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24461 Chapter Caring


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24461 Chapter Caring

  1. 1. Chapter 4 Want to Graduate Nurses Who Care? Assessing Nursing Students’ Caring Competencies Joanne R. Duffy F or several years, I have been measuring nurse caring behaviors and linking them to patient outcomes. Recently this work has led to the Quality-Caring Model© (Duffy & Hoskins, 2003) and the testing of caring-based interventions. In the course of this research, I have listened to patients tell me the positive outcomes that have resulted from caring interactions with nurses. Sadly, I also have heard patients voice concerns about lack of nurse caring and the resultant effects. For example, patients have reported feeling helpless, uncomfortable, anxious, unsafe, and even frightened when interacting with noncaring nurses (Duffy, 1992). Patients and their families long for human caring interactions with nurses and report negative consequences when such interactions are infrequent or absent (Reiman, 1986; Duffy, 1992). As an educator, ensuring that nursing graduates can meet the needs of patients and families is a paramount concern, and I have often wondered if nursing students are competent in caring on graduation. Identifying caring values, attitudes, and behaviors as important student learning outcomes and assessing the degree of their attainment provides im- portant evidence from which nurse educators can judge the success of their programs. The challenges of evidence-based practice are prompting nurse educators to evaluate the results of their programs in terms of specific learning outcomes. In fact, the evaluation of educational outcomes is 59
  2. 2. 60 ASSESSMENT AND EVALUATION an integral component of contemporary nursing education and a stan- dard for accreditation (Garbin, 1991; National League for Nursing Accrediting Commission, 2001; Commission on College Nursing Educa- tion, 2002). Daggett, Butts, and Smith (2002) suggested that evidence- based clinical practice and educational outcomes for nursing students are interconnected. Measuring educational outcomes and using the resultant data to continuously improve end-of-program competencies contribute to quality patient care and fulfill an important social responsibility of nurse educators. Educational outcomes evaluation is the “systematic process of col- lecting and interpreting information as a basis for decisions about learn- ers” (Oermann & Gaberson, 1998, p. 3). The National League for Nursing Accrediting Commission (NLNAC) has defined program evalu- ation as “the constant assessment and refinement of the program through a combination of process-focused and outcomes-focused approaches” (p. 3). It forms the basis for judging the quality and ultimately the value of a program. The recent emphasis on evidence-based quality improvement has shifted the focus of program evaluation to a student outcomes-focused approach. Educational outcomes are the result of the teaching and learning process; they are frequently measured formatively with tools such as quizzes, examinations, skills assessments, and written papers. Summative evaluation, on the other hand, occurs at the end of a course or program to determine if objectives have been met and are the basis for curricular revision. End-of-program evaluation of students’ performance, a form of summative evaluation, occurs at graduation and “provides culminating information about internal educational effective- ness” (Lenburg, 1991, p. 35). Students’ performance on key indicators at the time of graduation is an essential component of comprehensive outcomes assessment. Sum- mative evaluation of concepts considered central to the program’s curric- ulum and based on that program’s philosophy and objectives provides important evidence of programmatic success. Such evaluation helps meet the mandate of producing competent clinicians who ground their practice in research. “The most significant indicators of success are whether or not graduates can meet professional expectations” for prac- tice (Lenburg, 1991, p. 35). One such practice expectation is caring. Caring and its associated values, attitudes, and behaviors is consid- ered a major component of professional nursing education (American Association of Colleges of Nursing [AACN], 1998) and has been de-
  3. 3. WANT TO GRADUATE NURSES WHO CARE? 61 scribed as the essence of nursing (Watson, 1979, 1985). The nursing curricular revolution of the 1980s (Tanner, 1990), together with the American Nurses Association’s (ANA) revised Social Policy Statement for Nurses (2003), have promoted the renewed focus on caring and caring knowledge. The curricular revolution encouraged nurse educators to revise curricula to meet the needs of a significantly changed health care system. New pedagogies emerged such as Toward a Caring Curriculum: A New Pedagogy for Nursing (Bevis & Watson, 1989) that challenged nursing educators to teach, role model, and develop innovative learning strategies that promote caring. The Social Policy Statement for Nurses (ANA, 2003) acknowledges that “provision of a caring relationship that facilitates health and healing” (p. 5) is an essential feature of nursing knowledge. Caring content is typically integrated throughout nursing curricula but is rarely included in skills labs or other competency-based examina- tions. It is frequently assessed formatively during students’ clinical courses. However, minimal end-of-program evidence exists about nurse caring resulting in a paucity of knowledge about graduates’ competency in this crucial area. The purposes of this chapter then are to discuss what is known about nurse caring in the educational environment and to suggest methods for assessing the learning outcome of students’ competence in caring on graduation. REVIEW OF RELEVANT LITERATURE Although caring exists in a generic sense in all cultures (Leininger, 1988), the caring that exists in nursing practice is embedded in the daily work of nurses and has as its aim health and healing (Duffy, 2002). Caring competence in nurses, better known as clinical caring processes (Watson, 2002b), represent those values, attitudes, and behaviors that engender “feeling cared for” by recipients. Clinical caring processes are relationship-centered and incorporate physical acts, being with (inter- acting), connecting, and knowing another (Duffy, 2003). Caring is theo- rized to make a difference in patients’ sense of well-being, dignity, healing abilities, and self-knowledge, while simultaneously benefiting nurses (Watson, 1985). Caring is an expectation of patients and families and is the predominant adjective used by nursing students and nurses to characterize nursing practice (Duffy, 2003). Nurse caring is consid-
  4. 4. 62 ASSESSMENT AND EVALUATION ered the core or essence of nursing (Watson, 1985) and the basis for nursing interventions. Measurement of Nurse Caring Over the past two decades, nurse caring has been studied both qualita- tively and quantitatively. Early qualitative studies have helped define, assess the importance of, and evaluate the meaning of caring in various patient populations (Cronin & Harrison, 1988; Larson, 1987; Reiman, 1986; Swanson-Kaufman, 1986). Quantitative studies have added to the knowledge base regarding the measurement of nurse caring (Cronin & Harrison, 1988; Coates, 1997; Duffy, 1990; Wolf, 1986). Various mea- sures of nurse caring have been developed, albeit with differing concep- tual foundations and in specialized populations; they are currently organized in a recent publication (Watson, 2002a). Additionally, studies focused on nurse caring and patient outcomes have begun to link nurse caring with patient satisfaction, and other positive patient outcomes (Duffy, 1992; Issel & Kahn, 1998; Latham, 1996; Larson & Ferketich, 1999). The obvious implication is that health care outcomes are en- hanced as a result of human caring interactions with nurses. Nurse Caring in Schools of Nursing Educational studies of caring can be grouped into two broad categories: experiences of caring and caring teaching strategies. Hanson and Smith’s (1996) phenomenological study identified three themes of faculty caring based on interviews with nursing students: recognition, connection, and confirmation. The congruence of these characteristics with Watson’s carative factors (Watson, 1979, 1985) implies that faculty should strive for connectedness with students in an effort to maximize learning. In Beck’s (2001) metasynthesis of caring within schools of nursing, 14 qualitative studies were analyzed. Using a meta-ethnographic method, four major themes emerged: caring among faculty, faculty–nursing stu- dent caring, caring among nursing students, and caring between nursing students and patients. The central component of these themes was “reciprocal connecting” which consisted of presencing, supporting, shar- ing, competence, and uplifting effects. This synthesis of caring knowl-
  5. 5. WANT TO GRADUATE NURSES WHO CARE? 63 edge in education was limited by the small sample size, but, nevertheless, provided a model for creating caring environments in schools of nursing. Beck suggested that experiencing caring in the educational environment is contagious and even has a “trickle down effect” (p. 108) that can be translated into the practice environment. Teaching Caring Teaching caring is controversial; yet, several studies were found that suggested strategies that proved successful. In an early study, Darbyshire (1994) investigated the use of the arts and humanities to arouse a deeper appreciation of caring. Using a phenomenological approach, the author concluded that the students experienced this course as inclusive and cohesive; it allowed them to be open to new ways of learning about a concept already known. Simonson (1996) also used a phenomenological approach to study how faculty communicates caring to students. Through interviews with faculty and students and classroom observa- tions, she found patterns that were congruent with Watson’s carative factors. She concluded that faculty must exhibit caring as “a way of being” if they wished to teach it. Similarly, Gramling and Nugent (1998) suggested that knowledge of caring is attained through role modeling. They used Watson’s carative factors in a reflective journaling process together with a didactic caring unit that was placed in a professional nursing course early in the program. They found that when caring is introduced early, together with the concept of health, and modeled and reinforced throughout the curriculum, students’ performance shifted toward mastery. Grams, Kosowski, and Wilson (1997) used student/faculty groups to study how to create a caring community in nursing education. The aim was to allow students to experience caring through these groups. Using a phenomenological approach, including interviews with 25 sub- jects, the authors identified three patterns, namely, the creation of a caring community, experiencing reciprocity, and being transformed. Characteristics of the student/faculty relationships included mutual re- spect, helpfulness, attentive presence, recognition, connection, affirma- tion, meeting needs, role modeling, and genuineness. They concluded that students learn caring through faculty role modeling and must expe- rience it if they are to practice caring.
  6. 6. 64 ASSESSMENT AND EVALUATION Similarly, Schaffer and Juarez (1996) developed a strategy to en- hance caring in the learning environment and also concluded that the use of opportunities for genuine dialog between students and faculty resulted in increased communication, support, and reciprocal relation- ships. In this study, a sample of 42 seniors and 34 juniors met in small groups with a faculty facilitator four times a semester. This was purposely scheduled during class time to assure adherence. The authors concluded that teaching caring involves more than “how to” but includes role modeling. They believed the intervention was worth the 16 hours of class time! Pullen, Murray, and McGee (2001) reported on a new teaching and learning strategy employed after students expressed concerns about faculty. Issues such as inconsistency of grading, perceived lack of pa- tience, and unavailability created anxiety in students regarding perfor- mance in the skills laboratory. Using Watson’s carative factors, a pilot study was instituted for five faculty members who agreed to mentor one to five students each during the skills laboratory course. The consis- tency of a mentor who developed a trusting relationship and nurtured faith/hope resulted in decreased student anxiety and increased skill competence. Although limited, the authors concluded that use of the “care” group had the single most important effect on students’ improve- ment in performance. Hoover (2002) investigated a 15-week course developed to assist students’ capacity to be caring practitioners. Twenty-five students partic- ipated; focus group interviews of 30–60 minutes each were audiotaped and transcribed for each session. Findings of this study included the identification of interesting themes. First, students reported increased self-awareness related to clarification of values and connecting relation- ships. Second, a professional impact was reported in which an increased knowledge of caring and holistic practice was obtained. Hoover con- cluded that this work provided evidence that caring practices may be enhanced through education. In summary, nurse caring behaviors in nursing education have been studied (Table 4.1), albeit qualitatively, and using one predominant method. Faculty caring through role modeling seems to enhance stu- dents’ caring behaviors, while students’ knowledge of caring increases through innovative teaching methods. The available literature has pro- vided nursing faculty with preliminary evidence about teaching and learning nurse caring; however, gaps and inconsistencies remain in terms
  7. 7. WANT TO GRADUATE NURSES WHO CARE? 65 TABLE 4.1 Summary of Educational Studies: Teaching and Learning Nurse Caring Study Design Sample Results Beck, 2001 Meta- 14 qualita- Four major themes; unifying compo- analysis us- tive studies nent = “reciprocal connection” ing meta- ethno- graphic method Darbyshire, Phenomeno- Small Students who experienced the use of 1994 logical arts and humanities opened up to new ways of learning caring Gramling & Evaluation NA Knowledge of caring attained Nugent, methodo- through faculty role modeling; caring 1998 logy introduced early in the curriculum and reinforced throughout Grams, Phenomeno- 25 students Student/faculty groups identified 3 Kosowski,& logical patterns: creation of caring commu- Wilson, nity, experiencing reciprocity, and be- 1997 ing transformed Hanson & Phenomeno- Small Three themes emerged: recognition, Smith, 1996 logical connection, and confirmation Hoover, Focus 25 students After 15-week course students re- 2002 Groups ported increased self-awareness and increased knowledge of caring, sug- gesting caring can be enhanced through education Pullen, Evaluation 10–15 stu- Consistency of caring faculty mentor Murray, & pilot study dents in decreased student anxiety and in- McGee, skills lab creased skill competence 2001 Schaffer & Evaluation 42 seniors Teaching caring includes not only Juarez, 1996 methodo- and 34 ju- “how to” but role modeling logy niors Simonson, Phenomeno- Small Consistent with Watson’s (1985) car- 1996 logical ative factors; faculty should exhibit caring as a “way of being”
  8. 8. 66 ASSESSMENT AND EVALUATION of sampling techniques, designs, and analytical methods. While caring is a concept considered central to nursing practice, an expectation of patients and families, and a major component of nursing education, comprehensive evaluation is not routinely performed suggesting that competency in caring values, attitudes, and behaviors at graduation cannot be assured. A more thorough, systematic, outcomes-focused approach is needed to assure competence for practice. From a program evaluation point of view, assessing nursing students’ caring competen- cies will allow for the examination of influencing factors and provide a measure of the quality of the program. Finally, end-of-program (sum- mative) evaluation of nurse caring will provide the foundation for longi- tudinal comparative analysis, allow for external benchmarking activities, and stimulate educational research. APPROACHES TO ASSESSING NURSING STUDENTS’ CARING COMPETENCIES Conceptual Framework for Evaluation A framework for program evaluation helps guide the assessment process. To that end, an adaptation of the Quality-Caring Model© (Duffy & Hoskins, 2003) is proposed (Figure 4.1). This mid-range model was developed for use with patients and families and is based on the works of Donabedian (1966) and Watson (1979, 1985). The Quality-Caring Model for Educational Program Evaluation©, on the other hand, reflects the trend toward outcomes-focused program evaluation; it is dynamic and evidence-based. The model helps to identify structure and process variables that contribute to educational outcomes. In this model, the structure component includes characteristics of faculty, students, and the educational system. Concepts and subconcepts included in this component may directly or indirectly influence educational outcomes. The process component includes the two essential caring relationships that comprise the work of nursing faculty. The independent relationship between students and faculty is primary and includes values, attitudes, and behaviors that faculty members carry out in partnership with stu- dents during the learning process. Such relationships undergird and facilitate student learning, leading to specific educational outcomes.
  9. 9. WANT TO GRADUATE NURSES WHO CARE? 67 FIGURE 4.1 Quality-Caring Model for Educational Program Eval- uation©. Adapted from the Quality-Caring Model©. Reprinted with permission of Duffy and Hoskins (2003). Collaborative relationships include those activities and responsibili- ties that nursing faculty members share with other faculty members and administrative personnel throughout a university system. Meetings, task forces, and coordinating activities among university departments repre- sent many disciplines working together in collaborative relationships that ultimately lead to shared educational outcomes. For example, two university departments may work together to develop and teach a course for nursing students. Such planning is collaborative and essential for quality educational outcomes. The third major component of the model, outcomes, corresponds to the end result of the educational process. Two forms of outcomes
  10. 10. 68 ASSESSMENT AND EVALUATION are apparent. Intermediate outcomes represent a change in students’ behaviors, emotions, or knowledge while terminal outcomes are those major end-result concepts that affect the future of a program. Such variables as satisfaction, personal growth, specific student learning out- comes, and resource use are examples. There are reciprocal interactions between intermediate outcomes and terminal outcomes (see Figure 4.1). Intermediate outcomes often include attainment of specific learning goals but also can include feelings about the learning process. Of impor- tance is the intermediate outcome—feeling “cared for.” “When one feels ‘cared for,’ a sense of security develops making it easier to learn, change behaviors, and take risks” (Duffy & Hoskins, 2003, p. 83). Students who feel “cared for” while in the learning environment have reported less anxiety and more skill acquisition (Pullen et al., 2001). Although not reported in the literature, faculty who feel “cared for” in the work environment may report increased satisfaction. The major proposition of the model is that relationships character- ized by caring contribute to positive educational outcomes. Furthermore, the structure-process-outcomes components are a function of time and circumstance and are not simply a linear chain of events. Ongoing feedback and revisions are consistent with a continuous search for excellence. Assessment Strategies With a foundational model as a guide, several approaches for assessment of nurse caring behaviors are recommended, culminating in end-of- program summative evaluation. Measuring nurse caring can be accom- plished from the perspective of the student, the faculty, and most im- portant, the recipients of caring (patients). Although subjective, student self-reports of nurse caring can provide a baseline at program entry and then be followed annually (or more frequently) to determine improve- ment. This allows for trending by program level and over time. The Caring Abilities Index (CAI) (Nkongho, 1990) is an example of an instrument that can be used for student self-report. This instrument is a 37-item tool that quantifies a person’s degree of caring ability relative to others. The conceptual basis for the CAI is Mayerhoff’s (1971) philosophy of caring in which eight indicators comprise the concept and form the basis for item development. Content validity was estab- lished and factor analysis revealed three distinct subscales, namely, knowing, patience, and courage. Coefficient alphas for each of the sub-
  11. 11. WANT TO GRADUATE NURSES WHO CARE? 69 scales range from .71–.90 with an overall alpha of .81. Test–retest relia- bility at 2-week intervals was .75. The close item responses (1 strongly disagree to 7 strongly agree) are summed and interpreted as low, me- dium, and high caring. Faculty perceptions of students’ caring behaviors are paramount and are typically used in the formative clinical evaluation process. As experts in nursing and role models of nurse caring, faculty members can assess (through observation) students’ interactions with patients, families, and members of the health care team. Such assessment, when communicated to students through constructive feedback, provides an important viewpoint through which revised behaviors can be developed. Ongoing faculty assessment of students’ caring behaviors can also be assessed by faculty through written reflections, clinical logs, and care plans. Finally, students’ caring behaviors can also be assessed by faculty during verbal presentations and interactions with peers in the classroom. Probably the most important measure of nursing students’ caring competence is patients’ perceptions. Determining how patients and their families perceive students’ interactions is a direct measure of their (stu- dents’) ability to translate the concept of caring to the bedside. Using tools for measuring nurse caring during the educational process provides faculty and students alike with opportunities to better understand how patients and families perceive their care. An example instrument is the Caring Assessment Tool (CAT-version II) developed by this author (Duffy, 1990). This 100-item instrument has established validity and reliability, is theoretically based and assesses patients’ perceptions of nurse caring. Twenty minutes are generally required to complete the questionnaire and a 5-point Likert scale is summed for a total score. Evaluations of patients’ perceptions of student nurse caring behav- iors can be carried out during clinical nursing courses. Although not technically considered research, because patients are involved in comple- tion of questionnaires, faculty members should become aware of clinical sites’ policies regarding data collection. In some cases, the process may require approval from the Internal Review Board. Nurse Caring and the Program Evaluation Plan As an important indicator of a quality nursing curriculum, assessing students’ caring competence can best be accomplished both formatively and summatively. The school’s evaluation plan should reflect the facul- ty’s decisions about responsibility, frequency of assessment, specific
  12. 12. 70 ASSESSMENT AND EVALUATION measurements, and acceptable criteria. Choosing instruments that are practical and have established psychometric properties is essential. For- mative assessment of students’ caring competence is best evaluated from multiple points of view. From the students’ perspective, self-assessment data can be gathered on admission and then annually thereafter to compare growth. Clinical evaluation tools can be amended to include an objective measure of nurse caring that is consistent across the program. Such a measure can be as simple as one item (Figure 4.2) with higher scores expected as students progress in the program or composed of multiple items that are summed for a total score. Faculty evaluation of students’ caring competencies can then be easily assessed in each clinical course and compared across the program. To prevent faculty and patient bur- den, one summative evaluation is recommended at the culmination of the program from the perception of the patient. Scores from such evaluations should be shared with students and used by faculty (along with the other evaluations) to provide feedback about performance and make judgments about the effectiveness of the curriculum in preparing caring graduates. Finally, students’ perceptions of faculty caring behaviors (e.g., feel- ing “cared for”) can be assessed using established instruments. As noted in the literature review, creating caring environments during the educa- tional process and role modeling caring seem to raise awareness and facilitate learning. Assessing students’ perceptions of faculty caring can yield important data about the structure and process of the educational program. The Caring Assessment Tool–Educational Version (CAT-edu) (Duffy, 2002) is an example instrument for evaluating this valuable educational outcome. The CAT-edu is a 94-item instrument scored in Demonstrates caring to facilitate spiritual, mental, and physical health. Self-direct (5) Supervised (4) Assisted (3) Marginal (2) Dependent (1) FIGURE 4.2 Faculty assessment of student nurse caring behaviors. Adapted from The Catholic University of America Performance Evaluation Tool. Reprinted with permission.
  13. 13. WANT TO GRADUATE NURSES WHO CARE? 71 Likert format designed to capture students’ perceptions of faculty caring. Validity and reliability have been established. NURSING EDUCATIONAL RESEARCH This comprehensive approach to assessing students’ caring competencies together with ongoing educational research will build an evidence-based foundation for assuring an important learning outcome. To that end, responding to a call for educational research from the National League for Nursing, I proposed and was awarded funding to investigate how best to assess the caring competencies of senior nursing students. Features of this ongoing study, Caring Competencies of Graduating Baccalaureate Students, are noted as follows: This study seeks to answer the following questions: 1. What is the feasibility of using the Caring Assessment Tool— Version II (CAT-version II) among senior baccalaureate students? 2. How do self-reports, faculty perceptions, and patient percep- tions of student nurse caring behaviors vary among senior baccalaureate students during their final clinical course? 3. What are the relationships between selected student variables and patients’ perceptions of student nurse caring behaviors? 4. How do senior baccalaureate students describe the experience of participating in an ongoing research project? This nonexperimental, correlational study used a purposive sample of 50 students selected voluntarily from two schools of nursing during the students’ final clinical course. Five instruments were used: a demo- graphic form, the CAI (Nkongho, 1990), the CAT-version II (Duffy, 1990), the Faculty Assessment Tool (The Catholic University of America, 2000), and a Student Evaluation Form. After approval from the Human Subjects Committees of the two schools of nursing and associated clinical agencies, the principal investigator met with the teaching faculty of the clinical courses to review the study protocol (see Table 4.2). Students were recruited during class time and offered a 1-hour review class of their choice as an incentive for participation. In addition, student sub- jects received an analysis of their patients’ perceptions of nurse caring at the end of the study.
  14. 14. 72 ASSESSMENT AND EVALUATION TABLE 4.2 Summative Evaluation of Baccalaureate Students’ Nurse Caring Behaviors Study Protocol After IRB approval from clinical agencies and student selection: 1. Prior to clinical course, faculty will attend a 1-hour training session to include procedure for administration of CAT to patients, faculty responsi- bilities, and the required one-item faculty evaluation of students’ nurse caring behaviors. 2. During class time, the principal investigator (PI) will administer the Stu- dent Demographic Form and the CAI to student subjects. 3. Student subjects will attend a 30-minute educational session regarding interacting with patients for the purpose of research including informed consent procedures. 4. During the final clinical course, student subjects will select three pa- tients whom they have cared for at least once and discuss with faculty the appropriateness of patients for study. 5. Once approved by faculty, student subjects will complete the patient in- formed consent procedure. 6. After obtaining patient informed consent, student subjects will adminis- ter the CAT to the three patients. 7. Faculty will accompany the student subjects to the first patient CAT administration. 8. At course completion, faculty will complete the one-item student evalua- tion of nurse caring. 9. At course completion, student subjects will complete the Student Evalua- tion Form. 10. The 1-hour review class will be performed by the PI at a time of the stu- dent subjects’ convenience during the semester. Those students expressing a desire to participate in the study com- pleted an informed consent, the Demographic Form, and the CAI. After attending an educational session, student subjects selected a minimum of three patients who they cared for at least once in their clinical course. After conferring with the instructor and obtaining patient informed consent, the students administered the CAT-version II to the three selected patients. At the completion of the data collection period, student subjects completed the Student Evaluation Form to help the researcher evaluate the feasibility of the process. Faculty members completed the Faculty Assessment Tool at the completion of the course.
  15. 15. WANT TO GRADUATE NURSES WHO CARE? 73 The study design was chosen not only to summatively assess gradu- ating students’ caring competencies, but also to provide students experi- ence in the informed consent and data collection process and to assess the practicalities of the methodology. Consequently, the study has several limitations. The purposive sample limits the results to this sample only. Self-selection of patient subjects by the students may lead to bias, and students may inadvertently alter their interactions with these patients, thereby influencing the study results. Partial control for this has been built into the study methodology by measuring the mean total scores on the CAT-version II obtained from three patients. Preliminary results include a mean student age of 22.9 years, all female, with 85% generic students who have less than 12 months of clinical experience. Mean scores on the CAI were 208, indicating a moderate degree of self-reported student caring. An inverse relationship was found between student total years of education and self-reported caring competencies (r = −.43, p < .001). No other significant relation- ships were noted among student demographic variables and self-reported caring abilities. In terms of feasibility, approval from clinical site Internal Review Boards took longer than anticipated and the time required during clinical courses for student administration of the CAT-version II was a barrier. Faculty willingness to facilitate the process was crucial. Those students who completed the process indicated that the experience was helpful in terms of learning the informed consent process, and they seemed better informed about their patients’ perceptions of nurse caring behav- iors. Some used the results to revise their practice and suggested that the process be introduced and followed earlier in the educational pro- gram. The study is ongoing until the summer of 2005, when final results will be presented. Despite the noted limitations, empirical evidence will be generated from the study’s results, yielding important evidence about a major curricular concept. This information will strengthen the evaluation model in the two schools of nursing and provoke examination of associ- ated structure and process variables. Results will add to the validity and reliability of CAT-version II and its usefulness in program evaluation. The different perspectives of nurse caring will help determine the appro- priate approach for further study and will inform other nursing educa- tional researchers. Future studies may be designed based on these results
  16. 16. 74 ASSESSMENT AND EVALUATION with larger probability samples that may lead to a comparative database. As one approach to assessing caring competencies at graduation, this study provides a blueprint for future program evaluation. CONCLUSION Because nurse caring has been linked to patient outcomes, students’ competence upon graduation from nursing programs must be assured. Programmatic evaluation, then, should include caring as an important (if not crucial) student learning outcome that is evaluated both forma- tively and summatively. The nursing educational literature has provided models for promoting caring environments for learning, faculty role modeling, and specific teaching strategies that have successfully im- proved students’ caring practices. This chapter has provided a framework and several approaches to assessing students’ caring competencies. In addition, an ongoing educational study is discussed that seeks to under- stand how best to assess nursing students’ caring competencies. Results of this study will provide further direction to nurse educators and stimulate new inquiries. Although evaluation of nursing students’ caring competencies pre- sents challenges for nursing educators, the suggested approaches may assist in program evaluation. Data gathered in a comprehensive manner and used in curricular revision provides evidence of an essential practice expectation. Strengthening the link between student learning outcomes and clinical practice ultimately contributes to meeting the needs of patients and their families for caring interactions with nurses. REFERENCES American Association of Colleges of Nursing (AACN). (1998). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. American Nurses Association (ANA). (2003). The social policy statement for nurses. Washington, DC: Author. Beck, C. T. (2001). Caring within nursing education: A metasynthesis. Journal of Nursing Education, 40, 101–109. Bevis, E. O., & Watson, J. (1989). Toward a caring curriculum: A new pedagogy for nursing. New York: National League for Nursing Press.
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