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A longitudinal study on caring behaviors of Italian nursing students
Nurse Education Today 88 (2020) 104377
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A longitudinal study on caring behaviors of Italian nursing students a,⁎
Elisa Fenizia , Luca Navarini a b c
b,1
c,2
c,3
, Sarah Scollo , Angelo Gambera , Massimo Ciccozzi
T b,4
Department of Biomedicine and Prevention, School of Nursing, Faculty of Medicine, Tor Vergata University, Rome, Italy Department of Medicine, Campus Bio-Medico University of Rome, via Alvaro del Portillo 21, 00128 Rome, Italy School of Nursing, Faculty of Medicine, University of Catania, Catania, Italy
A R T I C LE I N FO
A B S T R A C T
Keywords: Behavior Caring Education Nursing students Nursing Surveys and questionnaires
Aim and objective: The aim of this study was to analyze the caring behavioral differences taking place over the nursing academic period. Background: Caring is a core value in nursing education and many of its features can be measured as specific behaviors. The Italian Caring Behaviors Inventory is a tested psychometric questionnaire, useful to this aim. The use of the questionnaire facilitates the student's self-reflection and awareness. Design: Descriptive longitudinal study. Method: The Italian Caring Behaviors Inventory questionnaire was filled out by 103 undergraduate nursing students at two Italian universities from May 2016 to May 2018 both during the second and the third year course. The questionnaire features 24 items with four caring factors: Factor 1 ‘Being with’, Factor 2 ‘Doing with competence’, Factor 3 ‘Responding to individual needs’, Factor 4 ‘Providing effective care’. The Wilcoxon signedrank test was used to assess differences between factors. Multiple regression analyses were conducted in order to evaluate variables associated with the increase or decrease of factors over time. Results: Results show a significant increase in Factor 2 during the selected period, which is positively associated with delta-Factor 1 and delta-Factor 3 and negatively associated with surgery clerkship during the third year of their course. Moreover, there is a significant decrease in Factor 3 between the second and third academic year and the variable positively associated to this decrease is the delta-Factor 4. Conclusions: One of the main risks of nursing education is an asymmetric impact in favour of doing at the expense of being. In this study, we demonstrated that nursing students reported an increase in instrumental caring and a decrease in expressive caring. These results suggest that a specific training in expressive caring in the third term could be a viable answer to this unmet need in nursing education.
1. Introduction and literature The importance of caring, in terms of good and effective nurse-patient relationship (Watson, 2012; Mortari and Saiani, 2014), is internationally acknowledged by the nursing community as a fundamental value in the education of healthcare workers (Hills and Watson, 2011; Duffy, 2018; Gierach et al., 2019). The growing body of research on this issue (Turkel et al., 2018; Duffy, 2018) as well as the correlation found between caring and professional identity among nursing students (Guo et al., 2018), show how critical is caring for both quality assistance and
healthcare workers' satisfaction. The Nursing Theory of Transpersonal Caring through carative factors (Watson, 1979, 2008), is an effective tool to measure some caring features in nursing practice (Di Napoli et al., 2010; Watson, 2009; Sitzman and Watson, 2019). Nursing students have to develop relational and listening skills and understand that it's not a mistake spending time engaging in conversation with and listening to their patients (Haugland et al., 2018; Rosser et al., 2019). Caring is expected to increase in importance among nursing
⁎
Corresponding author at: Tor Vergata University, Via Montpellier 1, 00133 Rome, Italy. E-mail addresses: [email protected] (E. Fenizia), [email protected] (L. Navarini), [email protected] (S. Scollo), [email protected] (A. Gambera), [email protected] (M. Ciccozzi). 1 Unit of Allergy, Immunology and Rheumatology, Department of Medicine, Campus Bio-Medico University of Rome, via Alvaro del Portillo 21, 00128, Rome, Italy. 2 University of Catania, Piazza Università 2 - 95124 Catania, Italy. 3 School of Nursing, Faculty of Medicine, University of Catania, Piazza Università 2 - 95124 Catania, Italy. 4 Unit of Medical Statistic and Molecular Epidemiology, Department of Medicine, Campus Bio-Medico of Rome University, via Álvaro del Portillo 21 - 00128 Rome, Italy. https://doi.org/10.1016/j.nedt.2020.104377 Received 2 June 2019; Received in revised form 17 December 2019; Accepted 15 February 2020 0260-6917/ © 2020 Elsevier Ltd. All rights reserved.
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students during their university years (Murphy et al., 2009) and ‘expressive caring’ should, in turn, become more relevant in the student's academic preparation (Labrague et al., 2015a,b). Literature denounces that computerization of services and healthcare organizations, being increasingly task and routine-oriented translates into less time spent on actual caring (Vandenhouten et al., 2012; Tomietto et al., 2014; PérezFuentes et al., 2019). Students are affected by this phenomenon and should be helped to emulate the positive example of caring nurses (Fenizia et al., 2019a). Self-reflection is a learning tool that can help internalize the caring dimension. Students, helped by their clinical tutors (McClure and Black, 2013) should master the skills of reflective practice (Schön, 2017) balancing the two caring dimensions, the technical and the relational one, for both the patients' and their own wellbeing. In fact, self-reflection is considered the precursor of the development of caring in students (Kim and Patterson, 2016). Moreover, being conscious of caring behaviors contributes to preparing professionals to be able to communicate effectively, to be competent, respectful, trusting and brave (Labrague et al., 2016). Also being the recipients of a care relationship by both colleagues and professors facilitates the development of caring behaviors on the part of the students (Smith et al., 2013). Conflicting views have been reported in relation to sex (Aupia et al., 2018), age and working years (Vandenhouten et al., 2012). Regarding the time variable of the university years, it has been observed a significant decrease of caring levels among students between their first and last academic year (Murphy et al., 2009). These studies suggest a possible association between the above mentioned variables and levels of caring, putting forward the necessity to further investigate such decrease on larger samples of participants and in different cultural contexts (Labrague et al., 2015a,b; Loke et al., 2015; Murphy et al., 2009). More self-evaluations during clinical clerkship would allow students to participate more actively to their academic learning, making it easier to reach their educational objectives (Alvaro et al., 2009). One of the tools that was developed since the advent of nursing caring theories (Smith et al., 2013), is Wolf's Caring Behaviors Inventory (Wolf, 1986), which can be used by students for their caring behaviors self-evaluation tests during their clinical clerkship. The efficacy of the impact of nursing education on the students' caring behaviors is not clear (Loke et al., 2015; Labrague et al., 2015b; Aupia et al., 2018). More research on the associations between the students' caring behaviors and variables such as their university year and the department or ward where their clinical clerkship takes place, might establish a stronger generalization of results, thus facilitating the implementation of effective educational strategies (Salgado et al., 2015; Aupia et al., 2018; Fenizia et al., 2019b). The Caring Behaviors Inventory Short Form (Wu et al., 2006), is a questionnaire made up of 24 items and four dimensions or factors. The ‘Italian Caring Behaviors Inventory’ version (CBIta) has been validated (Tomietto et al., 2014) and psychometrically tested with Italian students (Fenizia et al., 2019b). This last analysis found that the 24 statements represent the following four correlated caring factors (F1–F4): F1 ‘Being with’ is correlated with F3 ‘Responding to individual needs’, and F2 ‘Doing with competence’ with F4 ‘providing effective care’. This wording is in line with the definitions used in other nursingrelated studies (Loke et al., 2015): the questionnaire highlights concrete features that can help students reflect on their clinical practice to improve their caring skills in both the expressive caring and the instrumental caring dimensions. The aim of the present study is to investigate and account for the students' caring behaviors during clinical clerkship with a specific focus on behavioral differences taking place over the academic period.
2. Methods 2.1. Study design Descriptive longitudinal study. Data were collected between May 2016 and May 2018. 2.2. Sampling Participants were all undergraduate nursing students of two Italian Universities (Catania and Rome) who were present in the classroom when the project was outlined and the questionnaire was distributed by the researcher; during a class chosen at random. Informed consent was implicit if they chose to participate filling out the form they were given. Every student completed the questionnaire at two different stages: time zero (t0) and time one (t1), that is, second and third year course, both during their respective second semesters. The participants were also asked to fill out a grid with their demographic details: sex, age, university term, university, clinical sector of their clerkship, religion, marital status (married, single, in a partnership), previous caring experiences. Criterion of inclusion was that participants had already completed at least two weeks of clinical clerkship. 2.3. Tool The Italian Caring Behavior Inventory for students (CBIta) is a 24item questionnaire with four dimensions: ‘Being with’ (F1), ‘Doing with competence’ (F2), ‘Responding to individual needs’ (F3) and ‘Providing effective care’ (F4) (Fenizia et al., 2019b). The answers to the questionnaire are based on a six-point Likert scale (1 = never, 2 = seldom, 3 = occasionally, 4 = usually, 5 = almost always, 6 = always). The theoretical framework of the questionnaire is based on the carative factors mentioned in the introduction (Watson, 1979, 2008) adapted from the original version (Wolf, 1986). Answers were then analyzed grouping the items' values according to the questionnaire's factor solutions. These factors, which are latent variables underlying a group of statements are also called dimensions (Barbaranelli and Ingoglia, 2013). 2.4. Data analysis Data were analyzed using the Shapiro-Wilk test to evaluate its normal distribution. The non-parametric indexes positions of the sample were then calculated. The Wilcoxon signed-rank test for paired data was used to test differences between the second and third year course regarding F1, F2, F3 and F4. The Chi-squared test was used to determine the contingency tables. The differences between factors in the third year (t1) and factors in the second year (t0) are called deltaFn (delta F1, deltaF2, deltaF3, deltaF4). Continuous variables are expressed as median (25th–75th percentile). Univariate linear regression was used to identify variables related with deltaFn; only the factors associated to the dependent variables with p ≤ 0.05 in univariate analysis were considered suitable for multivariate analysis. STATA v.14.0 software was used for descriptive analysis and for the associations between the variables. 2.5. Ethics Approval (IRB approval number 25.16 TS) and relative authorization to use the questionnaire was obtained from the ethics committee and the competent academic authorities. Data protection was guaranteed. 2
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A significant decrease in F3 was also found from the second to the third year: 34 (32–35) and 33 (31–35), respectively (p = 0.042). No significant difference between the second and the third year was found regarding F1 and F4 (Fig. 1). As reported in Table 2, deltaF1, deltaF3, and deltaF4 were positively associated with deltaF2, whereas surgery clerkship during the third year course and baseline F1 were negatively associated with deltaF2. In multivariate analysis (Table 3), only deltaF1 and deltaF3 were positively associated with deltaF2, while surgery clerkship during the third year course was negatively associated with deltaF2. As shown in Table 4, deltaF1, deltaF3, and deltaF4 and surgery clerkship during the second year course were positively associated with deltaF3, whereas F2baseline and F4baseline were negatively associated with deltaF3. In multivariate analysis (Table 5), only deltaF4 was positively associated with deltaF3.
Table 1 Students' socio-demographic characteristics (n = 103). % Sex Male (%) Female (%) Marital status Single (%) Partner (%) Religion Defined (%) Undefined (%) Previous caring experiences Yes (%) Not (%) Unit t0 Surgery (%) Other units (%) Unit t1 Surgery (%) Other units (%)
30.10 69.90 72.70 27.30 84.85 15.15 36.89 63.11 43.70 56.30
4. Discussion and conclusions
19.40 80,60
The study analyzed how the caring levels of undergraduate students changed from the second to the third year course. The CBI questionnaire measures both instrumental and expressive caring (Loke et al., 2015; Fenizia et al., 2019b). The findings show a dichotomous progress in the two aspects of caring. We found a significant improvement in the dimension ‘Doing with competence’ and a significant decrease in the dimension ‘Responding to individual needs’ both of which refer to the ‘instrumental caring’ and ‘expressive caring’ dimensions respectively (Fig. 1). In other words, the technical skills grow over time, whereas all relational skills struggle to take off. We inferred that teaching instrumental caring is more effective and more in line with current teaching techniques. In Italy, as in other countries (Labrague et al., 2015a,b),
Note: t0 = second year course; t1 = third year course.
3. Results A total of 103 nursing students, median age of 21 (21−23) years, filled out the questionnaire from May 2016 to May 2018. Each student completed the questionnaire both in the second and the third year course. Socio-demographic characteristics have been summarized in Table 1. A significant increase in F2 was found to take place from the second to the third year: 27 (25–28) and 27 (25–29), respectively (p = 0.044).
Fig. 1. Levels of caring of the sample in the four dimensions during the second and third year course. The values are expressed by the median scores and calculated with the Wilcoxon signed-rank test for paired data. Note: * = p < 0.05; F = caring factor or dimension. 3
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Table 2 Univariate analysis with the different scores of F2 between the second and the third year of the course. Socio-demographic characteristics
Coef. (95% CI)
p
Age Sex M Marital status (partner) Religion (defined) Previous caring experiences (yes) Surgery II year vs other units Surgery III year vs other units F1 baseline F3 baseline F4 baseline Delta F1 Delta F3 Delta F4
−0.0858285 (−0.2260145–0.0543574) −0.7777778 (−1.953216–0.3976606) 0.0271382 (−1.093479–1.147755) −0.6214286 (−2.167062–0.924205) 0.9732794 (−0.1370877–2.083646) 0.1 (−0.9960475–1.196047) −1.605422 (−2.942962 to −0.2678812) −0.1307728 (−0.2130544 to −0.0484912) −0.1599919 (−0.335362–0.0153782) −0.2291701 (−0.5454304–0.0870902) 0.1582154 (0.0993763–0.2170544) 0.2570792 (0.1163389–0.3978195) 0.333091 (0.0664909–0.5996911)
0.23 0.19 0.96 0.43 0.085 0.86 0.019 0.002 0.073 0.15 < 0.001 < 0.001 0.015
Note: bold = p < 0.05; F1 = Being with; F2 = Doing with competence; F3 = Responding to individual needs; F4 = Providing effective care.
the minutest aspects of their relationship with their patients, nurses and the other students. An excellent educational program and the presence of clinical tutors is not enough. Students have to be able to reflect, ask the right questions, draw comparisons and evaluate answers and behaviors. What makes learning a meaningful process, is not only the repetitiveness of their experiences to enhance their technical skills, but the depth through which meanings are investigated and given significance to. It is worth noticing that the delta of the two expressive caring dimensions, ‘Being with’ and ‘Responding to individual needs’ were positively associated with the delta of ‘Doing with competence’. This may mean that the commitment to enhance aspects of expressive caring could also have positive effects on instrumental caring, remarking the importance of a harmonic development of expressive caring and instrumental caring, as well as its relative educational challenges. Nursing is about following standard procedures and implementing techniques, but excellent nursing is about a strongly humanized approach which unites technical competences and relational skills. The negative association between the increase in the “Doing with competence” caring dimension and the clinical clerkship in the area of clinical surgery in the third year requires further research in order to bridge the gap between the two dimensions. A possible path could be measuring the expressive caring levels in all clinical environments which could help identify the departments whose dynamics facilitate the development of expressive caring among third year course students. Another observation regards the number of items in the questionnaire. The one we used, which features 24 items, allows us to differentiate the four dimensions stimulating the self-assessment on both
Table 3 Multivariate analysis with the different scores of F2 between the second and the third year of the course. Socio-demographic characteristics
Coef. (95% CI)
p
Surgery III year vs other units F1 baseline Delta F1 Delta F3 Delta F4
−1.418485 (−2.583614 to −0.253357) 0.0230389 (−0.0883258–0.1344036) 0.138869 (0.0499211–0.2278168) 0.200038 (0.0170741–0.3830019) 0.1005765 (−0.1558231–0.3569761)
0.018 0.68 0.003 0.032 0.44
Note: bold = p < 0.05; F1 = Being with; F2 = Doing with competence; F3 = Responding to individual needs; F4 = Providing effective care.
expressive caring education needs a more effective approach. The multivariate regression findings show that a possible cause for the decrease in the dimension ‘Responding to individual needs’ lies in the variation of the levels of the ‘Providing effective care’ dimension. This would confirm the hypothesis that there is an asymmetric educational impact: the development of instrumental caring takes place at the expense of expressive caring, while both dimensions should grow over time. At the end of the third year, students have learned many things, and they perform their tasks well and responsibly. This does not mean however, that their communication performances and their own identity as nurses are adequately grounded in the concept transpersonal caring. This second set of skills, which has a lot to do with the nurses' professional style and their humanization, depends on the students' observation and reflection skills and on their capacity to reprocess even
Table 4 Univariate analysis with the different scores of F3 between the second and the third year of the course. Socio-demographic characteristics
Coef. (95% CI)
p
Age Sex M Marital status (partner) Religion (defined) Previous caring experiences (yes) Surgery II year vs other units Surgery III year vs other units F1 baseline F2 baseline F4 baseline Delta F1 Delta F2 Delta F4
0.1138765 (−0.0710645–0.2988175) 0.4632616 (−1.098065–2.024589) 0.1743421 (−1.322454–1.671138) −1.269048 (−3.316507–0.7784121) 0.0315789 (−1.455152–1.518309) 1.518391 (0.1034658–2.933316) −0.2006024 (−2.013724–1.612519) −0.0573404 (−0.170552–0.0558713) −0.3879683 (−0.6451904 to −0.1307463) −0.382595 (−0.709255 to −0.0559348) 0.1112524 (0.0261529–0.1963519) 0.4475031 (0.2025136–0.6924926) 0.5469613 (0.2798686–0.8140541)
0.23 0.56 0.82 0.22 0.97 0.036 0.83 0.32 0.003 0.022 0.011 < 0.001 < 0.001
Note: bold = p < 0.05; F1 = Being with; F2 = Doing with competence; F3 = Responding to individual needs; F4 = Providing effective care. 4
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Funding source
Table 5 Multivariate analysis with the different scores of F3 between the second and the third year of the course. Coef. (95% CI)
p
0.9864054 (−0.0277776–2.000588) −0.1958521 (−0.4607458–0.0690416) 0.2116682 (−0.2141878–0.6375242) 0.0519672 (−0.019657–0.1235914) 0.1218766 (−0.1364725–0.3802258) 0.5390488 (0.1943354–0.8837622)
0.056 0.15 0.33 0.15 0.35 0.003
None declared. Ethical approval
Surgery II year vs other units F2 baseline F4 baseline Delta F1 Delta F2 Delta F4
IRB approval number 25.16 TS. Declaration of competing interest Not applicable.
Note: bold = p < 0.05; F1 = Being with; F2 = Doing with competence; F3 = Responding to individual needs; F4 = Providing effective care.
Acknowledgements
the expressive and instrumental caring, which is critical during the academic training. However, when we wish to measure caring behaviors from the point of view of the patients, it is better to use tools with less items such as the 16-item CBI (Wolf et al., 2017) or the NCBS (Nurse Caring Behaviours Scale) (Piredda et al., 2017), to avoid tiring the patients.
The authors would like to thank Professor Jean Watson for the contribution of the Transpersonal Caring Theory, Professor Zane Wolf for the CBI development, Doctor Marco Tomietto for the CBI translation, the authors of the Italian students' questionnaire validation and Doctor Robert Martini for the language revision. We are also most grateful to all the students who made the study possible by filling out the questionnaire.
4.1. Limitations
References
We believe this study has four limitations: the sample was made up of participants of only two Italian Universities; it should have been larger; it should have included participant students of more universities as well as first year course ones with clinical clerkship experience (our sample had none), for the sample's stratification according to sociodemographic characteristics. Given the complexity of the reality of caring, our findings confirm that the issue calls for a comprehensive and multidisciplinary approach (Sitzman and Watson, 2019) through tools capable of measuring the clinical environment (Tomietto et al., 2012), empathy (Lee et al., 2018), humanization of care (Pérez-Fuentes et al., 2019) and the various skills involved (Kemery and Morrell, 2019). In conclusion caring self-assessments through tools such as the CBI questionnaire may help students stimulate their self-awareness and reflective practice, for a harmonious blend of technical skills, relational skills and ethical values. Faculty members and clinical nurses of the teaching hospital should also play a central role in the creation of the students' hidden curriculum. In turn, this would help students internalize their professors and clinical tutors' sets of values and relational styles so that these become their own. Therefore, ad hoc expressive caring training and tutoring could represent an answer to this unmet need in nursing education. Further research could focus on a number of areas. We would suggest further studies on clinical governance policies to enhance the clinical learning environment and tutoring methods, such as, for instance, whether a clinical clerkship period in pediatric wards may facilitate the development of caring in students. Teaching and learning methodologies and tools could be other areas of interest as well as on methods aimed at raising more awareness on the issue of ethics in relation to caring outcomes throughout the educational process.
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Authors' statement All authors have made substantial contributions as follows: Elisa Fenizia (EF), in the conception and design of the study; EF, Sarah Scollo (SS) and Angelo Gambera (AG) in the acquisition of data; EF, Luca Navarini (LN), Massimo Ciccozzi (MC) in the analysis of data; EF, SS, LN, and MC in the interpretation of data, in drafting the article or revising it critically and in the final approval of the version to be submitted.
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A longitudinal study on caring behaviors of Italian nursing students a,⁎
Elisa Fenizia , Luca Navarini a b c
b,1
c,2
c,3
, Sarah Scollo , Angelo Gambera , Massimo Ciccozzi
T b,4
Department of Biomedicine and Prevention, School of Nursing, Faculty of Medicine, Tor Vergata University, Rome, Italy Department of Medicine, Campus Bio-Medico University of Rome, via Alvaro del Portillo 21, 00128 Rome, Italy School of Nursing, Faculty of Medicine, University of Catania, Catania, Italy
A R T I C LE I N FO
A B S T R A C T
Keywords: Behavior Caring Education Nursing students Nursing Surveys and questionnaires
Aim and objective: The aim of this study was to analyze the caring behavioral differences taking place over the nursing academic period. Background: Caring is a core value in nursing education and many of its features can be measured as specific behaviors. The Italian Caring Behaviors Inventory is a tested psychometric questionnaire, useful to this aim. The use of the questionnaire facilitates the student's self-reflection and awareness. Design: Descriptive longitudinal study. Method: The Italian Caring Behaviors Inventory questionnaire was filled out by 103 undergraduate nursing students at two Italian universities from May 2016 to May 2018 both during the second and the third year course. The questionnaire features 24 items with four caring factors: Factor 1 ‘Being with’, Factor 2 ‘Doing with competence’, Factor 3 ‘Responding to individual needs’, Factor 4 ‘Providing effective care’. The Wilcoxon signedrank test was used to assess differences between factors. Multiple regression analyses were conducted in order to evaluate variables associated with the increase or decrease of factors over time. Results: Results show a significant increase in Factor 2 during the selected period, which is positively associated with delta-Factor 1 and delta-Factor 3 and negatively associated with surgery clerkship during the third year of their course. Moreover, there is a significant decrease in Factor 3 between the second and third academic year and the variable positively associated to this decrease is the delta-Factor 4. Conclusions: One of the main risks of nursing education is an asymmetric impact in favour of doing at the expense of being. In this study, we demonstrated that nursing students reported an increase in instrumental caring and a decrease in expressive caring. These results suggest that a specific training in expressive caring in the third term could be a viable answer to this unmet need in nursing education.
1. Introduction and literature The importance of caring, in terms of good and effective nurse-patient relationship (Watson, 2012; Mortari and Saiani, 2014), is internationally acknowledged by the nursing community as a fundamental value in the education of healthcare workers (Hills and Watson, 2011; Duffy, 2018; Gierach et al., 2019). The growing body of research on this issue (Turkel et al., 2018; Duffy, 2018) as well as the correlation found between caring and professional identity among nursing students (Guo et al., 2018), show how critical is caring for both quality assistance and
healthcare workers' satisfaction. The Nursing Theory of Transpersonal Caring through carative factors (Watson, 1979, 2008), is an effective tool to measure some caring features in nursing practice (Di Napoli et al., 2010; Watson, 2009; Sitzman and Watson, 2019). Nursing students have to develop relational and listening skills and understand that it's not a mistake spending time engaging in conversation with and listening to their patients (Haugland et al., 2018; Rosser et al., 2019). Caring is expected to increase in importance among nursing
⁎
Corresponding author at: Tor Vergata University, Via Montpellier 1, 00133 Rome, Italy. E-mail addresses: [email protected] (E. Fenizia), [email protected] (L. Navarini), [email protected] (S. Scollo), [email protected] (A. Gambera), [email protected] (M. Ciccozzi). 1 Unit of Allergy, Immunology and Rheumatology, Department of Medicine, Campus Bio-Medico University of Rome, via Alvaro del Portillo 21, 00128, Rome, Italy. 2 University of Catania, Piazza Università 2 - 95124 Catania, Italy. 3 School of Nursing, Faculty of Medicine, University of Catania, Piazza Università 2 - 95124 Catania, Italy. 4 Unit of Medical Statistic and Molecular Epidemiology, Department of Medicine, Campus Bio-Medico of Rome University, via Álvaro del Portillo 21 - 00128 Rome, Italy. https://doi.org/10.1016/j.nedt.2020.104377 Received 2 June 2019; Received in revised form 17 December 2019; Accepted 15 February 2020 0260-6917/ © 2020 Elsevier Ltd. All rights reserved.
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students during their university years (Murphy et al., 2009) and ‘expressive caring’ should, in turn, become more relevant in the student's academic preparation (Labrague et al., 2015a,b). Literature denounces that computerization of services and healthcare organizations, being increasingly task and routine-oriented translates into less time spent on actual caring (Vandenhouten et al., 2012; Tomietto et al., 2014; PérezFuentes et al., 2019). Students are affected by this phenomenon and should be helped to emulate the positive example of caring nurses (Fenizia et al., 2019a). Self-reflection is a learning tool that can help internalize the caring dimension. Students, helped by their clinical tutors (McClure and Black, 2013) should master the skills of reflective practice (Schön, 2017) balancing the two caring dimensions, the technical and the relational one, for both the patients' and their own wellbeing. In fact, self-reflection is considered the precursor of the development of caring in students (Kim and Patterson, 2016). Moreover, being conscious of caring behaviors contributes to preparing professionals to be able to communicate effectively, to be competent, respectful, trusting and brave (Labrague et al., 2016). Also being the recipients of a care relationship by both colleagues and professors facilitates the development of caring behaviors on the part of the students (Smith et al., 2013). Conflicting views have been reported in relation to sex (Aupia et al., 2018), age and working years (Vandenhouten et al., 2012). Regarding the time variable of the university years, it has been observed a significant decrease of caring levels among students between their first and last academic year (Murphy et al., 2009). These studies suggest a possible association between the above mentioned variables and levels of caring, putting forward the necessity to further investigate such decrease on larger samples of participants and in different cultural contexts (Labrague et al., 2015a,b; Loke et al., 2015; Murphy et al., 2009). More self-evaluations during clinical clerkship would allow students to participate more actively to their academic learning, making it easier to reach their educational objectives (Alvaro et al., 2009). One of the tools that was developed since the advent of nursing caring theories (Smith et al., 2013), is Wolf's Caring Behaviors Inventory (Wolf, 1986), which can be used by students for their caring behaviors self-evaluation tests during their clinical clerkship. The efficacy of the impact of nursing education on the students' caring behaviors is not clear (Loke et al., 2015; Labrague et al., 2015b; Aupia et al., 2018). More research on the associations between the students' caring behaviors and variables such as their university year and the department or ward where their clinical clerkship takes place, might establish a stronger generalization of results, thus facilitating the implementation of effective educational strategies (Salgado et al., 2015; Aupia et al., 2018; Fenizia et al., 2019b). The Caring Behaviors Inventory Short Form (Wu et al., 2006), is a questionnaire made up of 24 items and four dimensions or factors. The ‘Italian Caring Behaviors Inventory’ version (CBIta) has been validated (Tomietto et al., 2014) and psychometrically tested with Italian students (Fenizia et al., 2019b). This last analysis found that the 24 statements represent the following four correlated caring factors (F1–F4): F1 ‘Being with’ is correlated with F3 ‘Responding to individual needs’, and F2 ‘Doing with competence’ with F4 ‘providing effective care’. This wording is in line with the definitions used in other nursingrelated studies (Loke et al., 2015): the questionnaire highlights concrete features that can help students reflect on their clinical practice to improve their caring skills in both the expressive caring and the instrumental caring dimensions. The aim of the present study is to investigate and account for the students' caring behaviors during clinical clerkship with a specific focus on behavioral differences taking place over the academic period.
2. Methods 2.1. Study design Descriptive longitudinal study. Data were collected between May 2016 and May 2018. 2.2. Sampling Participants were all undergraduate nursing students of two Italian Universities (Catania and Rome) who were present in the classroom when the project was outlined and the questionnaire was distributed by the researcher; during a class chosen at random. Informed consent was implicit if they chose to participate filling out the form they were given. Every student completed the questionnaire at two different stages: time zero (t0) and time one (t1), that is, second and third year course, both during their respective second semesters. The participants were also asked to fill out a grid with their demographic details: sex, age, university term, university, clinical sector of their clerkship, religion, marital status (married, single, in a partnership), previous caring experiences. Criterion of inclusion was that participants had already completed at least two weeks of clinical clerkship. 2.3. Tool The Italian Caring Behavior Inventory for students (CBIta) is a 24item questionnaire with four dimensions: ‘Being with’ (F1), ‘Doing with competence’ (F2), ‘Responding to individual needs’ (F3) and ‘Providing effective care’ (F4) (Fenizia et al., 2019b). The answers to the questionnaire are based on a six-point Likert scale (1 = never, 2 = seldom, 3 = occasionally, 4 = usually, 5 = almost always, 6 = always). The theoretical framework of the questionnaire is based on the carative factors mentioned in the introduction (Watson, 1979, 2008) adapted from the original version (Wolf, 1986). Answers were then analyzed grouping the items' values according to the questionnaire's factor solutions. These factors, which are latent variables underlying a group of statements are also called dimensions (Barbaranelli and Ingoglia, 2013). 2.4. Data analysis Data were analyzed using the Shapiro-Wilk test to evaluate its normal distribution. The non-parametric indexes positions of the sample were then calculated. The Wilcoxon signed-rank test for paired data was used to test differences between the second and third year course regarding F1, F2, F3 and F4. The Chi-squared test was used to determine the contingency tables. The differences between factors in the third year (t1) and factors in the second year (t0) are called deltaFn (delta F1, deltaF2, deltaF3, deltaF4). Continuous variables are expressed as median (25th–75th percentile). Univariate linear regression was used to identify variables related with deltaFn; only the factors associated to the dependent variables with p ≤ 0.05 in univariate analysis were considered suitable for multivariate analysis. STATA v.14.0 software was used for descriptive analysis and for the associations between the variables. 2.5. Ethics Approval (IRB approval number 25.16 TS) and relative authorization to use the questionnaire was obtained from the ethics committee and the competent academic authorities. Data protection was guaranteed. 2
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A significant decrease in F3 was also found from the second to the third year: 34 (32–35) and 33 (31–35), respectively (p = 0.042). No significant difference between the second and the third year was found regarding F1 and F4 (Fig. 1). As reported in Table 2, deltaF1, deltaF3, and deltaF4 were positively associated with deltaF2, whereas surgery clerkship during the third year course and baseline F1 were negatively associated with deltaF2. In multivariate analysis (Table 3), only deltaF1 and deltaF3 were positively associated with deltaF2, while surgery clerkship during the third year course was negatively associated with deltaF2. As shown in Table 4, deltaF1, deltaF3, and deltaF4 and surgery clerkship during the second year course were positively associated with deltaF3, whereas F2baseline and F4baseline were negatively associated with deltaF3. In multivariate analysis (Table 5), only deltaF4 was positively associated with deltaF3.
Table 1 Students' socio-demographic characteristics (n = 103). % Sex Male (%) Female (%) Marital status Single (%) Partner (%) Religion Defined (%) Undefined (%) Previous caring experiences Yes (%) Not (%) Unit t0 Surgery (%) Other units (%) Unit t1 Surgery (%) Other units (%)
30.10 69.90 72.70 27.30 84.85 15.15 36.89 63.11 43.70 56.30
4. Discussion and conclusions
19.40 80,60
The study analyzed how the caring levels of undergraduate students changed from the second to the third year course. The CBI questionnaire measures both instrumental and expressive caring (Loke et al., 2015; Fenizia et al., 2019b). The findings show a dichotomous progress in the two aspects of caring. We found a significant improvement in the dimension ‘Doing with competence’ and a significant decrease in the dimension ‘Responding to individual needs’ both of which refer to the ‘instrumental caring’ and ‘expressive caring’ dimensions respectively (Fig. 1). In other words, the technical skills grow over time, whereas all relational skills struggle to take off. We inferred that teaching instrumental caring is more effective and more in line with current teaching techniques. In Italy, as in other countries (Labrague et al., 2015a,b),
Note: t0 = second year course; t1 = third year course.
3. Results A total of 103 nursing students, median age of 21 (21−23) years, filled out the questionnaire from May 2016 to May 2018. Each student completed the questionnaire both in the second and the third year course. Socio-demographic characteristics have been summarized in Table 1. A significant increase in F2 was found to take place from the second to the third year: 27 (25–28) and 27 (25–29), respectively (p = 0.044).
Fig. 1. Levels of caring of the sample in the four dimensions during the second and third year course. The values are expressed by the median scores and calculated with the Wilcoxon signed-rank test for paired data. Note: * = p < 0.05; F = caring factor or dimension. 3
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Table 2 Univariate analysis with the different scores of F2 between the second and the third year of the course. Socio-demographic characteristics
Coef. (95% CI)
p
Age Sex M Marital status (partner) Religion (defined) Previous caring experiences (yes) Surgery II year vs other units Surgery III year vs other units F1 baseline F3 baseline F4 baseline Delta F1 Delta F3 Delta F4
−0.0858285 (−0.2260145–0.0543574) −0.7777778 (−1.953216–0.3976606) 0.0271382 (−1.093479–1.147755) −0.6214286 (−2.167062–0.924205) 0.9732794 (−0.1370877–2.083646) 0.1 (−0.9960475–1.196047) −1.605422 (−2.942962 to −0.2678812) −0.1307728 (−0.2130544 to −0.0484912) −0.1599919 (−0.335362–0.0153782) −0.2291701 (−0.5454304–0.0870902) 0.1582154 (0.0993763–0.2170544) 0.2570792 (0.1163389–0.3978195) 0.333091 (0.0664909–0.5996911)
0.23 0.19 0.96 0.43 0.085 0.86 0.019 0.002 0.073 0.15 < 0.001 < 0.001 0.015
Note: bold = p < 0.05; F1 = Being with; F2 = Doing with competence; F3 = Responding to individual needs; F4 = Providing effective care.
the minutest aspects of their relationship with their patients, nurses and the other students. An excellent educational program and the presence of clinical tutors is not enough. Students have to be able to reflect, ask the right questions, draw comparisons and evaluate answers and behaviors. What makes learning a meaningful process, is not only the repetitiveness of their experiences to enhance their technical skills, but the depth through which meanings are investigated and given significance to. It is worth noticing that the delta of the two expressive caring dimensions, ‘Being with’ and ‘Responding to individual needs’ were positively associated with the delta of ‘Doing with competence’. This may mean that the commitment to enhance aspects of expressive caring could also have positive effects on instrumental caring, remarking the importance of a harmonic development of expressive caring and instrumental caring, as well as its relative educational challenges. Nursing is about following standard procedures and implementing techniques, but excellent nursing is about a strongly humanized approach which unites technical competences and relational skills. The negative association between the increase in the “Doing with competence” caring dimension and the clinical clerkship in the area of clinical surgery in the third year requires further research in order to bridge the gap between the two dimensions. A possible path could be measuring the expressive caring levels in all clinical environments which could help identify the departments whose dynamics facilitate the development of expressive caring among third year course students. Another observation regards the number of items in the questionnaire. The one we used, which features 24 items, allows us to differentiate the four dimensions stimulating the self-assessment on both
Table 3 Multivariate analysis with the different scores of F2 between the second and the third year of the course. Socio-demographic characteristics
Coef. (95% CI)
p
Surgery III year vs other units F1 baseline Delta F1 Delta F3 Delta F4
−1.418485 (−2.583614 to −0.253357) 0.0230389 (−0.0883258–0.1344036) 0.138869 (0.0499211–0.2278168) 0.200038 (0.0170741–0.3830019) 0.1005765 (−0.1558231–0.3569761)
0.018 0.68 0.003 0.032 0.44
Note: bold = p < 0.05; F1 = Being with; F2 = Doing with competence; F3 = Responding to individual needs; F4 = Providing effective care.
expressive caring education needs a more effective approach. The multivariate regression findings show that a possible cause for the decrease in the dimension ‘Responding to individual needs’ lies in the variation of the levels of the ‘Providing effective care’ dimension. This would confirm the hypothesis that there is an asymmetric educational impact: the development of instrumental caring takes place at the expense of expressive caring, while both dimensions should grow over time. At the end of the third year, students have learned many things, and they perform their tasks well and responsibly. This does not mean however, that their communication performances and their own identity as nurses are adequately grounded in the concept transpersonal caring. This second set of skills, which has a lot to do with the nurses' professional style and their humanization, depends on the students' observation and reflection skills and on their capacity to reprocess even
Table 4 Univariate analysis with the different scores of F3 between the second and the third year of the course. Socio-demographic characteristics
Coef. (95% CI)
p
Age Sex M Marital status (partner) Religion (defined) Previous caring experiences (yes) Surgery II year vs other units Surgery III year vs other units F1 baseline F2 baseline F4 baseline Delta F1 Delta F2 Delta F4
0.1138765 (−0.0710645–0.2988175) 0.4632616 (−1.098065–2.024589) 0.1743421 (−1.322454–1.671138) −1.269048 (−3.316507–0.7784121) 0.0315789 (−1.455152–1.518309) 1.518391 (0.1034658–2.933316) −0.2006024 (−2.013724–1.612519) −0.0573404 (−0.170552–0.0558713) −0.3879683 (−0.6451904 to −0.1307463) −0.382595 (−0.709255 to −0.0559348) 0.1112524 (0.0261529–0.1963519) 0.4475031 (0.2025136–0.6924926) 0.5469613 (0.2798686–0.8140541)
0.23 0.56 0.82 0.22 0.97 0.036 0.83 0.32 0.003 0.022 0.011 < 0.001 < 0.001
Note: bold = p < 0.05; F1 = Being with; F2 = Doing with competence; F3 = Responding to individual needs; F4 = Providing effective care. 4
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Funding source
Table 5 Multivariate analysis with the different scores of F3 between the second and the third year of the course. Coef. (95% CI)
p
0.9864054 (−0.0277776–2.000588) −0.1958521 (−0.4607458–0.0690416) 0.2116682 (−0.2141878–0.6375242) 0.0519672 (−0.019657–0.1235914) 0.1218766 (−0.1364725–0.3802258) 0.5390488 (0.1943354–0.8837622)
0.056 0.15 0.33 0.15 0.35 0.003
None declared. Ethical approval
Surgery II year vs other units F2 baseline F4 baseline Delta F1 Delta F2 Delta F4
IRB approval number 25.16 TS. Declaration of competing interest Not applicable.
Note: bold = p < 0.05; F1 = Being with; F2 = Doing with competence; F3 = Responding to individual needs; F4 = Providing effective care.
Acknowledgements
the expressive and instrumental caring, which is critical during the academic training. However, when we wish to measure caring behaviors from the point of view of the patients, it is better to use tools with less items such as the 16-item CBI (Wolf et al., 2017) or the NCBS (Nurse Caring Behaviours Scale) (Piredda et al., 2017), to avoid tiring the patients.
The authors would like to thank Professor Jean Watson for the contribution of the Transpersonal Caring Theory, Professor Zane Wolf for the CBI development, Doctor Marco Tomietto for the CBI translation, the authors of the Italian students' questionnaire validation and Doctor Robert Martini for the language revision. We are also most grateful to all the students who made the study possible by filling out the questionnaire.
4.1. Limitations
References
We believe this study has four limitations: the sample was made up of participants of only two Italian Universities; it should have been larger; it should have included participant students of more universities as well as first year course ones with clinical clerkship experience (our sample had none), for the sample's stratification according to sociodemographic characteristics. Given the complexity of the reality of caring, our findings confirm that the issue calls for a comprehensive and multidisciplinary approach (Sitzman and Watson, 2019) through tools capable of measuring the clinical environment (Tomietto et al., 2012), empathy (Lee et al., 2018), humanization of care (Pérez-Fuentes et al., 2019) and the various skills involved (Kemery and Morrell, 2019). In conclusion caring self-assessments through tools such as the CBI questionnaire may help students stimulate their self-awareness and reflective practice, for a harmonious blend of technical skills, relational skills and ethical values. Faculty members and clinical nurses of the teaching hospital should also play a central role in the creation of the students' hidden curriculum. In turn, this would help students internalize their professors and clinical tutors' sets of values and relational styles so that these become their own. Therefore, ad hoc expressive caring training and tutoring could represent an answer to this unmet need in nursing education. Further research could focus on a number of areas. We would suggest further studies on clinical governance policies to enhance the clinical learning environment and tutoring methods, such as, for instance, whether a clinical clerkship period in pediatric wards may facilitate the development of caring in students. Teaching and learning methodologies and tools could be other areas of interest as well as on methods aimed at raising more awareness on the issue of ethics in relation to caring outcomes throughout the educational process.
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Authors' statement All authors have made substantial contributions as follows: Elisa Fenizia (EF), in the conception and design of the study; EF, Sarah Scollo (SS) and Angelo Gambera (AG) in the acquisition of data; EF, Luca Navarini (LN), Massimo Ciccozzi (MC) in the analysis of data; EF, SS, LN, and MC in the interpretation of data, in drafting the article or revising it critically and in the final approval of the version to be submitted.
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