten d in g E xplaining Envolving (grow ing)
T im ing C o u ra g e
P r e s e n c e (b ein g ) C o n s c ie n c e
C o n ce rn in g
Limiting
S e lf-ev a lu a tin g
M oral / e th ic al g ro u n d in g
P o sitiv e p a tie n t o u tc o m e
C o m fo rtin g to p a tie n t
C h a n g e a g e n t
Other data were obtained from Question # 4. The respondents viewed 50
percent of the situation stories as a negative encounter. The negative impact players
were registered nurses (RNs), and certified nurse assistants (CNAs) in responses to the
students or nursing actions seen by the respondents. The respondents perceived these
scenarios as contrary to what they expected a caring nurse to be. One student shared
the following story of a negative encounter. While the student was in a convalescent
facility taking care of an elderly woman, the student encountered CNAs being less
than kind in feeding a woman. When the student later took over care of the same
woman, the woman at first seemed mean, and shouted for the student to get away from
her. The woman negatively stated, “You are just like everyone else.” Over time the
woman recognized that the student was providing good care by taking additional time,
and helping her out immensely. The student evaluated his/her performance as
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174
providing good care. But the student believed that after they left the facility the
quality of care would go back to the way it was. It would “deteriorate again.” The
student’s final response to this story was “it is terrible.”
The same student also provided a scenario using a RN. The student felt
unheard when a patient wound care problem was brought to the attention of the
assigned RN. The RN responded in a terse voice that she would “get to it when I get
to it.” Much later the student assessed the patient and the same problem existed. The
student was disappointed that the patient was not addressed in a timely manner-
meaning not at all. These two stories were frustrating for the student. In summarizing
the experiences, the student commented if I have to be [confined for care]... “I’m
making a will.. .if I have to go to a convalescent home.. .1 don’t want to go there.”
Over one-half of the respondent situations took place in a skilled nursing
facility (SNF) or convalescent hospital. Only one situation was a positive experience
for a student in these environments. This situation has no reference to care provided
by a RN or CNA, but the care provided only by the student.
A natural transition to Question # 4 was to ask if the respondents in their
educational or clinical sites found a nursing role model whom they could emulate.
None of the students reported seeing or working with a role model RN in the SNF or
convalescent settings. Eight of the respondents reported noting a role model RN in a
clinical hospital site. Two of these reported cases were the students’ instructors. Four
respondents reported observing no role model, and one provided no response. Two
examples of positive role modeling included the following:
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Example 1
“Oh yes, I’ve seen an RN at.. .hospital.. .1 just met her a couple weeks
ago, and I was following her and asking her questions. She always had
time for the patients. She did everything and before the patient needed
it.. .She communicated with me so clearly, so patiently, compared to
other RNs which I felt uncomfortable [with]. She made sure I
understood clearly [while] others just give you information.. .She
anticipated people’s needs. She is so joyful, and she talks to everybody
and you feel like so much happiness is coming from her. She loves
doing her job.”
Example 2
“Yeah, I have one. Well, she is a RN. She is real good for the patients.
She always.. .her tone of voice is always pleasant. She always asks
them how their day is and [she] just seems to be real attentive to their
needs. She’s also real good with the students. She is ready to help us.
I thought that was great ‘cause a lot of them don’t seem to want us
there... She will just call us.. .to come watch... So you are really
included in things.”
The respondents provided no examples of CNAs giving positive care. However, an
example of a teacher being a good role model is as follows:
“When I found out that the teacher had a lot of knowledge.. .you get
more respect for this person. She knew what she was doing. You want
to learn more from this person. I think she is a real good role model.
Because they [teachers] are not actually going out there and taking care
of patients, it’s hard to say ‘I want to be like her to take care of
patients...,’ but when they give a lecture and when we ask a lot of
questions they are able to answer and.. .give us a lot of feedback and
information. She knows what she is doing and I want to be like her. I
want to know more, and I want to know what I’m doing.”
Question # 5: What changes in your caring ability have occurred as a result o f your
enrollment in the nursing program?
In response to Question # 5, two students were either not sure or did not see
any change in their caring ability as a result of participating in the nursing program
thus far. However, their verbatim responses indicated otherwise. All respondents
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indicated that their nursing education had added new information, skill or personal
development. For some change occurred in all areas. The respondents shared details
in changes or additions to their caring ability repertoire. Table 10 provides a list of
category and subcategory change constituents. Respondents found that their
knowledge encompassed a wider scope of knowing, seeking, practicing, and
developing as a professional nurse. All respondents strived to pursue better or optimal
care for the individual placed in their charge. There was a strong emphasis in
communicating during caring events, and as a result of an inter-connecting with the
person receiving their care the respondent personally developed. Respondents found
themselves evaluating their performance on-going. Further, they strategized at a
beginning level how they could make things different or better in the caring process.
Examples of the category responses are as follows:
Nursing process application “I have learned a lot more, I think I am looking at people
on deeper levels than I was before.. .1 didn’t have the
nursing knowledge.. .1 see the possible things that could
be wrong with them.. .1 can also know to look for
that.. .1 am starting to learn structure.. .look at people
differently, and trying to figure out what I can do,
according to what T know.. .to take appropriate steps to
get help for them...”
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Nurse caring skills
Communicating
Self-development
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“Recently we did injections. We can do accu-checks,
the bathing and doing.. .we’ve done physical
assessments”
“[Nursing education].. .is teaching me to be a better
nurse, teaching me how to better care, teaching me how
to recognize everything.. .teaching me how to
communicate better. When I am interacting with a
patient I am assessing, looking, seeing, and
communicating.. .1 try to incorporate a little touch.. .tell
them I am listening to them.”
“Yes, I noticed a lot more knowledge.. .how to treat
them, how to care better for others not only for the
people who need it at the hospital, but others [who] are
working with me ‘like students’, or ‘even nurses.’ I try
to ... learn how to operate... better, ... correctly
and.. .correct things with others.. .There are positive
ways of caring towards other people that I learned from
he classes.. .1 think I’d rather stick to that than the way I
used to think of others or the way I expressed my caring
to others. I might have lacked some other stuff that I
now know is a lot more comforting for myself as well. I
might have done a little bit, but now I double that
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178
little...You feel more satisfied [in doing good
care]. You ask yourself well ‘did I do it right or wrong,
did they need that or not?’ Now I know that they did
need the care and I know it was right.”
Table 10
List of Category & Subcategory Change Constituents Noted From Question # 5
NURSING PROCESS
APPLICATION C O M M U NICATIO N
NURSING/CARING
SKILLS (ACTIONS) SELF-DEVELOPMENT
W ider scope Culture specifics Technical skills Knowledge / Theory
Inclusion of Family G ender specifics New nursing skills Professional Standards / Development
Prevention Rem ove b iases Correctness/restrictions
Psychosocial Trust developm ent Organization
A ssessm ent Em pathy for Moral/ethical aw areness
Patience Disciplined
Ustening Better nurse
Verbalizing Better care - higher level of care
Explaining More caring - positive ways
Understanding Confidence
Touching Comfort (self & patient)
G enuineness Study skills
Telling
The majority of the respondents focused on changes in using or applying the
nursing process, communicating, and self-development. Over one-half of the
respondents offered responses reflecting the same three categories. However, the
categories of nursing process and communication are contained in the development of
technical and nursing skills. To reflect respondents who were general in their
description in answering this question, the researcher created the category of nursing
and technical skills.
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Additional Findings
Peer-to-Peer Student Relationship(s)
The respondents reflected upon three constituent categories for interactions
among student peers. Table 11 provides a list of the categories and subcategories. For
the most part, peer-to-peer interactions were positive experiences. Respondents
recognized that they bonded with their “comfort” groups. Comfort groups shared the
same gender, age or connection. The respondents discovered that sharing in peer
groupings provided positive support and encouraged personal success. Interviewees
reported competition among groups or students, and isolation of students. Students
recognized as better than the other students because of their previous knowledge
acquisition were perceived as isolating themselves from the other students. Several
respondents recognized this event, but remained bonded to their core comfort group.
Later, one respondent reflected that an isolated student requested assistance from the
respondent. After helping the student the respondent reflected that this event
positively changed the interaction between the two students. Overall, several
respondents noticed that working with a peer study group encouraged a closer bond
among the peer students. Table 11 provides the specifics of identified peer-to peer
relationship constituents noting that communication and action promoted a positive
student outcome.
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Table 11
Peer to Peer Relationship(s)
C O M M U N I C A T I O N A C T I O N O U T C O M E
S h a r in g E n c o u r a g in g C o n f id e n c e
B o n d in g H e lp in g C o m m itm e n t
U n d e r s ta n d in g W o rk in g T o g e t h e r S u c c e s s f u lly S u c c e s s
W illin g n e s s T im e G iv in g P e r s o n a l C h a n g e
H o n e s ty S h o w in g ( D e m o n s tr a tin g ) G o a l O r ie n te d w ith P e e r s
F a i r n e s s G iv in g S u g g e s t i o n s C o m p e titio n
C o n c e r n in g C lo s e r B o n d in g ( S tu d y G r o u p )
C o n n e c tin g
P o s itiv e
U p-L ifting
S u p p o r tin g
G e n d e r & A g e D if f e r e n c e s
C o m m u n ic a tin g
Teacher/RN Caring Role Models
The respondents collectively provided a list of caring constituents. Three
subcategories were identified: teacher/RN caring attributes, teacher/RN student
interaction episodes, and student transformation. Table 12 provides a comprehensive
list of the respondent answers.
The respondents readily recognized positive teaching caring attributes. These
traits were associated with a caring teacher in actual encounters or a desired quality
the student wished a teacher possessed and practiced. Most of the list of attributes was
identified from actual student-teacher interactions. These interactions were welcomed
by the respondents and always impacted the students in a positive manner. Even the
respondents who were not doing well in the nursing program appreciated a teacher
using the caring attributes when interacting with them.
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The respondents related that caring encounters with teachers and RNs brought
about numerous responses. A positive RN encounter assisted the student in
transforming to a professional role. The respondents were encouraged and
empowered. They were better able to accept constructive criticism, and return
demonstration to show what they had learned in the teacher’s/RN’s presence. Also,
they felt the beginnings of working as nursing colleagues, and working toward the
same goal of being nurses and providing good patient care.
Table 12
Teacher and RN Caring Role Models
TEACHER/RN C ARING
ATTRIBUTES
TEACHER / R N - STUDENT STUDENT TRANSFORMATION
IN T E R A C T IO N S E P IS O D E S (A C T U A L )
Knowledgeable Giving positive feedback R espect for
C ongruence of communication Informing Learn m ore
C om m unicates dearly Touching (pat on th e back) Desire to em ulate (teacher)
Calming Evaluating Calming
Listens Suggesting Encouraging - personal resp o n se
Helpful Offering Goal oriented (seeking sam e )
Patient Bonding Confidence
Understanding Giving tim e an d being timely Constructive critidsm (accepted)
Happy-joyful-pleasant D em onstrating Return dem onstration (to show w hat is learned)
Expressive Available Expect m ore
Polite Nurturing Perserverance
Fair C hecking-upon S u c c ess seeking
Motivating Coaching C olleagues in nursing
Affirming Asking Em powered
Supportive Looking out for
Friendly Sharing
Clarifying Explaining
Attentive Complimenting
Positive Encouraging student
Prompt Believing in
Genuine
Personal
Thorough
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Student Semester Status
The respondents knew their current grade status, and had a general idea as to
their educational weaknesses and strengths. A few students were disappointed in their
nursing performance in clinical, testing, or writing. All of these respondents knew
their performance and that success was their responsibility. They each expressed a
desire for caring interactions with their instructors to deal with their need to improve.
Also, they knew instructors who provided caring interactions to other peers who
needed help, and desired the same.
The student who withdrew from the program knew that a problem existed.
He/she had taken measures to impact a change in their status, but was unable to
improve in order to meet expected educational or clinical demands on time. It was in
his/her best interest to withdraw and not receive a failing grade or in the client’s
interest not to injure someone in the clinical component of first semester nursing
education.
Overall Emerging Themes/Summary o f Qualitative Inquiry
Questions 1 through 3 provided the foundation for understanding student
caring ability. Students’ definitions of caring were from both their personal definition
of caring and post nursing school admission. Concern for the patient in their care was
of highest importance, and evaluation of their performance was least important in their
personal definition of caring. Two-thirds of the respondents reported a change in their
definition of caring ability since becoming a nursing student. An increase in
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knowledge, nursing skill, interpersonal communication, personal growth and
development as a professional were noted. Respondents reported an extensive list of
events, relationships or situations that contributed to the development of their caring
ability. Seventy-five percent of the respondents maintained parents as the main
purveyors of caring ability development. Seven of twelve included a personal
accident/illness of themselves or significant other as affecting their development of
caring ability.
Question # 4 provided four-situation categories. The categories included
gaining information, intercommunicating, providing care, and student transforming.
Surprisingly, fifty percent of the respondent stories were from negative clinical related
encounters. These situations challenged the students’ ethical and caring thought
processes. However, the students maintained quality in their care regardless of their
current situation, but recognized the discrepancy. The majority of these negative
encounters took place in a skilled nursing facility (SNF) or convalescent facility.
Despite the negative encounters, 8 of 12 students reported noting a RN role model
with 2 of these being their clinical instructor.
All of the respondents indicated a change (Question # 5) in their caring ability
whether it was from gaining additional knowledge, improved skill or personal
development. Interpersonal communication with a patient in their care was of strong
importance among the respondents. Respondents were concerned about their clinical
performance and tried to make things different or better in their caring process. The
majority focused in using the nursing process, communication techniques, and self-
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development. Over fifty percent of the respondents reflected change in all three
categories.
Additional findings were noted. Bonding with a comfort group provided
support and encouraged personal success. Supporting the respondents’ feelings of
encouragement was a caring teacher. The respondents provided an extensive list of
teacher/RN caring attributes and supportive teacher/RN interactions. The respondents
readily identified positive encounters, which they enjoyed, and felt empowered. This
practice allowed the student to accept constructive criticism, and return student
demonstration was welcomed to show the teacher what they had learned. A positive
encounter for the student was a “right of passage” into the nursing profession.
Further, the respondents noted several areas of personal transformation since entering
the nursing program.
All of the respondents were aware of their grade/semester status. Respondents
who shared that they had writing, communication, or clinical performance difficulties
recognized this fact. They accepted responsibility in this matter. Each had plans to
improve their status or knew it was in their best interest to withdraw from the nursing
program.
Chapter IV presented the results of the combined quantitative and qualitative
study. Data included a synopsis of test results, figures, tables, interaction examples,
and overall themes. Next, Chapter V contains discussion and insights gleaned from
the data collected.
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Chapter V
SUMMARY, DISCUSSION, IMPLICATIONS, RECOMMENDATIONS, &
CONCLUSIONS
Summary
The final chapter of this study is comprised of several parts. The first section
includes a summary of the study including study background, purpose, theoretical
support, and brief overview of methodology and procedures. The next section
includes significant findings and a discussion or imparted conclusions of the main
themes noted from this study, followed by implications for nursing education and
practice, and nursing policy implications. Specific recommendations by the researcher
are listed from the above discourse. Finally, suggestions for future research are
provided, followed by a conclusion of the study.
During the discussion in this chapter, it is apparent that certain terms are not
yet clearly defined and universally agreed upon in the nursing literature. Because of
this fact, terms such as competent nurse, professional nurse, caring professional nurse,
and caring, competent nurse were used interchangeably in this study. It was not the
purpose of this study to debate their beginnings or specify their use under educational
and practice circumstances. However, the purpose was to recognize that caring is a
component in being a professional nurse, and being a professional nurse means being
competent. No matter how the terms are used, competency without caring, and caring
practice without competency deems no professional nurse.
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Study background
Healthcare has experienced many changes over the past 50 years. Clearly
many of these changes have affected the way in which healthcare is provided. Some
of the changes include: the development of managed care, sophisticated treatments
using high-tech focused care, quality of care concerns, client satisfaction issues,
nursing competency, the nursing shortage, recruitment and employment longevity
concerns, the aging population of clients and nurses, the rise in healthcare costs, the
image of nursing, identifying at-risk nursing students, increased client acuity and
strain on the current healthcare workforce, and many other related concerns stemming
from these main issues. Each change challenges nursing education to meet these rapid
healthcare modifications, plan for nursing education’s future, and manage healthcare
delivery business as usual without a reduction in quality of care. Nursing education
has a responsibility to prepare competent, entry level nurses to navigate these
healthcare possible obstacles to satisfy those receiving their care.
Healthcare recipients believe there is gap between what consumers receive and
what they expect to receive. Nurses are at the forefront of these concerns and
controversies. Nursing education has an important role to play in educating the next
generation of healthcare providers to acknowledge these concerns. It is nursing
education that provides the necessary groundwork for enabling the next generation of
nurses to meet the challenges of healthcare satisfactorily using the art, science, and
practice of nursing. Nursing education provides the basics of theory, practice, and
skill development for the neophyte nurse to be caring, competent, and skillful.
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Additionally caring, being the essence of nursing when combined with competency
and hands-on skill, become the art of nursing. Without caring there would be no art of
nursing and without competency there would be no profession. The amalgam of these
components is necessary to create the professional nurse.
There is little research (praxis) to confirm the existence of caring among
associate degree nursing students. Further, little is known of the development of
caring among nursing students. A problem exists when nursing education is mandated
to include caring theory in its curriculum, but no definitive research exists as to
whether or not this educational objective takes place as a result of formal education.
The problem is double-barreled. The issues of healthcare are challenging the nurse to
be caring, and a gap may exist between what the nurse believes is caring, and the
client’s expectations. Nursing education has the responsibility to acknowledge,
delineate, and teach that differences in caring perceptions exist, and it must develop
caring practice utilizing all perspectives.
Study purpose
The purpose of this study was twofold. One was to investigate potential
predictors of caring ability among first semester groups of associate degree nursing
students. The other purpose was to explore caring ability development and the impact
of formal nursing education among the same groups. The predictors used to
investigate the quantitative study were maternal care and paternal care during the
study participants’ first sixteen years of life, perception of current school climate, and
semester grade. Next, the qualitative portion of the study explored, and expanded the
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quantitative study using the predictors. Information from this study is to be used to
establish baseline information from which nurse educators can provide, revise, and
emphasize nursing curriculum to maximize professional caring development, and
promote student success in academic and clinical practice.
Additionally, the study focused on acquiring information on caring ability from
a variety of different perspectives. Demographics were used to correlate relationships
among key variables. Results of these factors provided information and potential
predictor capability. Also, information from this study provided nurse educators with
an intense look at caring ability development from the student perspective. Further,
the knowledge obtained from this study is important in monitoring quality control of
nursing education.
Caring is an important mandated factor in nursing education and nursing
practice. Students’ perceptions of both caring and school climate may enhance or
hinder their academic success. Nursing educators have the responsibility to create
educational environments in which students are encouraged to practice their
professional role and achieve success.
Research questions
Several questions were posed in the quantitative and qualitative portions of this
study. The research questions for the quantitative study were:
• What are the relationships among maternal, paternal care, nursing
school climate, academic success, and caring ability in first semester
associate degree nursing students?
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• What role does maternal care, paternal care, nursing school climate,
academic success, and caring ability in first semester associate degree
nursing students play in prediction of academic retention/success?
The research questions used in the qualitative student interview were:
• How would you define caring?
• Now that you are a nursing student, how has your definition of caring
changed?
• What events, relationships or other situations contributed to the
development of your caring ability?
• As a student nurse, describe a situation in which you were able to
practice your caring ability?
• What changes in your caring ability have occurred as a result of your
enrollment in the nursing program?
Theoretical support
Several nursing and non-nursing theorists, authors, researchers, and a
philosopher supported the researcher’s development of the current study. The
information from these literary sources was abounding with caring content, and it duly
related to nursing curriculum and practice. Chapter 2 of this study extensively
reviewed their works, and further legitimized caring and caring links as a unique
component in nursing.
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Caring was viewed from different venues. Some of the venues included:
philosophical, developmental, conceptual, theoretical, and scientific research. Caring
is a human connection, which has the capability to maintain, change, support, and
enhance human interaction. Defining caring from the perspective of a profession
remains a multidimensional, complex, and nebulous task. However, its clarification
must continue to further delineate the caring scope and practice of nursing.
Further, it is important to understand the many dimensions of caring as they
relate to nursing in order to ensure a sound curriculum and practice. Chapter 2
affirmed this process reiterating the fact that caring is instilled in the developing
student nurse through a program of studies, professional encounters, and real-world
nursing practice. The researcher recognizes that individual student nurse experiences,
and perceptions may vary, but it is the nursing curriculum— meaning the teacher-
student, student-client, and peer-to-peer encounters that link professional caring to
practice. Chapter 2 acknowledged the research made in these areas, and this gave
additional credence to the study’s theoretical structure.
Additionally, in summarizing Chapter 2 literary sources, several statements
were created and furnished definitive information on caring as it relates to nursing
education and practice. The following list provides a summary of the axioms obtained
from mainly nursing related research and literary review:
• Physical care is ranked higher than affective behaviors
(Greenhalgh,Vanhanen, & Kyngas, 1998)
• Compassion is the core of caring in nursing (Wilkes & Wallis, 1998)
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• Communication is an important medium for expression of caring actions
(Wilkes & Wallis, 1998)
• Senior nursing students present more depth and richness in descriptions
of the themes of caring; seniors reveal a deeper understanding of the
interrelationships of nursing care (Welch, 1999)
• School climate is an important influence on role definitions, norms
expectations, values, and beliefs; socialization affects student
achievement, academic self-concept, and other affective responses
(Brookover, Wilbur, Beady, Flood, Schweitzer, & Wisenbaker, 1979)
• Student caring ability in nursing school is the strongest predictor of
postgraduate caring ability (Simmons & Cavanaugh, 2000)
• Nursing and caring are not perceived as synonymous at entry into nursing
education, but 12 months later they are perceived more synonymously;
nursing students after 12 months of education loose some of their
idealism (Watson, Deary, & Lea, 1999)
• A nursing student who is nurtured in a caring school climate is more
inclined to role model the same caring behavior (Simmons & Cavanaugh,
1996)
• The capacity to care must be nurtured and valued (Roach, 1987)
• Human care knowledge is forwarded when caring is experienced in
academic life (Bush, 1988)
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• The basic constituents of caring encounters are a sense of acceptance and
self-worth, personal and professional growth, motivation, appreciation of
role-modeling, and long-term gratitude and respect (Halldorsdottir,
1990)
• The main constituents of a caring experience are selfless sharing,
enriching effects, authentic presence, and fortifying support (Beck, 1992)
• A caring teacher establishes a climate that promulgates caring through
nurturance and valuing (Dillon & Stines, 1996)
• The essential elements of professional caring are: professional
competence, genuine concern for the student, a positive personality from
the teacher, and professional commitment (Halldorsdottir, 1990)
• The three clusters of themes noted in a student-faculty caring experience
are attentive presence, sharing of selves, and consequences whereby the
student feels valued and respected (Beck, 1991)
• The “five Cs” of caring unique in nursing are confidence, conscience,
compassion,, commitment, and competence (Roach, 1984, 1987)
• In the student-teacher caring interaction, the student is recognized as an
individual and special person; the student’s whole life is recognized
through an attitude of flexibility, warmth, and genuineness (Hanson &
Smith, 1996)
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• Modeling, dialogue, practice, and confirmation/affirmation in
faculty-student interactions promote a climate for caring and components
of a moral education (Hughes, 1992)
• Five metaphors or themes pervading through nursing education based on
reciprocal connecting are supporting, sharing, presencing, compentence,
and uplifting effects of caring (Beck, 2001)
• The three themes noted in a student-teacher interaction are expecting,
helping, and hindering (Poorman, Webb, & Mastorovich., 2002)
• A nurse educator or practitioner who is non-threatening, warm, and
caring, establishes a climate in which caring may be learned (Higgins,
1996)
• The four basic elements of a caring student-teacher encounter are
teacher’s professional approach, mutual trust, a professional teacher-
student relationship, and a positive student caring encounter
(Halldorsdottir, 1990)
• A caring interaction can be created and learned; creating caring has seven
dominant themes: “connecting, sharing, being holistic, touching,
advocating, being competent, and feeling good;” and learning caring has
five modes “role modeling, reversing, imaging, sensing, and
constructing” (Kosowski, 1995, p. 238)
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• A caring environment has the potential for empowering students to create
an egalitarian relationship among caring communities (Grams, Kosowki,
& Wilson, 1997)
• Caring needs to be demonstrated through a relationship with a teacher;
dialogue between teacher and student is crucial in learning roles of carer
and cared-for (Sanford, 2000)
• Job satisfaction is strongly correlated to organizational culture, climate,
and goals (Johnson, & McIntyre, 1998).
• A nurse’s perception of caring are influenced by the philosophy of the
educational institution and the environment in which services are
provided (Bamum, 1998; Meleis, 1997)
• In order to foster communities of care, faculty must feel cared for and
valued by students, colleagues, and administrators (Paterson & Crawford,
1994)
Method and Procedures
Sample
The sample population in this study was from three Southern California
Associate Degree Nursing Programs using only first semester nursing students. Out of
a potential sample of 131 nursing students, 124 voluntarily participated in the
quantitative portion of the study. In the qualitative portion of the study, 123 nursing
students agreed to participate. From this number, a 10 percent sample was randomly
drawn from each nursing program, and each student was interviewed separately. This
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process provided the input for the qualitative portion of the study. The final count of
first semester nursing students interviewed was twelve.
Model and Instrument(s)
The research model used in this study was composed of both a quantitative
and qualitative approach. A combination of three instruments was used to acquire
quantitative data. These included the Caring Ability Inventory (Nkongho, 1990),
Charles F. Kettering Ltd. School Climate Profile (Howard, Howell, & Brainard, 1987),
and the Parental Bonding Instrument (Parker, Tupling, & Brown, 1979). No
prescribed instrument was used in the qualitative portion of the study. The questions
posed during the interview were developed from the literature review. They focused
on the main aspects of the quantitative research to elicit data not available through the
questionnaire approach, and corresponded to the epistemological premise of this
study. Chapter 3 reviews in detail the research model and methodology.
Data analyses
Both quantitative data and qualitative data were analyzed. Quantitative data
analysis was comprised of descriptive and inferential statistics. For each of the
criterion and predictor variables, shapes, frequency distribution, and frequency
statistics were performed. These included caring ability, maternal care, paternal care,
and school climate. Distribution of scores approximated a normal distribution.
Inferential statistics included: Pearson product moment correlation, simple t-test,
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and simple linear regression. Qualitative data analysis included: multiple readings,
coding, and establishing patterns to substantiate overall themes.
Summary o f Selected Findings and Discussion
Quantitative Summary
A summary of selected findings and discussion of this study is presented in
this section. The sample population was predominantly female (14 were males) with a
mean age of 30 and spread of 19 to 55 years of age. The age factor was similar among
all the associate degree programs. The addition of males into the study provided an
introduction of new data compared to studies using only females.
Additional demographics were included and provided further discussion.
Greater than half (54 percent) of the students were never married, 62 percent had no
children, and 44 percent had a less than $20,000 annual income. Although the current
results of income were expected, lower annual income can become a risk factor
affecting student success and performance. Wilson (2003) previously identified
income as an area for social concern in retention survival. Further, higher income and
caring ability are related in the current study. The group greater than or equal to
$60,001 annual income scored significantly greater in caring ability than the less than
or equal to $60,000 group. Perhaps, the higher income group has the financial means
to act on their caring concerns therefore reflecting an increase in caring ability score.
The majority of students selected their birth mothers and fathers to complete
the parental bonding questionnaire. This was expected and similar to the study by
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Simmons (1994). Further, in the current study the majority of students responded to
seeing or talking to a parental figure daily or weekly. Previous literature noted a
connection between parental support and academic success (Cutrona, Cole, Colangelo,
Assouline, & Russell, 1994), and self-efficacy development and academic
achievement (Cassidy & Eachus, 2000). No connection was made in this study of
these facts.
In today’s understanding of human behavior, it is important to discover the
impact of ethnic heritage and religious affiliation on affective/emotional development.
Students from a variety of ethnic heritages and religious affiliations participated in the
study, but to a limited extent. Less than one quarter (18.5 percent) identified no
religious affiliation, and 15.3 percent noted that religion was not important to them.
Ethnicity, religious affiliation, and religious importance were not significant factors
with caring ability in the current study. In the Simmons’s (1994) study, religion was
found to be significant. Students who perceived religion to be very important had a
higher caring ability score (Simmons, 1994).
Career choice, degree accomplishment, nursing related experience, NSNA
membership, and pass/fail status provided additional data. Nursing was a first career
choice by 73.4 percent (n = 91). Fifty-three students (42.7 percent) held a previous
college degree before entering the nursing program. This seems to be a growing trend
among nursing school admissions.
Many other non-degree accomplishments were noted. A variety of
respondents reported noting previous nursing-related experience before entering the
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nursing program. Less than half of the respondents (40.3 percent, n = 50) reported
limited nursing-related experience (less than 6 months experience) while a larger
amount (58.6 percent, n = 71) reported greater than 6 months nursing-related
experience. The fact is that students entering into a nursing program are being
exposed to nursing care prior to school admission. This is a change from earlier years
of nursing program enrollees.
There was no difference in caring ability and nursing-related experience
among the groupings Grouping 1 with less than 6 months to 5 years, and those
greater than 5 years of nursing-related experience and Grouping 2 with less than 6
months to 1 year of nursing-related experience and those greater than 1 year to 5 years
or more). This result was comparable to Simmons (1994). However, Simmons (1994)
groupings included no nursing-related experience as the lower end of the grouping.
The current study results for Grouping 1 were t = .43, p = .67, df = 119 and t = .53, p =
.60, df = 119 for Grouping 2.
A small number reported National Student Nurses Association (NSNA)
membership (16.9 percent). This is expected since other members are usually
advanced semester nursing students, and membership announcements recruit students
into NSNA. Membership usually increases as the student bonds with the nursing
program, peers, and additional recruitment strategies.
Over one third (39.7 percent) of the students reported a weekly routine of
meeting with a nursing peer/study group. This is not uncommon because students
have an inordinate amount of nursing related material to organize and accomplish in a
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field of study that is new for most of them. Participating in a nursing peer or study
group weekly did significantly impact caring ability (t = 3.19, p = .002, df = 119.
The weekly group reported a higher caring ability mean than any other group it was
matched with. No previous study reported comparing these groups with caring ability.
The result suggests that a weekly meeting with a peer or study group enhanced caring
ability.
Finally, of the 124 study participants, 103 passed the semester, 14 failed, and 7
withdrew by the drop date. A total of 21 first semester students either failed or
withdrew. The number of students not completing the first semester has become an
issue in education since a seat space is taken up and not filled after the student leaves
during a semester in progress. The vacancy is not filled until the next semester
(meaning the second semester roster). It is important to note in the above discussion
that all data outliers were included in all data analysis.
Hypothesis # 1: First semester nursing students who experience affectionate
and warm care from their mothers in early life will show a greater caring ability than
those who experienced detached and cold care from their mothers in early life.
The first hypothesis stipulated that first semester nursing students who
experienced affectionate and warm care from their maternal figure in early life would
show a greater caring ability than those who experienced detached and cold care from
their maternal figure early in life. A relationship was found to be significant between
caring ability and maternal care (r = .254, p = .004), but in testing high/low maternal
care groups, the result was not significant. Therefore, the hypothesis was not
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supported. There was no difference between high/low maternal care score groups and
caring ability. Linear and quadratic regression analysis further confirmed that a
relationship existed between the two variables (maternal care and caring ability). See
Figure 1 (p. 144). Also, the regression analysis suggests a slight curvilinear
relationship. An explanation of the finding is that students who received cold and
indifferent care from their mothers did not model the same. Both Peplau’s (1989)
theoretical support, and Simmons’s (1994) empirical evidence lend credence to the
development of “complementary patterns of behavior.” This concept was previously
noted in Simmons study as theoretical support for the finding. It is a process whereby
a particular pattern of need of one person fits that of another so there is a union
resulting in a functioning of the whole (Peplau, 1989). The demonstration of this
phenomenon is that a student raised by a non-caring parent finds a different way of
acquiring caring ability in herself/himself despite the lack of a caring model or
experience.
Hypothesis # 2: First semester nursing students who experience affectionate
and warm care from their fathers in early life will show a greater caring ability than
those who experienced detached and cold care from their fathers in early life.
There was no significant relationship between caring ability and paternal care.
The results indicated that the hypothesis was not supported. In testing the high/low
paternal score groups with caring ability, the result was not significant. There was no
difference between high/low paternal score groups and caring ability. Regression
analysis indicated non-significance and was nearly a straight line. See Figure 2
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(p. 146). There is no obvious explanation for the non-significant relationship.
Simmons (1994) reported a weak curvilinear relationship between the two variables
with a larger sample size and this may account for no relationship in the current study.
Hypothesis # 3: First semester nursing students who are educated in a
nursing school climate perceived as considerate, warm, and supportive will show
greater caring ability than nursing students who are educated in a climate perceived
as inconsiderate, cool, and non-supportive.
The relationship between caring ability and school climate was significant (r =
.225, p = .005). However, only half of this hypothesis was supported. Students with
a high positive perception of school climate were significantly related to positive
caring ability (r = .30, p = .003). However, students who perceived moderate or low
school climate were not significantly related to caring ability (r = -.26, p = .213). This
group perceived school climate as non-cooperative, uncaring, and non-supportive. If
this group score had been significant then the hypothesis would have been entirely
supported. However, evidence still suggests that a caring school climate fosters caring
ability among students. Regression analysis was significant noting that as school
climate increased so did caring ability. However, school climate scores around the
mean are dipped until a nadir is reached before caring ability scores again begin to
climb. See Figure 3 (p. 149). An explanation for this event is that a caring school
climate fosters caring ability. These findings were similar to those reported by
Simmons (1994).
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Hypothesis # 4: Maternal care will account for more variance in first
semester nursing student caring ability than paternal care or the climate in which the
nursing student is educated.
A stepwise regression analysis revealed that the hypothesis was not supported.
Maternal care accounted for less variance in caring ability (5.4 percent). School
climate explained a small percentage (7.2 percent), but more than maternal care.
Paternal care provided no explanation in variance. A total of 12.6 percent of the
variance in caring ability was explained by maternal care and school climate.
Maternal care did not account for more variance in first semester caring ability as the
hypothesis proposed. A total of 13 percent (maternal care 6 percent, school climate 5
percent, and paternal care 2 percent) of the variance in caring ability was explained in
Simmons’s (1994) study. School climate explained more variance in the current study
than did Simmons’s (1994) study. A possible explanation for this difference is that
first semester students were relatively new to the environment and the excitement of
being a nursing student added to a higher perception of the school climate or perhaps
the environment really was supportive and caring as previously defined by the
instrument.
The results do indicate that school climate plays a significant role in caring
ability development. Also, maternal care impacts caring ability far greater than
paternal care. There is no reasonable explanation for this finding. However, the
unfound variance for both studies are nearly the same with 87.0 percent and 87.4
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percent. There still remains a large percentage of variance that is not yet discovered,
and it is presumed to be important in the development of caring ability.
Hypothesis # 5: First semester nursing students who pass the first semester o f
nursing will have a higher caring ability than those who fail the first semester.
An independent sample t-test explicated that no significant difference existed
between the grade groups (pass and fail) and caring ability. Therefore, the hypothesis
was not supported. However, the fail group did report a mean greater than the pass
group by 4 points. There is evidence in the literature that notes nursing as a physically
demanding and emotionally challenging profession. It is possible that a beginning
student may face such elements in academe and clinical practice. As a result of this
encounter, a student with a high caring ability may become disillusioned when the
results of his or her nursing care are met with resistance or negative results. This
encounter can have a deleterious effect on the emotions of a practicing nurse. This
result could add to the possibility of academic failure or a decreased interest in
becoming a nurse.
Selected Demographic Variables with Selected Criterion Variables and
Discussion
Several t-tests were run to test groupings with caring ability, school climate
and parental care. Gender groupings and membership in NSNA did not significantly
affect caring ability. A significant difference did exist between the less than or equal
to 26 and greater than or equal to 27 age groups. The less than or equal to 26 group
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scored significantly higher in caring ability (t = 2.44, p = .016, df = 120). Simmons
(1994) reported that greater than or equal to 25 years age group had a significantly
higher caring ability mean than the less than or equal to 24 years age group. The
results of the current study were opposite those of Simmons (1994). There is no
explanation for the differences other than the groups possessed their own unique
qualities.
Next, both higher income (greater than or equal to $60,001) and meeting with a
study or peer group weekly groupings each had a significantly higher score with
caring ability perception. Explanations for these findings could be that economic
stability may allow one to focus on affective personal development, plus they may
perceive that they have the means to act on this feeling. Regarding meeting with
others weekly, an explanation for this finding could be that togetherness fosters
friendship and caring for another resulting in a higher caring ability perception.
Marital status, number of children, maternal communication, paternal
communication, ethnic heritage, religious affiliation, and religious importance
were not significant with caring ability. Simmons (1994) found religion to be
significant with caring ability perception. There is no explanation for this difference
in the current study.
Three t-tests determined differences among specific groupings and school
climate perception. First, the income grouping greater than or equal to $60,001
reported a significantly higher perception of school climate than the lower grouping.
An explanation for this fact could be that because of the higher income the student is
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able to enjoy the educational environment with less income pressures. The second
grouping tested was career choice. There was a significant difference between two or
more groups. The “first career choice” group had a significantly higher perception of
school climate than those who did not select nursing as a first career choice. An
explanation for the difference may be the student’s excitement of fulfilling a personal
career choice for the first time brings a more positive perception of the school
environment. Third, grade groups were significantly different among one another.
The combined grade group of A, B, and C perceived a significantly higher school
climate that the group who received a D or F grade. It is plausible that a passing
grade promotes a positive regard for the school.
Further, t-testing a combination of high/low maternal care and paternal care
and high/low school climate with caring ability yielded one significant result.
Grouping 1 of paternal care greater than or equal to 24 and school climate greater than
or equal to 49 and Grouping 2 of paternal care greater than or equal to 24 and school
climate less than or equal to 48 resulted in a significant difference between the two
group means. Group 1 scored higher in caring ability than Group 2 (t = 2.02, p = .047,
df = 65). It stands to reason that a higher perception in paternal care and school
climate would result in a higher caring ability score since school climate and caring
ability are positively and significantly already related in the current study.
Finally, in a study by Nelson, Howell, Larson, and Karpiuk (2001) a
comparison of Associate Degree in Nursing (ADN) beginning students and Bachelor
of Science in Nursing (BSN) beginning senior students caring ability was made. The
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researchers found no difference in caring ability based on gender. The mean caring
ability for ADNs was 210 and 201.3 for BSNs in the study. The ADN result was
slightly higher in Nelson et al.’s (2001) study than the current study result (206.62).
No standard deviations or score ranges were reported in Nelson et al.’s (2001) study.
However, Nelson et al.’s (2001) BSN mean scores were lower on two occasions than
Simmons’s (1994) senior finishing students. The difference in the scores could be that
Nelson et al.’s (2001) seniors reflected the beginning of the semester and Simmons’s
scores were students nearing the end of their senior year. Further, Nelson et al. (2001)
reported a finishing caring ability score of 207.1 that was comparable to Simmons’s
(1994) 208.2 score.
Nelson et al. (2001) attributed the difference in beginning ADNs and senior
BSNs as to the naivete and idealism of the beginning ADN student who has not
participated in actual experience with caring skills and abilities. Perhaps, the type of
caring ability being measured in seniors reflects a more intense personal evaluation
and thought because of being further along in their nursing education. This may
account for the slight difference seen between freshmen (first semester) and senior
nursing students caring ability. Also, the results may look similar, but the quality of
caring ability (a well-earned score) may reflect a professional judgment
noted only by the more experienced senior respondents.
Selected Qualitative Inquiry Summary and Discussion
The qualitative data review was determined to be reliable, valid and credible.
Twelve respondents provided copious amounts of information during the interview
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process. The group included 10 passes, and 2 fails, both genders, various age
groups, high and low caring ability scores, varied ethnicities, and the extremes of
grading A through F as well as withdrawals.
Question #1: How would you define caring?
The students provided a varied list of caring definitions. Upon further
analysis, the students declared concern for the clients in their charge as a major
component of their caring definition 83.3 percent of the time. More than 50 percent of
the students included assessment and personal action, while only a small percentage
were concerned with evaluation of their action or care (16.7 percent) in their definition
of caring. Several student examples from Question # 1 were:
• Putting others before yourself, thinking what other people would want
— meeting their needs.
• Showing consideration for other people, going out of your way to help
someone, just showing kindness.
Question # 2: Now that you are a nursing student, how has your definition o f
caring changed?
The majority of the respondents noted that their personal definition of caring
had changed since being a nursing student. Even the four respondents who said their
definition of caring had not changed noted several adjustments in their thinking about
additional areas of caring development. These included: more knowledge about
caring, the caring environment, prioritizing care, learning about technical devices,
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performing nursing skills, therapeutic communication development, and different
ways people care. Five major areas were identified by respondents who changed in
their view of caring: leaming/knowing/seeking/planning (L), communicating (C),
performing (P), personal recognizing/reviewing/growing (R), and developing as a
professional (D). The identified list seemed to have a connection to newly studied
material, self-evaluation, and professional self-discovery when questioned further.
Question # 3: What events, relationships or other situations contributed to the
development o f your caring ability?
A number of events, relationships, and other situations contributed to caring
ability development. The majority of the respondents (75 percent) declared the
parents as the main persons who were responsible for caring ability development.
However, grandparents, accident/illness of a parent, grandparent, or self were thought
of as events that shaped caring ability development. Additional constituents were
noted, but to a lesser degree in the development of caring ability. All identified
persons, events, and situations seemed to aid the respondent in caring ability
development. This provided empirical evidence to support other factors that assist in
caring ability development.
Question # 4: As a student nurse, describe a situation in which you were able
to practice your caring ability?
Several categories emerged from situations in which the students were able to
practice their caring ability. The categories included: gaining information,
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intercommunicating, providing care, and transforming as a result of the caring
encounter. The largest percentage of situations in which the student was able to
practice caring was in intercommunicating (91.6 percent). Other categories such as
physical expression of caring, and caring transformation had a greater than or equal to
75 percent student response. The caring foundation category had a 25 percent
response. Half of the expressed student situation stories were negative encounters-
meaning a negative interaction with a registered nurse (RN) or certified nursing
assistant (CNA). The respondents perceived the situation as not caring, and contrary
to their personal belief and current knowledge of what a caring event should be. The
majority of these negative encounters took place in a skilled nursing facility (SNF) or
convalescent hospital. This reported fact could have a strong impact on the student’s
caring ability or even withdrawal from nursing as a valued career choice. The students
in personally seeing and experiencing a not-so-caring situation were marked with an
uncomfortable impression that they had to personally handle. The question still
remains as to how these impressions will affect students in future successes,
development, and clinical practice.
Further, another issue was derived from this question. No student reported
seeing a RN role model in the SNF or convalescent settings. However, eight students
reported seeing a role model in the clinical hospital setting. Two of these were
instructors. No CNAs were reported as giving positive care in the students’ presence.
An explanation for the lack of RN role models is that SNFs mostly use CNAs and
licensed vocational nurses (LVNs) for bedside care. These persons are the most
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frequent role models the students encounter. Again, these student observations of care
may have a lasting impression on the developing neophyte student, and to what extent
it is unknown.
Question # 5: What changes in your caring ability have occurred as a result
o f your enrollment in the nursing program?
All students reported a change in their caring ability as a result of their
enrollment in the nursing program. New skills, knowledge, and personal experiences
had taken place. All the interviewees were interested in providing better or quality
care for the client(s) placed in their charge. Communicating with the client during
events of care personally aided in their caring ability development. Also, students
were evaluating their performance both as a student, and in giving client care. Four
distinct categories emerged from this question noting a change in their caring ability:
nursing process application, communication, nursing/caring skills (actions), and self
development. The majority of the respondents focused on changes in using or
applying the nursing process, communication, and self-development. These changes
are expected considering that the students are enrolled in the first semester of a
nursing program, and similar nursing fundamentals are important to reiterate and teach
such as nursing process.
Additional Summaries.
Peer-to-peer relationships remained important in the students’ academic life.
Communication and action amongst students promoted a positive student outcome.
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Students tended to migrate to a comfort group, which usually shared the same gender,
age or connection. The comfort group became bonded and assisted one another in the
first semester educational process. The literature notes that peer support aids in
student acclimation to program culture and increased academic success. The students
found this “value added” to their nursing educational experience.
The students were observant to providing a list of caring constituents for
teacher and RN caring role models. Three subcategories were identified: caring
attributes, interaction episodes, and student transformation. The respondents readily
recognized positive teaching/caring attributes. These were derived mostly from actual
student-teacher interactions. Also, the students noted that a positive interaction
(approach) promoted positive student response such as accepting criticism,
demonstrating a skill, and empowering etc. These encounters assisted in student
transformation and they were welcomed by the students.
Finally, all the respondents were aware of their semester status. They had a
general idea of their strengths and weaknesses when addressed in a non-threatening
manner. Weaknesses were easily identified whether it was in writing nursing papers,
communicating, or in clinical performance. Students who were in a less than
satisfactory status in the semester were taking measures to improve while others knew
it was in their best interest to withdraw. The student’s knowledge of his or her status
empowered the student and provided a general plan for his/her to follow. Even
students with considerable weaknesses had insight about themselves through this on
going self-evaluation process.
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Discussion of Current Research to Related Subjects and Implications for Nursing
Education and Practice
Nursing education has the responsibility to recruit and admit qualified
applicants that are provided state-of-the-art educational tools, instruction, and support.
From this beginning phase, neophyte student nurses are molded in an on-going
educational process over many semesters of nursing education. This process works
toward each student being able to practice at an entry level in nursing using
cumulative knowledge, skill, and caring practice. If all goes as planned, the successful
outcome in nursing education is to prepare a student who is competent, ready for entry
into nursing practice, and infused with the ideal and desire to continually develop as a
professional.
Nursing education has an important, difficult and rewarding task to prepare
qualified nurses to practice the art and science of nursing in a competent and caring
fashion. This researcher purports that the process of nursing education can be viewed
from different venues: selecting the best candidates into a nursing program, molding
and developing the student for the practice of professional nursing, and promoting a
positive outcome of student success, namely the commitment to life-long learning
and quality practice by the graduate. Simply put, this process is brought about in three
entwined phases: beginning (recruitment, admission, and beginning learning),
working (on-going learning throughout semesters of nursing education), and acquiring
(competency, skill and success). The contents of these phases will be the focus of
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discussion in the following sections as it relates to the complexity of infusing caring in
nursing education and results of the current study.
Beginning Phase
In the beginning phase, many current topics in nursing education and practice
are linked to caring, but before caring can take place students must be in attendance.
Recruitment of qualified applicants is not an easy assignment. Wieck (2003) reported
that the emerging workforce (individuals bom between 1968 to 1983) have definable
skill deficits in math and reading which challenges their ability to tackle advanced-
level reading of nursing textbooks and drug calculations using long division. This
generation of workforce candidates is also referred to as the graphics-rich media
entertained generation who value their role in the emerging workforce differently than
those entrenched in the workforce (Wieck, 2003). The emerging workforce has
several characteristics: they demand instant value; they want nice things, but prefer
fun to working lifestyle; they want quality time, feedback and recognition; they are
interested in goals, deadlines, but hate process; they are skeptical of one-size fits all
methods and solutions; they see each job or educational opportunity as a stepping
stone to the next achievement (Wiech, 2003).
These values set the tone from which nurse educators must recognize, expand,
and teach. Teaching methods, styles, and teacher image must reflect this tone in order
to make nursing an appealing profession. Nursing education must recognize and
investigate other ways to teach the emerging generation in order to expand the image
of nursing to include worker opportunities and outcomes valued by these prospective
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students. This understanding and change in curricular implementation should have a
dynamic effect on recruitment and retention of student nurses. The current nursing
educational system may not be as inclusive of these potential workforce values as it
should be in setting curricular reform. Here in lies the problem requiring clear action.
Students must be able to assimilate the values of nursing practice, and the emerging
workforce must value caring. Noting what the emerging workforce brings to the table
of nursing education can impact how the values of nursing education are being taught
and infused. An assimilation must be noted between the emerging workforce values
and nursing education’s focus in order to maximize the learning transformation
experience of the individual student nurse.
The “age-old question” is why does a person choose nursing as a career, and
can recruitment strategies capitalize on these facts? Several factors influence a
person’s decision to become a nurse. Larsen, McGill, and Palmer (2003) reported on a
study of beginning nursing students. The authors reported factors that influenced their
decision to become a nurse were: past experience with a loved one or self being ill
and/or hospitalized. Other factors influencing the decision of becoming a nurse
included past healthcare work (71.7 percent), family member or friend who was a
nurse (65.3 percent), a nurse role model (53.3 percent), and television/media (21.6
percent). Several other factors emerged in the decision-making: helping, religious
reasons, the variety, flexibility, security, money, and childhood dream (Larsen et al.,
2003).
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These responses reflected a similarity to the current study participants. Care
and concern, job security, and a variety of work setting, prestige of nursing, autonomy,
and work with technology were most influential in the decision to become a nurse
(Larsen et al., 2003). Although the desire to help and care for others was the primary
factor influencing a student’s decision to become a nurse, nonetheless it is still the
most important reason why people are attracted to the profession in the first place.
Facts such as these are instrumental in recruitment of potential nursing students, and
they must be capitalized on to increase the number of applicants.
There is a call-to-action by a variety of sources to stem the nursing shortage.
Bleich, Hewlett, Santos, Rice, Cox, and Richmeier (2003) noted that the complexity of
the shortage makes it difficult to explain in a singular fashion. Several imperatives
emanated from their study and they are relevant to nursing education:
• strategies to overhaul recruitment efforts to expand the healthcare
workforce
• promote advanced nursing education that keeps current with market
demands
• identify and create research to collect workforce data that area accessible
to stakeholders
• ensure satisfactory salaries, safe working conditions, and integration o f
technology to assist nurses in working more efficiently and safely
• create academic and service partnerships to change and upgrade provider
education and utilization
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• commit personal time to seek a voice and action in organizational and
professional decision making
• actively support colleagues who partake in workforce initiatives
• reflect on personal openness toward change, recognize that nursing will
continue to evolve (Bleich et al., 2003)
Each of these imperatives can have a strong impact on recruitment of students
and retention of nurses in practice. Ultimately, the reverses of these imperatives are
the issues of nursing which have added to creating the nursing shortage. The
researcher believes it is these issues that nursing education must acknowledge, change
and overcome to provide effective learning environments, so graduates can
successfully navigate the organizational structure of healthcare. It is no wonder that
the caring part of nursing has taken a back seat because of the tug-of-war nurses must
play in performing their role with these practice distractions. Distractions must be
understood and minimized so nurses can perform their professional role in a quality
care manner.
Several recent reports shed light on nursing admissions. Chong, Johnson, and
Garvey (2003) noted that California’s 108 community colleges provide a gateway for
young adults from poor families or older adults seeking a career change. Currently,
the colleges are scaling back classes due to budget cuts even though the demand for
degrees steeply rises. The same holds true in nursing education, however, not all 108
community colleges have nursing programs. The cost to educate nurses is rising in all
institutions thus adding to the financial strain of becoming a nurse. Subsequently with
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rising costs in education fewer prospective students will apply. This impacts nursing
applicants and leads to a further shortage of nursing graduates. Relating the concept
of reduced income and rising costs, the current study noted that a decrease in income
was associated with a decrease in caring ability. Special efforts must be made to
recognize that income groups possess different caring ability perceptions, and nursing
education must assist all income groups to learn the caring ways of nursing.
Additionally, it is well known that student financial need and income can have
an effect on a student’s educational success. These issues must continue to be
addressed so students are afforded the means to meet their educational goals and
become viable members in the healthcare workforce. Financial obstacles must be
removed.
Aside from increased student fees and decreased college funding noted in
California’s educational system, both Wilson (2003), and Phillips, Spurling, and
Armstrong (2002) reported on associate degree nursing studies, which have a direct
relationship to student success. With limited spaces in nursing education programs, it
may become necessary to select applicants with the highest degree of predicted
success in a nursing program. These studies were designed to predict the most likely
students who would be successful. Wilson (2003) reported that the science index
(Anatomy and Physiology grade point average (GPA) and science course repetitions)
as the major variable yielding a 78 percent prediction for retention. Other factors
including ethnicity, English fluency, self-efficacy, and high school grade point average
were explored and provided prediction data. Similarly, Phillips et al. (2002) noted the
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top four overall predictors of success to be overall GPA, English GPA, core Biology
GPA (Anatomy, Physiology, Microbiology), and core Biology repetitions (number of
repeats). A success formula was created from the data, yielding a 9 percent increase in
student success. However, only 8 percent of the variance was explained using the
formula in relation to associate degree nursing (ADN) completion success. Not
surprisingly, there is skepticism and concern regarding the exclusion of applicants
using a success formula that does not take into consideration the other 92 percent of
the variance not explained.
Overall, both studies recognized the influence of GPAs, science courses, and
repetitions in predicting student success. It stands to reason that the process of
choosing successful candidates who are intellectually open to understanding the values
of nursing practice would be the best candidates to admit into a nursing program.
However, caution must be taken in applying this action as the only criteria. Who is to
say whether or not caring graduate nurses are cultivated in this 8 percent variance?
Perhaps, there are other qualities that should be considered when creating a success
formula.
Codependence may be another factor affecting student success and
adaptability. Entering nursing for the right reasons is important. Because nursing
evokes care-taking qualities, there has been an association to codependency. Women
have been socialized to be dependent, lack self-esteem and live vicariously through
others (Wetzel, 1991). Sources recognize this to be an oppressive, social and political
structure in shaping the personalities of women, and to blame others for personal
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shortcomings. Codependent persons have the tendency to be addicted to misery
(Strasen, 1992). Persons who have this view perceive themselves as inadequate,
worthless, and have a chronic poor self-image (Strasen, 1992). Theoretically, a person
who cares too much could be a risk and exhibiting codependence tendencies. Students
at-risk for codependency must be recognized, referred, and supported. The focus of
current nursing education promulgates a healthy caring professional practice. This
practice must continue.
Professional nursing promotes a positive self-image. It is through the
educational process that students are socialized and change in their thoughts, beliefs,
actions, performance, and achievements. Students may come into the nursing
educational system with shortcomings. Through formal education, however, they
overcome many of the issues, which stand before them in order to practice safe,
competent, and caring nursing practice. Students continue to meet the challenge to
improve their self-image, and professional practice while in a nursing program. For
some, personal issues are debits and become risk factors affecting their success in a
nursing program. Nursing education must continue to assess for at-risk students. At-
risk students must be assisted in developing a plan to ensure their success.
A student’s past history may impact current learning and practice. Anderson
(1994) noted that women must continue to understand their cultural factors, gender
and socialization process. It is through this consciousness raising that gender roles can
be optimized and roles changed for the better. As a result of the self-knowledge,
increased self-worth, self-esteem, self-efficacy and empowerment of the individual
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can become a reality. The focus should not be in labeling the person because of their
past, but what the person can currently achieve through increasing personal power and
forward action. Recognition of one’s social development and past is important to
provide consciousness raising, but only to resolve difficulties and change social and
political institutions who created these difficulties which impede personal
achievement. Nursing education focuses on optimizing a person’s potential.
Although the focus of social oppression is seen primarily in women, similar
socialization issues can be made for men in nursing. Recruitment and retention of
men in nursing is a positive step towards creating a human inclusion of gender in the
practice of nursing. These practices must continue.
Addressing a related issue, both men and women are socialized to care.
Results of the current study showed no evident difference in caring ability between
men and women. Each has the ability to care in nursing practice. This finding
supports men as caring associates in nursing practice.
Working Phase
In the working phase of becoming a student nurse, knowledge, practice and
skill are at the forefront of the educational experience. Besides the outward signs of
practicing the art and science of nursing, students begin to acknowledge and develop
their values, attitudes, and beliefs about the profession of nursing. They learn to
initiate, support and encourage themselves through the use of certain affective domain
characteristics that support student success. Some of the main support characteristics
reported in the literature are self-efficacy, hardiness, and resilience. A description of
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these characteristics and their importance to nursing education and the current study is
provided.
Bandura (1986) furnished an explanation of the importance of self-efficacy.
This is a belief whereby an individual can succeed at a task in light of obstacles and
difficulties, and commit whatever energy is needed to accomplish the job (Bandura).
Kobasa, Maddi, and Kahn (1982) proposed the term hardiness, which is an optimistic
orientation to life that enables an individual to convert or eliminate stressful situations.
Hardiness is seen as a desirable trait that enables a person to achieve a major life goal.
It is composed of three characteristics: commitment, challenge, and control (Hegge,
Melcher, & Williams, 1999). Resilience is another characteristic associated with
success. Resilience is the ability to resist or recover from adversity (Jacelon, 1997). It
is made up of a variety of personal traits:
• activity level, contemplativeness, higher cognitive skills, positive
responsiveness to others
• equanimity (a balanced perspective of one’s life experiences)
• perseverance (persistence in spit of adversity)
• self-reliance (belief in oneself and capabilities)
• meaningfulness (realization that life has a purpose and value one’s
contributions)
• existential aloneness (realization that each person’s path is unique)
(Jacelon, 1997)
Family and community support were also found to be an abiding feature of
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resilient people (Jacelon, 1997). The fact is that students enter into nursing with
unique attributes and traits, some of which may add to their success potential. Nursing
educators must recognize, promote and encourage all students to develop and practice
personal success strategies. Utilizing positive traits and attributes in education leaves
the student open to understanding the caring nature of the nursing profession. These
success characteristics must be seeded and fostered in the developing nurse. A
positive feeling of self allows the individual to be more open to others, which
ultimately factors into being a caring nurse. A caring competent nurse is a successful
nurse.
Another factor important to student success and caring ability development is
critical thinking. It is the ability to perform purposeful, informed, outcome-focused
reasoning utilizing thoughtful assessment, judgments, and strategies to meet or
improve a specific outcome (Alfaro, 2003). Shell (2001) reported that evidence exists
that critical thinking is not being realized in student outcomes, and critical thinking is
a necessary element of competent nursing practice. Much could be said about the
importance of critical thinking, but one thing is certain, without it success in a nursing
program is impeded. Critical thinking is a key tool in the practice of nursing. It
allows students to think deeper and make an appropriate connection of knowledge,
practice action, and evaluation in nursing practice. Its use can be recognized in
understanding the caring nature of nursing. Critical thinking enables the nurse to
reflect on a nursing action, and evaluate it from both nurse and client perspectives.
The climate for nursing education is important throughout the working phase
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of nursing education. Several authors noted the importance of the practice or learning
environment as a factor impacting the individual or student. Garrett and McDaniel
(2001) noted that environmental uncertainty predicts staff nurse burnout. The same
may be said for the student nurses practicing in a similar environment. Robins,
Gruppen, Alexander, Fantone and Davis (1997) noted that the professional school-
learning environment exerts a powerful and enduring influence on students’ attitudes,
behavior, performance and well-being. Simmons and Cavanaugh (1996) noted that a
caring professional school climate might be the strongest predictor of the student’s
ability to care. Additionally, less than one half (40 percent) of the variance in student
satisfaction with the learning environment was explained by timely feedback,
promotion of critical thinking, and student perceptions of the priority faculty placed on
student education (Robins et al., 1997). These study examples note the powerful
influence the practice or learning climate has on the individuals. Clearly it can aid or
deter in student transformation and success.
Further, the current study notes that students who selected nursing as a first
career choice and students who received a final grade of A, B, or C had a higher
perception of school climate. These groups are limited— meaning that the other
respondents thought less of the school climate. This fact is to be noted and understood
so changes can be made to increase school climate perception— recognizing that school
climate affects student learning. Also, the current qualitative study recognizes that a
negative clinical practicum occurred for some respondents. These perceptions can
have a strong impact on how students see the environment as supportive and caring.
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The effect of negative encounters is unknown but should be monitored carefully.
Potentially, the impact could be that students may require an educational intervention
to reverse any negative perceptions in developing a caring practice demeanor.
Another factor that fosters success and caring ability development is
mentoring. Mentoring during the educational process proves to be a crucial asset in
student learning and adaptation. It supports the development of caring nursing
practice. Also, mentoring reported in the literature is linked to better academic
performance. Barba (2003) noted the importance of peer mentoring as a vital role in
retention of students in a nursing program. Students who are mentored have the
opportunity to learn from another in a social setting. Mentors are seen as the linchpin
of student learning whilst in practice (Gray & Smith, 2000). The mentoring literature
adds positive support to student learning and success. All domains of learning are
enhanced with mentoring. Additionally, the current qualitative study notes that peer
support has a positive influence on student learning. Both mentoring and peer support
must be encouraged in nursing education and they must continue to be a staple in
clinical practice for the graduate nurse as well.
Student stress adaptability has become another topic that affects student
performance. The literature noted that beginning students lack social and emotional
maturity to cope (Meadows, 1998). Therefore, they must learn to value their own
health and self-worth while adopting positive coping behaviors when placed in
stressful nursing situations. It is possible for a nursing student with a dysfunctional
family background to learn better coping skills while developing a professional
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identity at school (Meadows). Self-awareness leads to introspection (knowing self).
Self-knowledge is a precursor to professionalism (Arnold & Boggs, 1999).
Nursing education has the responsibility to teach stress (self) care while
students are adapting to the new role of nurse. The nursing practice environment is
stressful and complex; each of which taxes a person’s ability to learn, practice, and
deal with the emotionally challenging daily concerns of being a student nurse
(Shipton, 2002). The nursing community (as a whole) has the responsibility to
demonstrate how to care, support, and nurture one another. Otherwise, the mindset
will never change that “nursing devours its young” (Shipton, 2002). A supportive
nursing educational community goes a long way in encouraging and supporting
students to practice the caring art of nursing in a healthy manner. The practice of
healthy adaptability to stressful learning and practice situations must be promoted
within nursing students.
Students who experience caring in an educational program are better prepared
to be a caring practitioner and colleagues in the future (Birx & Baldwin, 2002).
Nursing education must review all levels and discern any deleterious efforts that
demote self-concept development, as noted by Sasat, Bumard, Edwards, Naiyapatana,
Hebden, Boonrod, Arayathanitkul, & Wongmak (2002). Self-concept and self-esteem
are recognized as high at the beginning of a nursing program, but decrease in
subsequent years thereafter (Ellis, 1980). Evidence of the practice still exists today,
and it will be a challenge for nursing education to change this fact. Table 10 (p. 180)
in the qualitative report of this study reiterates the students’ need to be in contact with
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caring teachers. Teachers who have a positive regard for students during teacher-
student interactions promote learning. This is not to say that caring teachers are
among the few in nursing education. Students’ perceptions must be considered and
how these perceptions affect student learning.
Role socialization is an important component in the developing nurse. Grindel
and Roman (2002) reported that 50 percent of new graduates leave their first
professional nursing job in less than one year, and see mentoring as one of the best
ways to help a person fulfill his or her potential. Mentoring assists in the socialization
process of a nurse. Good educational and clinical role models can ease student
transition into the clinical setting and promote the role of a qualified nurse (Taylor,
Westcott, Bartlett, 2001). Both the educational and clinical environments benefit from
qualified staff and role models that can socialize the student. Everyone who comes in
contact with a student has the responsibility to enhance the student’s learning in a
positive manner using socialization into practice. A positive role model assists the
student nurse in the socialization process of adapting the caring ways of a professional
nurse. In the current qualitative portion of this study, negative role models were
identified and their impact on students in future practice is unknown. This is an area
of concern that needs to be investigated. Positive clinical sites and role models must
be sought and created so the socialization process of a caring, competent nurse takes
place. The administrative relationships between clinical sites and nursing academe
must work towards sharing objectives, goals and evaluative shortcomings so the right
environment is cultivated in which to bring students for actual nursing practice.
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Basic teaching-learning strategies are necessary to convey the caring nature of
nursing and promote student success. They are an integral part in the working phase
of nursing education. Nursing education has the responsibility to utilize up-to-date
learning strategies to foster the development of a caring, competent, professional
nurse. The literature is replete with information on new methods of learning in
nursing education. Methods such as metacognition, self-regulation, narrative
pedagogy, and intuition are some of the more current strategies to increase ways of
knowing or learning.
The concept of caring is complex and all methods and ways of knowing can
aid in its understanding. The following styles of knowing are just possibilities which
could be used in learning to be a caring professional nurse. Metacognition is self
communication in which one engages before, during, and after performing a task
about task demands and cognitive strategies (Beitz, 1996). Self-regulation refers to
metacognitive, motivational, and behavioral activities using critical thinking skills and
directed to the learning process (Schunk & Zimmerman, 1994). Narrative pedagogy is
openly shared and interpreted stories of lived experiences with teachers and students
that expand a way of thinking about community practices (Ironside, 2003). This
process allows for egalitarian classroom experience and excites students to think
differently. It is a classroom experience that is not teacher-centered, but focuses on
learning and teaching together. Intuitive knowing is an immediate knowledge about a
fact, or truth, as a whole and awareness of all events without conscious use of such
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processes as linear reasoning, analytics or rationality (Rew & Barrow, 1987; King &
Appleton, 1997).
These strategies are not part of mainstream nursing education practice, but
have merit in presenting other scientific ways of knowing, and understanding caring.
Failure to acknowledge the multiple ways of knowing inhibits students from
developing the full extent of mental abilities they bring to the learning situation (Beck,
1998). Ruth-Sahd (2003) noted that inclusion of intuitive ways of knowing allows a
more holistic multicultural perspective in recognizing all ways of knowing.
Nursing students bring different ways of knowing into nursing education. All
ways of knowing need to be respected, developed, encouraged, and acknowledged.
Regardless of the method used in gaining a caring practice, the ultimate outcome is a
caring, competent, graduate nurse in practice, and up-to-date learning strategies must
be part of this learning process.
Another important factor associated with student success, and development of
caring in professional practice is self-actualization. Self-actualization is the process
whereby an individual carries out actions and does the best they are capable of doing
in order to fulfill themselves (Maslow, 1995). Fetzer (2003) found that a positive
correlation existed between self-actualization and professionalism among ADN nurses
(as self-actualization scores went up so did professionalism). The findings o f this
study supported that the greater self-actualization amongst ADN nurses, the more
likely the assimilation and integration of behaviors, attitudes and values of a
professional culture. Self-actualized ADN nurses may have the propensity to
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assimilate and integrate professional ideals when in an uncertain new practice culture
(Fetzer, 2003). Fetzer (2003) endorsed that professionalism can develop after an
individual occupies a role. However, professionalism is in on-going state of
development throughout nursing education and beyond. In order to provide effective
nursing, understanding of self as a nurse leads to an evaluative practice that pilots
better client care and professional caring application. Therefore, self-actualization has
proven to be a valued asset in the development of professionalism, especially in
integrating the values of a professional culture. This practice should be encouraged in
student development.
Throughout all the above discussion, it still remains of utmost importance to
assess the needs of learners. Collins (2002) reiterated this fact. It is an essential
prerequisite to planning effective nursing curriculum. Collins (2002) noted that there
are copious amounts of anxiety, frustration and decreased job satisfaction among
practicing nurses. It is important for nursing education to acknowledge these trends
while identifying the strengths and weaknesses of the new recruits to the profession. It
is through understanding of workplace environments and organizational structures in
which students learn and practice that nursing education must be able to recognize its
own strengths and capitalize on them to redirect the practice focus. As a result of this
understanding, nursing education has the responsibility to modify, create and
strengthen its curriculum to reflect skills, knowledge and practice necessary for
professional nursing to deliver its valuable dynamic commodity to be exercised in an
ever-changing healthcare system.
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Besides the student focus in nursing education, teachers have concerns and
have a direct impact on the learner. Nursing instructors are the human link for
students between nursing theory and practice in the working phase of education. The
current study provides input in this process. In the qualitative portion of the study,
students were aware of positive teacher qualities and the impact of these qualities on
their learning and practice. Effective teachers elucidate subject matter beyond the
mundane and develop a spirit, which transcends philosophical and metaphysical
meanings (Smith, 2000). It is the nurse educator who has the power to bridge the gap
between learning and practice and set forth a transcendental quality in the student.
Self-transcendence is a concept that is receiving literary support in nursing.
Several nursing theorists assisted in the development and illumination of this concept
(Reed, 1991a, 1991b, 1996; Watson, 1979, 1985, 1988c; Parse, 1981, 1987, 1992,
1995; Newman, 1986, 1990, 1995; Newman, Sime, Corcoran-Perry (1991).
Self-transcendence is defined as the capacity to reach out beyond self-boundaries to
achieve a broader perspective of self in order to achieve discovery or meaning of the
experience (Coward, 1996). Watson (1979, 1985) acknowledged that transcendence is
integral to understand the caring-healing relationship of nurse and patient.
Transcendence promotes a higher, spiritual level of consciousness that extends beyond
the physical or material world and is encompassing in the caring-healing
consciousness.
It is through an understanding of the concept of transcendence that students
make meaning of their purpose as a nurse. Consequently, they develop satisfying
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emotional growth in practicing in a community of pain and suffering to give hope,
care, inner peace, and end-of-life acceptance. Transcendence is a concept that is not
usually addressed in an associate degree nursing program curriculum, but it is
recognized as existent during discussions between students and nursing instructors in
clinical practice. It is a caring practice worth investigating, understanding, and
incorporating in teacher-student interactions and nurse-patient encounters.
Nursing instructors (nurse educators) play an important role in promoting the
development of professional caring practice and student success. Most assuredly,
instructors who are competent in teaching and satisfied with the practice environment
provide an optimal learning opportunity for the nursing student. No matter how much
nursing education changes, the ultimate practice experience must be satisfying. Job
satisfaction is important in halting the decline of nursing faculty. Job satisfaction
equates to professional autonomy (Gormley, 2003). Nursing education needs faculty
who are motivated, qualified and satisfied with educating future nurses.
Besides teacher concerns and job satisfaction, competence is an essential
component for nursing instructors (educators). Kelly (2002) defined competence as
the possession of knowledge, attitudes, and skills mix to meet a certain standard of
practice. The overall quality of an educational program is determined by the quality of
the teachers in the program (Princeton, 1992). Quality teachers are professional
nurses who practice caring, competent nursing education and practice. They are the
role models students want to emulate and the tools to make these quality teachers must
be available.
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One of the tools that assist creation of a quality caring teacher is mentoring.
As with students, mentoring works for teachers adjusting to a practice environment.
Mentoring is a process that promotes competency in new faculty. Overall, teachers
should be encouraged, recognized, promoted, and valued for their professionalism.
Faculty mentors promote competence in teaching, and assist in evaluating and
promoting the positive assets of a teacher in educational practice. Acknowledging all
assets promotes self-efficacy and this affects motivation, behavior, thought processes
and emotional reactions from which the teacher practices his or her role in the
educational setting. Additionally, heightened self-efficacy affects his/her perceived
and actual ability to teach more effectively (Prieto & Altmaier, 1994). An effective
teacher can transmit the caring quality of a nurse in practice. New nursing instructors,
especially, must be mentored in the caring ways of teaching nursing education and
practice.
Further, ways of teaching come under scrutiny regularly. Evaluating the way
nursing is taught and applied allows for removal of aspects that do not work.
Resistance to change deflects the need to up-date learning and practice that can result
in negative consequences (not meeting future nursing generations learning and
practice needs). Veenema (2001) reported teaching the same ways as always results in
the loss of the best and brightest students to other more exciting professions. As
Diekelmann, Swenson, and Sims (2003) pointed out, nursing education must reform
conventional approaches and create new pedogogies. Ways must be created for
students to be more involved in their own learning. Teaching must hold tight to what
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works and revise what does not work. According to Lusk and Conklin (2003) the
ultimate goal of nursing education is to produce competent, skill practitioners.
Finding ways to identify and teach competent nurses is the challenge. Self-efficacy is
one key to nursing instructor development. Promoting self-efficacy among nursing
instructors will enable them to strive to do a better job. Caring practice both in
teaching and clinical practicum is a part of that job. Dynamic nursing instructors are
the link in creating students who are enthusiastic about nursing practice, enough so to
practice nursing for a long time in a caring, competent, professional manner. This
type of instructor must be found, created and fostered in an effort to bring back and
keep the best and brightest students to the profession of nursing.
Acquiring Phase
In the final phase, acquiring competence in nursing practice is a successful
outcome of nursing education. Success in a nursing program is built upon many
factors: personal characteristics of the student, academic support, and acquisition of
skill, knowledge, student perception of their performance, and many others less
obvious factors. Throughout the educational process, students learn the art and
practice of nursing. However, the core of nursing is still professional caring. The
term “professional caring” is still not yet clearly defined in the literature, and requires
all three domains of learning in attempting to capture its essence at a basic level. The
affective domain of professional caring is one of the hardest to define. But it is
recognized that there is a change in values, attitudes and even performance when a
competent professional nurse is committed to practicing the art of professional caring.
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The terms associated with a graduate nurse lead to debate. Throughout this
study competent nurse, professional nurse, caring professional nurse are used. The
literature is not definitive about which term best suits the graduate, and it may depend
on type of educational program. It was not within the scope of this study to debate the
issue, but to recognize that a student must be competent in his/her role as a practicing
professional. Competency reflects the caring nature of a practicing nurse using the art
and science of nursing. It is what nursing programs want students to accomplish at the
completion of their program of studies— a caring, competent, graduate nurse.
Another term not agreed upon for its use in nursing academe is “technological
competency.” It is defined as practicing nursing as caring through the efficient use of
technologies knowing persons in their wholeness (Locsin, 2001). Technological
competency combines the coexistence of technology and caring. Locsin (2001)
maintained that just being technologically competent is not nursing. This type of
competency must be grounded in nursing otherwise it will be just an impersonation
equating to a robot nurse. It is important for nursing education to be mindful of the
terms used to describe a competent nurse, and continue to delineate what
qualities/outcomes the student must deliver to satisfactorily complete a program of
nursing education in order to practice competent nursing practice.
Nurse educators provide a forum for the student nurse to be successful.
Success is measured by academics, performance of skills, and observed practice. The
change a student nurse makes to be caring is not easily assessed. There is still a
question as to when a nurse becomes caring or develops a caring nature in practice.
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Regardless, healthcare consumers want competent practitioners, and it is assumed that
a caring professional emerges in the same practitioner. Clearly, the literature supports
that a caring nurse promotes the well-being of an ill individual and this affective skill
(caring) put into actual practice is not readily noted for the economic and personal care
value it provides. Competent nurse graduates are being sent into the workforce from
nursing programs, but who is monitoring the caring component that is vital in
separating nurses from other caregivers? Nurse educators must continue to define
what competency means in relation to a caring professional nurse and integrate ways
of quantifying or qualifying its development along the nursing course of studies.
Further, nurses who have professional qualities are said to utilize the norms,
values, ethics, skills and caring ways to provide a deeper level of care sought after by
public consumers. Many ingredients make up a caring, competent, professional nurse.
For this reason, nursing theories that describe the role of the nurse using caring
practice need to be further developed, promoted and integrated into nursing
curriculum. These theories should to incorporate current healthcare trends, but not
driven by the trends. Also, an understanding of organizational theory, systems theory,
and healthcare management would be helpful in determining the future role of the
nurse in healthcare.
Nursing provides holistic care and in the process of teaching this concept to
student nurses, they must understand their own self in providing meaningful,
deliberate holistic care. Understanding their personal values, attitudes, and beliefs
gives nurse educators a starting point from which to guide, teach, and mould the
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neophyte student. It is the value component that compels individuals to be and to act
personally, and professionally (Thorpe & Loo, 2003). Knowing the student assists
nursing instructors to maximize individual learning needs. In a sense nursing
education practices holistic learning— seeing the student in both the classroom and
clinical setting. As a result, a competent caring nurse is created through understanding
and assimilating the knowledge and practice of nursing.
A competent nurse is equated with quality nursing care. However, quality care
remains unclearly defined in practice. Some refer to care in terms of high quality and
good care while others use the term competent care. Gradients of care are introduced
in the literature. Several authors presented information on this subject (Kemppainen,
2000; Mateo & Young, 2001; Oerman & Templiln, 2000; Larson-Dahn, 2001;
Jennings, Loan, DePaul, Brosch, & Hildreth, 2001; Rowell, 2001; McPherson,
Headrick, & Moss, 2001; Attree, 2001).
Nursing education must synthesize the different views of quality and adjust
curriculum accordingly. Quality is not just doing the right thing, but brings with it
human care and valuing of the individual. Quality care has economic consequences as
well. Money is saved and healthcare recipients are getting better faster and with fewer
complications (Turkel and Ray, 2000; Turkel, 2001; Chang, Price, & Pfoutz, 2001). It
is evident that a caring professional nurse provides far more than just physical care;
therefore quality care must be clearly defined and understood by nursing students and
nurses in practice as well.
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Summary o f Phases
The three entwined phases (beginning, working, acquiring) presented in this
discussion are complex and require an on-going review of legitimate resources by
nurse educators who must incorporate the necessary changes into nursing education
and practice. All of the issues presented in these phases evolve around educating
caring, competent nursing graduates to enter the field of healthcare practice. Every
concern, teaching strategy, and practice system need on-going assessment in order to
provide the best learning environments for students. The public has voiced their
concerns as have the nursing authors, theorists, and students in this study. The
literature is replete with many ways to address the current issues. It is now up to the
creative and definitive efforts of nurse educators in nursing programs to take a stand
and advance the practice of nursing to meet the current and future needs of health care
practice.
Policy Implications for Nursing Education
The following policy implications are recommended for nursing education
based on the results of this study. Although many suggestions were identified
throughout this chapter, these implications provide the core of nursing education and
practice as it relates to instilling the value of caring among associate degree nursing
students. Associate degree nurse educators must:
1. Recognize the unique differences in caring ability among nursing students.
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2. Follow a designated theoretical framework in conceptualizing caring in
nursing education.
3. Provide a comprehensive approach to creating, fostering, implementing
and monitoring the development of caring ability among nursing students
throughout the curriculum.
4. Use positive experiential practicum sites to socialize the nursing student to
the caring practice of the profession.
5. Provide opportunities to promote peer support among nursing students.
6. Utilize a mentoring approach to support caring ability development for
nursing students.
7. Promote a positive nursing school climate to enhance caring development
from all levels (academic, and clinical).
8. Clearly define the nursing student caring behaviors in terms of objectives
and/or competencies that are recognized by all nursing faculty.
9. Develop and practice ways of knowing that will enhance the development
of caring among nursing students.
10. Maintain an on-going review of nursing literary sources that delineate the
caring ways of the professional nurse in order to revise and implement the
current strategies into the nursing curriculum.
11. Foster professional caring ability development that is consistent with
semester student outcomes regardless of the starting point from which the
student entered the nursing program.
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12. Provide professional nursing role models throughout the curriculum both in
education and practice.
13. Promote the development of reciprocal relationships among nursing
practice sites that recognize the unique features of today’s healthcare and
set forth to navigate the challenging terrain.
14. Construct and support self-care nursing student strategies that enhance
student success in the nursing program.
15. Promote the caring ways of the profession in all levels of nursing
education.
16. Use mentoring to support new nursing faculty in adapting the caring ways
of education and nursing.
17. Encourage nursing faculty and administrators to model the caring ways of
the profession.
18. Educate nursing faculty through seminars and conferences, and other in-
service forums when changes and innovations occur in the concept of
caring in nursing education and practice.
The policy implications noted above must be presented and agreed upon at the
highest levels within the educational structure. Implementing changes in nursing
education occurs when they are integrated through all levels of management.
Leadership teams must be open to changing the current practices to address today’s
ever-changing potential workforce. Finding, educating, and retaining the best possible
nursing candidates will result in a more favorable outcome for everyone. As
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healthcare consumers, the ultimate expectation is to receive caring, competent, and
quality focused nursing care. Further, two Appendices (D & E) are added to provide
models for teacher-student caring, and caring-competent nurse development. They
may serve as guides for nursing programs in fostering, developing, revising and
practicing a caring curriculum.
Research Recommendations
This study provides copious amounts of information that will add to the
body of knowledge about caring in nursing. From this study several areas were
identified, which would benefit from fixture research. As a result, the
following future research questions are proposed:
• Does caring ability change in the student throughout each semester of nursing?
• What affect does stress in the clinical setting have on a student’s caring ability?
• Does caring ability increase and remain stable only after graduation from a
nursing program?
• Are all the elements that create caring ability in an individual identified?
• What are the similarities and differences between caring ability perceived by a
student and actual caring practice by the student?
• Does a caring curriculum create a caring nurse?
• Is a leveling of caring ability growth expected after completion of each
semester of nursing?
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• Do student-teacher caring encounters differ in their effect on men and women
in nursing?
• What are the similarities and differences between professional caring, technical
caring, and practical caring?
• Is there a difference in how caring ability is practiced among different student
ethnic groups?
• Does the caring ability instrument measure the “right” caring ability for
today’s graduates?
• Does school climate perception determine academic success in any other
semester of nursing?
Continued research is needed to understand caring in professional practice.
Issues remain as to how much and to what extent caring is a part of competency.
Also, does nursing education create a caring professional or is caring brought out to
the forefront as a result of nursing education? Further research will provide
clarification. The student brings to the educational environment a variety of both
positive and negative traits and attributes. It is possible that exposure to nursing
education clarifies, enhances, and creates enhanced skills that give momentum to
students wanting nursing as their career choice. There is still a need to investigate
what brings current students to nursing, keeps them in practice, and captivate on its
presence to create dynamic graduate nurses.
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Conclusions
The conclusions set forth resulted from the hypotheses and questions proposed
in both the quantitative and qualitative portion of this study. The purpose of gaining
data from both methods was to triangulate information that would not be obtained by
using only one method. Consequently, much information was gleaned and added to
the body of empirical knowledge for nursing education and the profession of nursing.
Hypotheses # 1, # 2, and # 3 expanded information between perception of
caring ability and parental perception, and between perception of caring ability and
school climate perception. A higher perception of caring ability was linked to a higher
perception of school climate (noted in Hypothesis # 3). Hypothesis # 4 resulted in
explaining 12.6 percent of the variance in perception of caring ability with school
climate and maternal care perception scores. No difference was found between
passing and failing students and their perception of caring ability (noted in Hypothesis
#5).
Certain demographics noted significant results with the criterion variables.
The less than or equal to 26 age group scored higher in caring ability perception, as
did the greater income and weekly study groups. Also, the greater income group rated
a higher perception of school climate, as did the grade group of A, B, and C grouping.
School climate perception was higher in first career choice students as well.
Additionally, perceptions of maternal and paternal care, school climate and caring
ability individually had no significant connection to semester completion.
Next, the noting of specific themes in the qualitative portion of the study
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yielded an in depth understanding of personal views from selected first semester
students. Questions # 1 and # 2 provided insight into the students’ perception of
caring ability— both personally and as a student. Question # 3 found that parents are
the main purveyors in promoting the development of caring ability, but other persons,
events, and situations assist in the development as well. Question # 4 found
communication in practice as the largest percentage of situations in which the students
were able to practice caring ability. A result not expected from this question was the
occurrence of negative encounters in clinical practice by students. This is an area of
concern and further investigation is needed to explore its impact on student learning.
Additionally, role models for the respondents were limited. This too may have
consequences for student satisfaction and learning. Question # 5 found that all
students reported a change for the better in their caring ability. Change is expected,
but as to what change provides information for nurse educators to ponder upon and
create the best learning academe.
Overall, the respondents in the qualitative study welcomed peer-to-peer
support, and found that using peer support enhanced student acclimation to the nursing
educational environment and learning. The respondents were acutely aware of caring
teachers who supported their efforts. Finally, regardless of the students’ semester
status all were aware of their strengths and weakness, and desired to set forth a plan of
action.
Although much discussion occurred in this chapter, caring is an immense
concept covering many areas in nursing practice and education. The study’s purpose
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was to provide empirical evidence of caring ability amongst first semester nursing
students, and the purpose was met. As a result of this study, a better understanding of
first semester nursing students is gained from which curricular changes and teaching
strategies can be enhanced. The respondents in this study spoke from their hearts and
intellect to provide experimental understanding for nursing education to take notice
and respond to. A basic premise of community college education is that knowledge
about the constituents (students) makes educational service meaningful if acted upon.
The researcher believes that the information (knowledge of the constituents) contained
in this study will make a difference in how a nursing caring curriculum is executed
(acted upon) among first semester nursing students.
The nursing educational system is not broken, but the healthcare environments
in which students operate are troublesome and difficult to maneuver. Nursing
education must be able to defend its purpose and deliver graduates to meet healthcare
needs. The consumers of healthcare have spoken and quality care is of utmost
concern. Quality care includes a caring nurse and nursing education must deliver
qualified, competent, professional nurses. Educating caring, competent, nursing
graduates is a hefty task, but it is necessary for the application of caring practice to
prevail.
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REFERENCES
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Faculty Collaborative Workshop, April 26, 2003.
Wilson, H. S., & Hutchinson, S. A. (1991). Triangulation of qualitative methods:
Heideggarian hermeneutics and grounded theory. Qualitative Health Research,
1(2), 263-276.
Windsor, A. (1987). Nursing student’s perceptions of clinical experience. Journal o f
Nursing Education, 26(4), 150-154.
Yates, P., Hart, G., Clinton, M., McGrath, P., & Gartry, D. (1998). Exploring
empathy as a variable in the evaluation of professional development programs for
palliative care nurses. Cancer Nurse, 21(6), 402-410.
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272
APPENDIX A
CONSENT TO PARTICIPATE IN RESEACH
RESEARCH TITLE: Associate Degree Nursing Students’ Perceptions of Caring
Ability, Parental Care and Nursing School Climate: A Quantitative and Qualitative
Study of Caring Links Among Freshmen Nursing Students and Its Relationship to
Semester Completion.
Dear Freshman Nursing Student:
You are being asked to participate in a research study conducted by Linda Serra
Hagedom, Ph.D. (principle investigator/advisor, and Diane Restelli, R.N., M.S.N.
(student investigator) from the Rossier School of Education at the University of
Southern California. The results of this study will be used to fulfill a dissertation
requirement necessary for the Doctor of Education degree for the student investigator.
You have been selected as a possible participant in this study because you are a
freshman nursing student enrolled in a Southern California Associate Degree Nursing
Program. A minimum of 100 subjects will participate in the study from no specific
ethnic, age or gender composition from several Associate Degree Nursing Programs.
Participation is voluntary.
PURPOSE OF THE STUDY
The study is designed to solicit your thoughts, feelings and perceptions of your caring
ability, past parental bond(s), and nursing school climate. This will provide the
researchers with information to understand the similarities and differences that may
occur among freshmen nursing students. Further, baseline information about
community college students who choose nursing as a career will be obtained.
PROCEDURES
If you volunteer to participate in this study, we would ask you to do the following
things:
1. Consent: You will be asked to read this consent and fill out the
information at the end of this form. Keep a copy of this form for your
records (enclosed in the student packet). The purpose of the consent is to
explain the study process and to note that all information received from
you will be confidential. At no time will information be identified to you
by name, and you will not be recognized by any likeness of an identifier.
A social security number or student identification number will be asked for
at the end of the consent. This is for the purpose of obtaining your
freshman nursing course completion grade (obtained from a grade roster),
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273
and to follow-up on the study process. Again, at all times information
obtained will be confidential.
2. Questionnaire: Next, please answer the five-part questionnaire, either
during an in-class nursing time (if nursing instructor permission is given)
or on your own time, after class.
3. Mail Back To Student Investigator: If you are unable to complete the
questionnaire, and return it to the researcher while you are on campus, then
return your signed consent form and completed questionnaire in the self-
addressed stamped envelope provided and drop it in your local mailbox.
4. Student Interview: A few weeks after receiving all the signed consents
and completed questionnaires including those by mail, approximately 10%
of the volunteer sample will be randomly selected for a personal interview
to obtain qualitative data not available in the questionnaire format. For
those who choose to return the information by mail, please return the
signed consent and completed questionnaire within two weeks so the
researcher can efficiently record your input, and to allow for adequate time
to prepare for student interviews.
5. At the Semester End: At the end of the Fall 2001 semester, your
completion of the semester will be verified and course grade documented.
Reading of the consent will take approximately 10-15 minutes. The questionnaire
portion of the study will take approximately 25 minutes of your time to complete. The
personal interview will take approximately 30 minutes to 1 hour of your time, and it
will be arranged at your convenience and campus location. The research plan is to
obtain all participant volunteer completed questionnaires by the middle of November
2001, and to complete all participant volunteer interviews by the middle of January
2002.
POTENTIAL RISKS AND DISCOMFORTS
You may feel more than unpleasant when recalling past and present life experiences.
The questionnaire may stimulate some thoughts that you may not have recalled in a
while, some of which could be less than a positive memory. It is not the study’s
purpose to make you feel emotionally uncomfortable, but only to gain your perception
of the statements in the instrument. Remember, your personal beliefs and perceptions
will be solicited in the questionnaire and possible interview. There are no right or
wrong answers in either phase of the study (questionnaire/possible interview). You
may choose to share your answers or thoughts, as you feel comfortable and
appropriate.
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274
POTENTIAL BENEFITS TO VOLUNTEER PARTICIPANTS/NURSING
EDUCATION’S FUTURE
The benefits of participating in this study are that you may learn something new about
yourself, you might discover a new strategy that would enhance your success in the
nursing program, and you might share your reactions to this questionnaire and
interview and realize that you have something in common with other freshmen nursing
students. In addition, your participation in this study will help the student researcher,
a currently practicing nursing professor, and other nurse educators to better understand
student nurses’ and their ability to care while in an associate degree nursing program.
REMUNERATION FOR PARTICPATION
In appreciation for participation in this study, an on-campus luncheon will be provided
around the time the questionnaire is administered.
CONFIDENTIALITY
Any information that is obtained with this study and that can be identified with you
will remain confidential. Your name or any other personal identifier will refer no
information to you. When the results of the research are published, discussed or
referenced, no information will be included to reveal your identity. If an audiotape
recording of you is required, the information will be transcribed within a day or two of
the recording, and your identity protected with a non-identifier I.D. After
transcription, the tape will be erased. You do have the right to review/edit the tape,
and have access to the tape after it is no longer needed.
All participant volunteer research data will be coded with a number that is only known
to the student investigator. Thereafter, all research analysis and volunteer participant
reference will be made by this code. Research information will be stored at the home
of the student investigator in a locked file cabinet. Once all data has been extracted
for analysis (end of Spring semester 2002), a commercial paper shredder will destroy
the original personal information sources, and interview tapes will have been
previously erased as well.
PARTICIPATION AND W ITHDRAW AL
You may choose whether or not to be in this study. If you volunteer to be in this
study, you may withdraw at any time without any consequences. You may also refuse
to answer any questions you do not want to answer and still remain in the study.
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275
IDENTIFICATION OF INVESTIGATORS
If you have any questions or concerns about this research, please feel free to contact:
Professor Linda Serra Hagedom (Principle Investigator, Advisor)
@ telephone # 213-740-6772
University of Southern California
Rossier School of Education
Waite Phillips Hall Room 70IE
Los Angeles, CA 90089-0031
(OR)
Diane Restelli (Student Investigator)
@ telephone # 949-589-6810
21476 Silvertree Lane
Trabuco Canyon, CA 92679
E-mail: diney@earthlink.net
RIGHTS OF RESEARCH SUBJECTS
You may withdraw your consent at any time and discontinue participation without
penalty. You are not waiving any legal claims, rights or remedies because of your
participation in this research study. If you have any questions regarding your rights as
a research subject, contact University Park IRB, Office of the Vice Provost for
Research, Bovard Administration Building, Room 300, Los Angeles, CA 90089-4019,
(213) 740-6709 or upirb@usc.edu.
The most important consideration in participating in this research study is that there
are no right or wrong answers to the questions. The investigators are interested in
your personal, honest thoughts and opinions, as you perceive them. Remember, you
are the expert and you possess the information that will further the study of Associate
Degree nursing students that the investigators want to learn more about.
RESEARCH INFORMATION
If you would like to receive a follow-up letter on this research study, please check
your request at the bottom of the consent form that you will be returning to the student
investigator.
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276
SIGNATURE OF RESEARCH VOLUNTEER
I have read the above information and I understand the procedures described above.
My questions have been answered to my satisfaction. I agree to participate in this
study, and I will allow the use of the information (data) collected in a professional
discussion or as referenced material in a published doctoral dissertation or article. I
have been given a copy of this form.
Name of Subject (Please Print)
Address
City Zip Code
Telephone Number
Student I.D. Number
(to reference course completion and grade)
Signature of Subject Date
Yes No Please send me a follow-up letter at the completion of this research
study.
Thank you for your participation in this research study.
Student Investigator Date Principle Investigator/Advisor Date
Diane Restelli R.N., M.S.N. Dr. Linda Serra Hagedom
Trabuco Canyon, CA. University of Southern California
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277
Appendix B
Questionnaire
The following questionnaire contains five parts. Each part if very important for you to
completely fill out in order to compile meaningful research data. Do not skip any
question, and answer them to the best of your knowledge. Your participation is very
much appreciated. Thank you.
PART ONE:
Questions 1-37 contain statements that reflect your thoughts and feelings. Use the
following Likert scale 1 to 7 to respond. Circle the degree to which you agree or
disagree to each statement. Remember there is no wrong or right answer to these
questions.
1 2 3 4 5 6 7
Strongly
Disagree
Strongly
Agree
1. I believe that learning takes time.
2. Today is filled with opportunities.
3. I usually say what I mean to others.
4. There is very little I can do for a person who
is helpless.
5. I can see the need for change in myself.
6. I am able to like people ever if they don’t
like me.
7. I understand people easily.
8. I have seen enough in this world for what I
need to know.
9. I make the time to get to know other people.
1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7
1 2 3 4 5 6 7
10. Sometimes I like to be involved and sometimes 1 2 3 4 5 6 7
I do not like being involved.
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Strongly
Disagree
11. There is nothing I can do to make life better. 1 2 3 4
12.1 feel uneasy knowing that another person depends 1 2 3 4
on me.
13.1 do not like to go out of my way to help other 1 2 3 4
people.
14.1 n dealing with people, it is difficult to let my 1 2 3 4
feelings show.
15. It does not matter what I say, as long as I do the 1 2 3 4
correct thing.
16.1 find it difficult to understand how the other 1 2 3 4
person feels if I have not had similar experiences.
17.1 admire people who are calm, composed, and 1 2 3 4
patient.
18.1 believe it is important to accept and respect 1 2 3 4
attitudes and feelings of others.
19. People can count on me to do what I say I will. 1 2 3 4
2 0 .1 believe that there is room for improvement. 1 2 3 4
21. Good friends look after each other. 1 2 3 4
22 .1 find meaning in every situation. 1 2 3 4
2 3 .1 am afraid to “let go” of those I care for 1 2 3 4
because I am afraid of what might happen
to them.
2 4 .1 like to offer encouragement to people. 1 2 3 4
25 .1 do not like to make commitments beyond the 1 2 3 4
present.
2 6 .1 really like myself. 1 2 3 4
278
Strongly
Agree
5 6 7
5 6 7
5 6 7
5 6 7
5 6 7
5 6 7
5 6 7
5 6 7
5 6 7
5 6 7
5 6 7
5 6 7
5 6 7
5 6 7
5 6 7
5 6 7
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279
Strongly Strongly
Disagree Agree
2 7 .1 see strengths and weaknesses (limitations) in 1 2 3 4 5 6 7
each individual.
28. New experiences are usually frightening to me. 1 2 3 4 5 6 7
2 9 .1 am afraid to be open and let others see who 1 2 3 4 5 6 7
I am.
30. I accept people just the way they are. 1 2 3 4 5 6 7
31. When I care for someone else, I do not have to 1 2 3 4 5 6 7
hide my feelings.
32 .1 do not like to be asked for help. 1 2 3 4 5 6 7
33 .1 can express my feelings to people in a warm and 1 2 3 4 5 6 7
caring way.
34 .1 like talking with people. 1 2 3 4 5 6 7
35 .1 regard myself as sincere in my relationships with 1 2 3 4 5 6 7
others.
36. People need space (room, privacy) to think and 1 2 3 4 5 6 7
Feel.
37.1 can be approached by people at any time. 1 2 3 4 5 6 7
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280
PART TW O:
Items 38-61 list various attitudes and behaviors of parents. As you remember your
M OTHER in your first 16 years, please place a circle around your response to
statements 38-49.
Very Moderately Moderately Very
Unlike Unlike Like Like
38. Spoke to me with a warm 1
and friendly voice
39. Did not help me as much as
I needed
40. Seemed emotionally cold
to me
41. Appeared to understand
my problems and worries
42. Was affectionate to me
43. Enjoyed talking things over
with me
44. Frequently smiled at me
45. Did not seem to understand
what I needed or wanted
46. Made me feel I wasn’t
wanted
47. Could make me feel better
when I was upset
48. Did not talk with me very
much
2
2
2
2
3
3
3
3
4
4
4
4
49. Did not praise me
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281
PART THREE:
As you remember your FATHER in your first 16 years, please place a circle around
your response to statements 50-61.
Very Moderately Moderately Very
Unlike Unlike Like Like
50. Spoke to me with a warm 1 2 3 4
and friendly voice
51. Did not help me as much as
I needed
52. Seemed emotionally cold
to me
53. Appeared to understand
my problems and worries
54. Was affectionate to me
55. Enjoyed talking things over
with me
56. Frequently smiled at me
57. Did not seem to understand
what I needed or wanted
58. Made me feel I wasn’t
wanted
59. Could make me feel better
when I was upset
60. Did not talk with me very
much
61. Did not praise me
2
2
2
2
3
3
3
3
4
4
4
4
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282
PART FOUR:
Items 62-77 give you an opportunity to respond to your perceptions about your
nursing school’s climate. Although is may not include every item you consider
important in your school, it does provide an overall assessment of a school’s climate.
Read each item carefully and circle your rating to these items.
Almost Occasionally Frequently Almost
Never Always
62. In my school even low 1 2 3 4
achieving students are
respected
63. Teachers treat students 1 2 3 4
As persons
64. Teachers from one subject 1 2 3 4
area respect those from
other subject areas
65. Teachers in my school are 1 2 3 4
proud to be teachers
66. Students feel that teachers 1 2 3 4
are “on their side”
67. While we don’t always 1 2 3 4
agree, we can share our
concerns with each other
openly
68. Students can count on 1 2 3 4
teachers to listen to their
side of the story and to
be fair
69. Teachers trust students to 1
Use good judgment
70. My school makes students 1
Enthusiastic about learning
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Almost
Never
71. Teachers feel pride in the 1
School and its students
72. Attendance is good; students 1
Stay away only for urgent
and good reasons
73. Parents, teachers, and 1
students would rise to the
defense of my school’s
program if it were
challenged
74. The department chairman 1
really cares about students
75.1 think people in my school 1
care about me as a person
and are concerned about more
than just how well I perform
my role at school
76.1 feel wanted and needed 1
in my school
77. Most people at my school 1
are kind
283
Occasionally Frequently Almost
Always
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
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284
PART FIVE:
Questions 78-100 request some information about you and your school. Please circle
the best response to each question or fill in the blanks. Your response to every
question is very much appreciated.
78. In which nursing semester are you currently enrolled?
1. First semester
2. Second semester
3. Third semester
4. Fourth semester
79. What is your gender?
1. Female
2. Male
80. Are you a member of the National Student Nurses Association?
1. Yes
2. No
(If your answer to question #80 is Yes, answer question #81)
81. How long have you been a member of the National Student Nurses
Association?
1. Less than six months
2. 7 months to 1 year
3. More than 1 year
82. What is your age? ____________
83. What is your marital status?
1. Single, never married
2. Single, separated or divorced
3. Married for the first time
4. Married more than once
84. How many children do you have?
1. None
2. One
3. Two
4. Three or more
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285
85. Which of the following best describes your present income (or your family)?
1. $20,000 or less
2. $20,001 to $30,000
3. $30,001 to $40,000
4. $40,001 to $60,000
5. $60,001 to more
86. Which of the following best describes the maternal figure(s) with whom you
lived? (Respond to all that apply).
1. Birth mother from age until age_____
2. Foster mother from age until age_____
3. Adoptive mother from age until age_____
4. Stepmother from age until age_____
5. Grandmother from age until age_____
6. Other________________ from age_____ until age
87. To which maternal figure were you referring as you answered the
questionnaire?
1. Birth mother
2. Adoptive mother
3. Stepmother
4. Grandmother
5. Other_______________
88. Which of the following best describes the paternal figure(s) with whom you
lived? (Respond to all that apply).
1. Birth father from age_____ until age____
2. Foster father from age until age_____
3. Adoptive father from age until age_____
4. Stepfather from age until age_____
5. Grandfather from age until age_____
6. Other________________from age_____ until age_____
89. To which maternal figure were you referring as you answered the
questionnaire?
1. Birth mother
2. Adoptive mother
3. Stepmother
4. Grandmother
5. Other
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286
90. How often do you see or talk with you maternal figure?
1. never
2. daily
3. weekly monthly
4. Other____________________
5. Maternal figure is no longer living.
91. How often do you see or talk with your paternal figure?
1. never
2. daily
3. weekly
4. monthly
5. Other____________________
6. Paternal figure is no longer living.
92. Which of the following best describes your ethnic heritage?
1. African American
2. Asian American
3. Caucasian
4. Hispanic
5. Native American
6. Other_____________________________
93. Which of the following best describes your religious affiliation?
1. Protestant
2. Catholic
3. Jewish
4. No religious affiliation
5. Other_____________________________
94. How important is your religion to you?
1. Not at all
2. Minimally
3. Somewhat
4. Very
95. Which o f the following best describes nursing as your career choice?
1. Nursing is my first career choice.
2. Nursing is my second career choice.
3. Other______________________________________________
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287
96. What degree(s) do you currently hold before your enrollment in the nursing
program?
Degree & Major:_________________________________________
Degree & Major:_________________________________________
Additional information:____________________________________
97. Not including your current nursing school experience, how many years of
nursing-related experience have you had? (Include caring for family members,
friends, work experience).
1. less than 2 years
2. 2 to 5
3. 5 or more
98. How many different nursing instructors have you had since you entered
nursing school? Approximate is you are not sure. _______________
99. In what campus organization(s) do you currently belong?
100. How often do you study with a nursing peer group?
1. weekly
2. only before an Exam
3. do not use a nursing peer group/study alone
4. other
Your assistance in this research project is very, very much appreciated.
THANK YOU.
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288
APPENDIX C
STUDY FOCUS of CARING
ABILITY DEVELOPMENT
" C A R IN G " CO M PETENT NURSE
N
U
R
S
I
N
G
FOURTH SEMESTER
C O G N IT IV E
A F F E C T IV E
PSY C H O M O T O R S K IL L
THIRD SEMESTER
C O G N IT IV E
A F F E C T IV E
P S Y C H O M O T O R S K IL L
KNOWLEDGE
SKILL
PRACTICE
KNOWLEDGE
SKILL
PRACTICE
c
u
R
R
I
C
U
L
U
M
SECOND SEMESTER
C O G N IT IV E
A F F E C T IV E
P S Y C H O M O T O R S K IL L
FIRST SEMESTER
C O G N IT IV E
A F F E C T IV E
PSY C H O M O T O R S K IL L
KNOWLEDGE
SKILL
PRACTICE
CAI
Knowing
Courage
Patience
PBI
Empathy
Emotional
Waimth
Affection
Trust
High Morale
Caring
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289
APPENDIX D
H onesty
C ourage
Humility
H ope
Trust
Knowing Alternating R hythm s
T each er a s
Growth in L earner a s Recipient
Patience
Simmon's Model of Teacher Caring Based on
Mayeroffs (1971) Discussion
Permission granted to reproduce 1994 model by Dr. P. Simmons
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290
APPENDIX E
MODEL OF CARING COMPETENT
NURSE DEVELOPMENT
PHASES and FACTORS
C
A
R
I
N
G
S
C
H
0
0
L
C
L
I
M
A
T
E
FA CUL TY
TO
FA CULTY
AD MINISTRATION
STUD EN T
N U R S E
OUTS IDE
INF LUENCES
P E E R S
PATIENT
C A R IN G INTERACTION
E X P E RT PRA CTIC E
S UC CE S S FU L STRATEGIES
M E NT OR IN G
BEGINNING
K N O W L E D G E
PERCE PTI ON /VA LU ES
SK IL L
RE C RUIT ME NT
A C Q U IR IN G
P RO FES SIO NAL ISM
C O M P E T E N C E
TR ANS FO RM AT IO N
R O LE S OC IAL IZA TIO N
CARI NG AS SI M IL AT IO N
W O R K I N G
AFF E C T IV E SU CCESS/
SKIL LS
ST RE SS AD AP T A B IL IT Y
K NO W LE D G E
S K IL L
M E N TO R IN G
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Asset Metadata
Creator
Restelli, Diane Marie
(author)
Core Title
Associate degree nursing students' perceptions of caring ability, parental care and nursing school climate: A quantitative and qualitative study of caring links among first semester nursing stud...
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Education
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
education, community college,health sciences, nursing,OAI-PMH Harvest
Language
English
Contributor
Digitized by ProQuest
(provenance)
Advisor
Hagedorn, Linda Serra (
committee chair
), Hitchcock, Maurice (
committee member
), Sundt, Melora (
committee member
)
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c16-414686
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texts
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University of Southern California Dissertations and Theses
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The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...
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Tags
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