Elsevier

Nurse Education in Practice

Volume 15, Issue 6, November 2015, Pages 421-429
Nurse Education in Practice

Caring behaviours of student nurses: Effects of pre-registration nursing education

https://doi.org/10.1016/j.nepr.2015.05.005Get rights and content

Highlights

  • We examine caring behaviour inventory (CBI) score of first and final year students.

  • We compare students' CBI scores with that of lecturers and nurses in practice.

  • First year scores resembled lecturers' and final year scores resembled nurses'.

  • Level of caring behaviours decreases from first to final year students.

  • More effort is required in nursing education to harness student caring attributes.

Abstract

In an increasing technologised and cost-constrained healthcare environment, the role of pre-registration nursing education in nurturing and developing the professional caring disposition of students is becoming far more critical than before. In view of this growing demand, the aim of this study was to evaluate the impact of Singapore's pre-registration nursing programmes on students' concept of caring. A descriptive quantitative cross-sectional survey collected data using the Caring Behaviour Inventory from first and final year student nurses, nurse lecturers and nurses in practice. The findings based on student surveys indicated a statistically significant reduction in the overall level of caring behaviour in first to final year students. When compared with the findings of lecturers and nurses, less variance to lecturers than to nurses was found amongst the first years' score, and the lowest variance to nurses was demonstrated amongst the final year. A greater reduction was evidenced amongst Singaporean students, which was exaggerated with exposure to pre-enrolled nursing education and magnified with caring job experience. This study indicates more effort is necessary to harness student caring attributes in students' entire educational journey so that expressive caring is not subsumed in the teaching of students to meet demands of complicated contemporary care.

Introduction

Caring as the essence of nursing is the core professional value recognised by many nursing-oriented professional and regulatory bodies (Nursing and Midwifery Council, 2010, Canadian Mental Health Association (CMHA), 2008, American Nurses Association (ANA), 2011). There are two co-existing dimensions to caring; 1) the instrumental caring which is the ‘doing’ of care, it is goal-orientated with an aim to achieve efficiency and good evidenced-based treatment; 2) the expressive caring, which involves a series of patient centred attitudes based on interactions, that are are carefully strategised in order to show respect, gentleness, sensitiveness and patience (Sherwood, 1995). In other words, instrumental caring behaviour is about achieving physical health and comfort (Sherwood, 1995) and expressive caring is about meeting psycho-social needs for inspiring a sense of hope and a sense of worth in order to encourage healing (Jourard, 1971). However, physical health and mental health are inextricably linked (CMHA, 2008). Individual's physical well-being is affected by one's psycho-social and emotional status which has the potential to impact the former. In this regard, expressive and instrumental caring behaviours are equally important factors in determining individuals' health and well-being.

Caring in nursing as a whole has long been regarded a critical core professional value of compassion and an ability to respond with humanity and kindness to others' pain, distress, anxiety or needs (Department of Health (DH), 2012). It is also, the possession of knowledge of assessed needs and related scientific principles to identify ways in which to give comfort and relieve suffering (DH, 2012). Hence, every professional nurse is expected to have a combination of instrumental and expressive caring attributes portrayed in self image, as well as to care receivers. However, such a dualistic caring concept remains difficult to measure and quantify (Curtis, 2013, Bray et al., 2014), particularly when being caring is about nurses being able to understand the world of a suffering patient (Eriksson, 1997) which not only varies between patients, but could also change from time to time in the same person. Yet any professional nurses were not only expected to display caring attributes but also, to do so skillfully.

While nurses are demanded to have the knowledge and skills to contextualise care to meet the unique needs of individuals, the ability to care as a nurse is expected to develop while individuals were being exposed to nursing education, particularly at early stages in pre-registration and pre-qualifying programmes (Fahrenwald et al., 2005, Willis, 2012). It was believed that any good nursing practices introduced prior to an individual obtaining a professional qualification and gaining entry to the professional nurse register, were more likely to be retained. In this regard, pre-registration nursing education in higher learning was expected to underpin high quality nursing care in practice (Davies et al., 2000). In North America, the nursing curricula in the late 1990's were underpinned by Watson's caring concept which was supposed to ensure that nurses developed caring behaviours (Hatem et al., 2008, Hughes et al., 1998, Simmons and Cavanaugh, 2000). Similar efforts were evidenced in other countries (Anthony and Landeen, 2009, Baldacchino, 2008, Khouri, 2011, Öhlén and Holm, 2005, Wu et al., 2009). In the United Kingdom (UK), the Nursing and Midwifery Council has also given pre-eminence to compassionate client-centred care; the concept of caring, in line with Watson's 10 carative factors was even emphasised in the new ‘all-graduate nursing programmes’ which were implemented nation-wide in September 2010. In essence, nursing curricula in many countries were putting increased emphasis on expressive care, based on Watson (1988) philosophical and ethical perspectives, grounded in humanism. Many of these curricula ended up being based on a human science perspective related to meeting patients' psychological and emotional needs (KaraÖz, 2005, Wolf et al., 1994, Woodward, 1997).

Section snippets

Background to Singapore nursing education

Singapore is highly influenced by developments in other countries and its advancement in nursing education is heavily influenced by the West (Loke, 2012). However, despite the all-graduate programmes being introduced in the UK and well-established in North America, Singapore pre-registration nursing education remains predominated by programmes at diploma level delivered in polytechnics. The diploma nursing programme was established to replace the certificate programme in 2001. Since then, it

Research design

This study employed a quantitative cross sectional survey using a structured questionnaire developed for this study and the Caring Behaviour Inventory tool (CBI) by Wolf et al. (1994); the former was to elicit demographic data and the latter was to establish the caring concepts of the participants. The surveys aimed to obtain structured responses from as many participants as possible within a given time period.

Methods

Between July and August 2012, a purposive sampling method was employed to access student nurses and nurse lecturers from one of Singapore's largest nursing schools, which was responsible for producing more than 50% of the current Singapore nursing workforce (Tan, 2012). The purposive sampling was subsequently repeated at a research seminar which was organised by the Singapore Nurses Association that was opened to all nurses from various care settings in hospitals and communities. At the point

Demographic data of students

Students who completed and returned the questionnaires were representative of the targeted cohort: 240 of the 320 first year students and 417 of the 500 final year students (Table 2) responded to the invitation giving a response rate of 75.0% and 83.4% respectively. Data showed that nursing continued to attract more females; in both cohorts, less than 20% of students were males. The mean age of the first year students was 19.34 (SD 3.577) and that of the final year was 21.32 (SD 3.691).

Discussion

Almost half of the student participants demonstrated to have the essential caring disposition in nursing [n1a = 117 (48.8%); n1b = 175 (42%)] (Table 3). Based on the findings, both cohorts of students scored a high CBI mean, with the first year resembling more of the nurse lecturers than the final year students, whose score difference from the clinical nurses was less and insignificant (t = 0.36, p < 0.72). A more positive response set was obtained among the first year students, especially the

Conclusions

While students who received pre-enrolled nursing education and had previous caring job experience appeared to have a higher level of caring attributes, there was a trend of reduction in the overall caring behaviour during pre-registration nursing education. This observation could be interpreted as a shift of students' concept from expressive caring towards instrumental caring by the educational process. In this regard, this study indicated educational success in moving students away from the

Acknowledgements

The study was conducted based on the Professor Sir Ron Cooke International Scholarship awarded to the first author. The authors would collectively like to thank all participants for taking their time to fill out the questionnaires. The authors also wish to thank the CEO, Nursing Director and the late Deputy Director of Nanyang Polytechnic for their permission of the study. Last but not least, the authors were grateful to Doctor Peter Willmot, Professors Kate Galvin and Roger Watson in reviewing

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      As Roach pointed out, if it can be learned, then students should show a change from a generic caring to that of a professional nurse over the duration of their course (Roach, 1984). The majority of previous studies (Wilkes and Wallis, 1998; Watson et al., 1999a, 1999b; Lundberg and Boonprasabhai, 2001; Mackintosh, 2006; Khademian and Vizeshfar, 2008; Murphy et al, 2009; Mlinar, 2010; Zamanzadeh et al, 2014; Labrague et al., 2015; Currie et al., 2015; Loke et al., 2015; Phillips et al., 2015) have showed that nursing students largely begin their programs with a compassionate outlook and an inclination to care. However, there has been some evidence that the educational process for nursing students does not always modify their caring behaviors (Khademian and Vizeshfar, 2008; Zamanzadeh et al, 2014; Labrague et al., 2015) or that the direction of the change is not always positive.

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