Caring has always been at the core of nursing education and practice. Yet there is little in the literature describing how undergraduate nursing students are taught or internalize caring. All 14 University Schools of Nursing (SON) in Ontario, Canada, state in different ways that they educate future nursing professionals to care for the person, the family and the community. But what does this really mean? What do we teach? How do we teach it? How effective are we? And how could we do better? The purpose of this multi-site, 18-month mixed-methods research was to examine how caring is defined, taught, integrated, measured and evaluated in nursing undergraduate curricula. The participants include senior BScN students, faculty members and recent BScN alumni (practicing for 2 to 3 years) from across the province.
Literature Review:
Caring has been linked to nursing since the time of Florence Nightingale. Nightingale was committed to promoting health rather than illness and believed medical interventions were not as important as care (Growe, 1991). Since then, theories of caring in nursing have been developed and applied in research, education, and standards of care (Wojnar, 2009). The literature describes many theories, definitions, and perspectives of caring within nursing. Nursing theorists such as Watson (1979, 1988, 1999), Benner (1984), Benner and Wrubel (1989), Boykin (1994), Boykin & Schoenhofer (2001), and Roach (1984, 1989), all contributed to an understanding of what nursing care encompasses.
While the literature indicates there are many definitions and lenses to examine caring in nursing, common themes emerge describing the caring interaction as a process that encompasses knowledge, being present with another, and actions leading to outcomes. The researchers concluded that caring for this research study can best be captured through Swanson’s (1991) mid-range theory based on the definition that caring is “a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility” (Swanson, 1991, p. 165). This process has also been described as being implemented with each nurse-client interaction that involves the nurses knowledge and understanding of the person’s needs (knowing); the verbal and nonverbal interactions that occur during the therapeutic relationship (being); and through actions striving to achieve the best client outcomes (doing) (Wojnar, 2009).
Nursing education involves the teaching of knowledge and skills for professional practice and attitudes, beliefs and values that are central to becoming a professional nurse (Brown, 2011; Larson, Brady, Engelmann, Prekins & Schultz, 2013). Nursing curricula are challenged in educating students to acquire the vast amount of knowledge needed to meet the demands of today’s complex healthcare environment and professional licensing requirements. Teaching professional caring within nursing curricula is increasingly important since with the multiple demands there is always a risk that learning how to be a caring relational healthcare professional may become less of a priority (Spadoni, Doane, Sevean, & Poole, 2015).
Although caring for others is a basic human trait, caring nursing practices and competencies must be an essential component of nursing education (Wagner, 2008). Teaching caring science should occur both in theory and practice. The literature states that teaching strategies which foster caring in students include critical reflection, role playing, narrative inquiry, role modeling, dialogue, journaling, clinical simulations, case studies, and other critically reflective tools (Brown, 2011, Adamski, Parsons & Hooper, 2009, Watson, 1989). However, there is little literature describing how nursing students internalize caring (Brown, 2011).
Drawing on the literature review, the purpose of this research study is to examine how the knowledge of caring is taught to undergraduate nursing students in Ontario; how it is embedded into the curriculum and translated into actual teaching-learning processes (the process of knowing); how students embrace caring practices within themselves and clients (being); and the nursing interventions they implement demonstrating caring while meeting their client’s needs (doing) to achieve positive outcomes as a student and graduate nurse.
Methods:
Data were collected through a mixed method of focus groups with senior nursing students and practicing nursing alumni, and an online faculty survey. Focus groups explored student (n = 100) and practicing alumni perceptions (n = 24) of how caring is taught, effective and ineffective learning practices, and learning experiences that helped strengthen their caring abilities. Faculty members (n = 50) in each School of Nursing were sent an email inviting them to participate in an on-line anonymous survey that elicited feedback on a definition of caring for nursing education, strategies and activities faculty think are effective for teaching caring and in which year of study they are being taught. An online repository of leading practices and strategies is being developed and findings from the study are being presented to each of the 14 schools of nursing, as a foundation for transforming caring in Ontario nursing curricula.
Data Analysis:
The 6 phases of thematic analysis based on Braun and Clarke (2006) were used to analyze the qualitative data. In Phase 1, familiarization of the data was done by reading through the entire data set to become immersed and intimately familiar with its content. Then, initial coding was conducted in Phase 2 to organize segments of data from the entire data set into meaningful codes. Phase 3 involved the examination of codes to identify significant broader patterns of meaning (potential themes) across the data. The initial 3 phases were conducted by the two co-principal investigators and three co-investigators who made up a steering committee. The reviews were conducted independently and then discussed by all members of the steering committee in order to reach consensus. In Phase 4, the themes were independently reviewed and revised by another member of the steering committee. This independent review and revision of themes involved re-examining the original data for relevant incidents of data for each potential theme; expanding, collapsing, or discarding of initial themes; generation of new themes; and re-discussion of themes with the full steering committee. The themes were presented as a model (Actualization of Caring) depicting the five themes and their interconnections. In Phase 5, the five themes were defined and named. Segments of text were then identified as exemplars for each theme. In the final phase, Phase 6, the literature review findings will be used to inform the themes for the final research report and manuscript. While these phases are meant to be sequential, each phase building on the previous phase, Braun and Clarke (2006) note that “analysis is typically a recursive process, with movement back and forth between different phases (p.86).”
Results:
The findings indicate that students enter nursing programs with a personal identification of caring. Through their nursing program, they undergo a process of growth and development of professional caring with the goal of them graduating with a professional identity of caring that is sustained and fostered in practice. A professional identity of caring is achieved through caring pedagogy practices, clinical experiences, and relationships with peers, faculty and nurses. As students go through this process they demonstrated ongoing self-awareness of professional caring that is influenced by facilitators and barriers within educational and clinical environments. The results for each of these themes will be presented in greater depth during the presentation.
Conclusion:
This study will inform which content, strategies, and practices in undergraduate nursing curricula are most effective in terms of fostering and maintaining caring in students and graduates. The findings will also facilitate future incorporation of more of these practices and content in Ontario university nursing programs with the development of the online repository. The researchers believe this online repository will be the first of its kind that not only schools within Ontario, but also SON’s nationally and internationally will be able to access.
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