SENIOR NURSING STUDENTS DESCRIPTION OF CARING FROM THEIR

EXPERIENCE: A QUALITATIVE RESEARCH

by

Alice Mathew

JOBETH PILCHER, PhD, Faculty Mentor and Chair

EDNA HULL, PhD, Committee Member

BONITA WILCOX, PhD, Committee Member

Amy Smith, PhD, Dean, School of Education

A Dissertation Presented in Partial Fulfillment

Of the Requirements for the Degree

Doctor of Philosophy

Capella University

December 2016




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 Alice Mathew, 2016
 Abstract

A gap existed in the literature as to whether nursing students are maturing to be a caring person

by the completion of their education. The purpose of this basic qualitative study was to explore

how senior nursing students described caring and the motivational factors that influenced their

caring behaviors so that nursing educators could understand the extent to which the student

nurses were acquiring the knowledge of caring and caring behaviors during their nursing

education. A basic qualitative study was performed to explore nursing students experience on

caring. The research questions were (1) How do senior nursing students describe the components

of caring and the motivational factors that influence their caring behaviors? (2) How do senior

nursing students describe the components of caring such as: maintaining beliefs, knowing, being

with, doing for, and enabling towards caring? (3) How are the senior nursing students motivated

to be a caring person? The target population included final semester ADN nursing students. A

non-probability purposive sampling was used to collect data from 10 participants through face-

to-face interviews. A constant comparative method of data analysis was used. Swansons theory

of caring was utilized to examine the meaning of caring, components of caring behaviors, and

the motivational factors of caring behaviors. The study findings provided answers to the research

question. Participants were able to sufficiently describe knowing the patient, being with the

patient, doing for the patient, and enabling the patient in relation to their caring attributes.

However, the study participants had only limited knowledge in maintaining patients beliefs to

help them overcome the crisis situation during their illness. Participants were unable to clearly

identify the need and the importance of incorporating patients religious, spiritual, and cultural

practices, which are essential in providing competent caring. Participants also described the

motivational factors that influenced their caring behaviors that included innate behavior, how
one was being raised, experience with faculty members and staff, personal desire, and religious

practices. One implication for practice is for faculty to review nursing curriculum and examine

whether ADN students are obtaining the theoretical knowledge as well as the clinical practice for

the development of culturally sensitive skills to provide holistic care to patients. Suggestions for

further research include a repetition study with other ADN groups and BSN groups and compare

how each group describe caring behaviors and another study how faculty members demonstrate

caring attributes when teaching.

 Dedication

This work is the culmination of many hours that my family and friends lovingly

supported and tolerated. I dedicate this dissertation to my husband Mathew without whose caring

support it would not have been possible for me to complete my educational journey. I also

dedicate this work to my son Collins, daughter-in-law Rini, and my grandson Luke who

constantly encouraged me to accomplish my dream. I am thankful to God for giving me a loving

family.

iv
 Acknowledgments

I want to acknowledge the faculty at Capella University for assisting me to complete this

journey. I want to express my special thanks to the distinguished faculty members, Dr. Jobeth

Pilcher, Dr. Edna Hull, and Dr. Bonita Wilcox who served on my dissertation committee. I am so

grateful to Dr. Pilcher who offered her knowledge, expertise, insight, and timely feedback with

her kindness and compassion, which helped to make my dissertation journey a positive one. I

have no words to express my thanks to Dr. Pilcher for all her given support and guidance. Dr.

Hull and Dr. Wilcox offered their time, guidance, and expertise for which I am grateful. I thank

my colleague and friend Dottie, for offering such help and support all through my study. A

special thank to Kelly, my colleague and peer who motivated me to take this course.

v
 Table of Contents

Acknowledgments v

List of Tables ix

CHAPTER 1. INTRODUCTION 1

Introduction to the Problem 1

Background, Context, and Theoretical Framework 2

Statement of the Problem 8

Purpose of the Study 9

Research Questions 10

Rationale, Relevance, and Significance of the Study 10

Nature of the Study 13

Definition of Terms 14

Assumptions, Limitations, and Delimitations 17

Organization of the Remainder of the Study 19

CHAPTER 2. LITERATURE REVIEW 20

Introduction to the Literature Review 20

Theoretical Framework 20

Review of Research Literature and Methodological Literature 29

Chapter 2 Summary 57

CHAPTER 3. METHODOLOGY 60

Introduction to Chapter 3 60

Research Design 61

vi
 Target Population, Sampling Method, and Related Procedures 63

Data Collection 66

Interview Questions 67

Field Test 68

Data Analysis Procedures 68

Limitations of the Research Design 69

Credibility 70

Transferability 72

Expected Findings 73

Ethical Issues 74

Chapter 3 Summary 77

CHAPTER 4. DATA ANALYSIS AND FINDINGS 78

Introduction 78

Description of the Sample 79

Research Design and Introduction to the Data Analysis 80

Summary of the findings 82

Chapter 4 Summary 92

CHAPTER 5. CONCLUSIONS AND DISCUSSION 94

Introduction 94

Summary of the Findings 95

Discussion of the Findings 100

Discussion of the Findings in Relation to the Literature 102

Discussion of the Findings in Relation to the Theoretical Framework 109

vii
 Limitations 112

Implication of the Findings for Practice 112

Recommendations for Further Research 114

Conclusion 115

REFERENCES 117

APPENDIX A. INTERVIEW QUESTIONS 129

viii
 List of Tables

Table 1. Demographic Data 80

ix
 CHAPTER 1. INTRODUCTION

Caring is the core component and fundamental concept of nursing. According to Watson

(2008), caring is the essence of nursing practice and authentic caring relationships exist between

the nurse and the patient during actual caring occasions and the transpersonal caring moments.

The ultimate goal of nurse caring is to enable patients to regain their well-being status. A person

is considered to be caring based on the capabilities, commitments and concerns, conditions,

caring actions, consequences, and beliefs and values that shape their caring nature (Swanson,

1999). The American Association of Colleges of Nursing (AACN) and National League for

Nursing (NLN) have identified caring as a fundamental value of nursing (AACN, 2008; NLN,

2007). Nursing education guides the progression from a caring person to a professional identity

of caring (Labrague, McEnroe-Petitte, Papathanasiou, Edet, & Arulappan, 2015; Rhodes, Morris,

& Lazenby, 2011; Watson). Through caring, nurses assist the person to find meaning in illness

and suffering in order to restore, promote, and enhance and preserve human dignity. Nursing

education prepares students to be competent and caring nurses upon graduation (AACN). Caring

is not about vague internal feeling of others; rather caring is required to fulfilling high quality

nursing practice standards and competencies (Porr & Egan, 2013). Patients and their families

have high expectations while in the hospital. Patient satisfaction is directly related to the care

they receive in hospitals. Hospital administrators and nurse executives strive hard to maintain

high quality care to attract patients and run their businesses. The linkage between caring, patient

1
satisfaction with nursing care, and patient satisfaction with hospital experience is of prime

importance in todays health care system (Hooper, Craig, Janvrin, Wetsel, & Reimels, 2010).

Previous studies have been conducted to measure how nursing students become a

competent and caring nurse (Hanson, 2004; Khademian, & Vizeshfar, 2008; Labrague et al.,

2015; Porr, & Egan, 2013; Sandvik, Eriksson, & Hilli, 2014; Sokola, 2013). However, little was

known whether nursing students matured to be a caring person by the end of their nursing

education. The topic for the basic qualitative research study was senior nursing students

description of caring and the motivational factors that influenced their caring behaviors. The

study finding was important for understanding how nursing students were maturing to caring

nurses. The gained information was expected to help faculty members to develop effective

teaching strategies that promote the professional identity of caring among nursing students so

that the future nurses might be skillful in providing safe and competent caring as soon as they

enter the profession.

Chapter 1 includes an introduction to background, context, and conceptual framework for

the study that explored senior nursing students description of caring and the motivational factors

that influenced their caring behaviors from their experience. Chapter 1 contains research

questions, rational and significance of the problem, and definition of terms for studying senior

nursing students role transition to caring nurses. The assumptions, limitations, and delimitations

of the study will be addressed. The conclusion of Chapter 1 will provide the reader with the

organization of the remaining chapters.

Background, Context, and Theoretical Framework

In order to understand the full extent of this manuscript, the background and the context

of the research topic are explained well. Theories describe or explain phenomenon in a

2
systematic way. Theories make scientific findings meaningful and generalizable (Kelly, 2010).

Constructivism and Swansons theory of caring are utilized to explain the research topic, answer

the research questions, and explain research findings.

Background and Context

Caring is a core competency and the hallmark of professional nursing practice (Porr &

Egan, 2013). According to Swanson (1991), caring is a nurturing way of relating to a valued

other towards whom one feels a personal sense of commitment and responsibility (p.165).

Caring is not a new concept in nursing. Caring has taken the most sophisticated place in nursing

since the time of Florence Nightingale who is the founder of nursing profession (Alligood,

2014). Though nursing has gone through many innovations and grown as a profession, caring

still remains as the soul of nursing practice. Recent studies demonstrated that patients and their

families were not receiving compassionate caring from nurses (Adamson & Denwar, 2015;

Blackmore, 2011). New nurses entering the nursing practice lacked the clinical decision making

skills to provide competent care (Dyess & Sherman, 2009). Clark and Holmes (2007) study

clearly documented that not all nurses were capable of providing competent care at the time of

registration.

Nursing education helps nursing students to progress from a caring person to a

professional identity of caring (Labrague et al., 2015; Rhodes et al., 2011; Watson, 2008).

Currently, new nurse graduates can take National Council Licensure Examination of Registered

Nurse (NCLEX-RN) State Board examination even within a week of their graduation and they

can start practicing as a licensed RN. Once they receive the RN license, they are expected to

assume full responsibilities of an RN. Patients do not care if they are new or seasoned nurses. All

3
patients expect quality care while in the hospital (Dyess, Sherman, Pratt, & Chiang-Hanisko,

2016).

One of the goals of Accreditation Commission for Education in Nursing (ACEN) is to

foster educational equity, access, opportunities, mobility, and preparation for employment based

upon type of nursing education (ACEN, 2015, p. 1). Nursing programs demonstrate the quality

of education by documenting graduates ability to meet the needs of the communities they serve

(Taylor, Loftin, & Reyes, 2014). As a part of the nursing education program evaluation, hiring

agencies are asked to provide reports on new graduates. When newly qualified nurses from a

particular institution do not perform caring attributes, the hiring agencies express reluctance on

hiring graduates from such institutions and it affects the accreditation status of that program

(ACEN). Thus, the quality of nurses reflects the type of education they receive. The unprepared

new nurses can be perilous to patient safety and competent patient care, and set them up for

professional dissatisfaction (Shipman, Roa, Hooten, & Wang, 2012). The Institute of Medicine

(IOM) and other major organizations have been reporting significant threats to quality and safety

of patient care for more than 10 years (Disch, 2012). The Quality and Safety Education for

Nurses (QSEN) is a national initiative to identify the competencies and knowledge, skills, and

attitudes needed by all nurses to continually improve health care quality and safety (Disch). The

IOM report of 2010 recommended a reform in nursing practice specifically focusing on quality

improvement and patient safety (Johnson et al., 2012). Patient satisfaction is the new marketing

tool for hospitals to attract patients. Medicares reimbursement is tied to patient satisfaction

scores. Maintaining patient satisfaction is highly important in the health care system (Cocchi,

2012) and it is directly related to the care they receive from nurses.

4
 In a cross-sectional study, Pai, Eng, and Co (2013) found that nurses were able to

demonstrate improved critical thinking skills when they demonstrated caring behaviors while

taking care of patients. Additionally, in a descriptive non-experimental study, Labrague et al.

(2015) discovered that nursing students could be professionally trained to develop the

competencies of caring when faculty members demonstrate positive role modeling. Murphy,

Jones, Edwards, James, and Mayer (2009) conducted a qualitative study to examine the

perception of caring behaviors in first year and third-year nursing students and revealed

contradictory findings that third-year nursing students scored less in the perception of caring

behaviors than the first year nursing students, which was opposite to what was expected. The

researchers assumed that the educational process might have reduced third year nursing students

perception on caring behaviors (Murphy et al). In a mixed method study, Porr and Egan (2013)

developed a tool named Caring Interaction Interview (CII) to measure the construct of caring.

Researchers measured the three dimensions of caring; intentionality, relationality, and

responsivity. Researchers argued that CII was an effective way to measure caring than self-

reporting. Labrague et al examined and asserted that about caring, could be read, taught, and

learned but it had to be experienced to understand what it was and caring would be understood

better by self-reporting. Khademian and Vizeshfar (2008) confirmed that caring was different

and similar among cultures and nurses should be culturally competent to provide holistic patient

care. Student nurses could be trained to be caring nurses and they could demonstrate caring

behaviors during role transition period (Chung, Wong, & Cheung, 2008; Nursing student caring

behaviors, 2008). The mentors support and clinical reflection were helpful in role transitional

process of nursing students (Kaihlanen, Lakanmaa, & Salminen, 2013).

5
 Through a phenomenological hermeneutic study, Kumaran and Carney (2014)

documented that new nurses felt excited upon qualification, but professional responsibilities and

accountability associated with the new role were overwhelming. Tsai, Tsai, Chen, and Lee

(2014) reported of nurses with high nursing competency maintained high career self-efficacy and

professional commitment. In a descriptive survey, Papastavrou et al. (2011) found significant

differences in the perception of caring between patients and nurses. The researchers reported an

alarming finding that patients provided a lower evaluation in the items of supporting the patient,

respecting individuality, being empathetic, giving opportunities to express feelings, and

satisfying patient needs.

Sokola (2013) conducted a descriptive correlational study and documented that nursing

students entered into nursing program with innate caring skills and behaviors and they gradually

assimilated behaviors that demonstrated professional caring attributes into their interactions with

patients. Sokola recommended for a study to investigate factors that motivate students to

incorporate caring in practice and factors that contribute to adjustments in caring behaviors (p.

53). Additionally, Sandvik et al. (2014) conducted a phenomenological hermeneutical study to

elucidate the meaning and understanding of student and development in becoming a nurse. The

researchers asserted that caring relationships promoted warmth and trust in nursing students.

Sandvik et al strongly recommended for further studies to focus on the ontological perspectives

on the process of transformation of a nurse.

The studies of Sokola (2013) and Sandvik et al. (2014) were the basis for this study as

they recommended for further studies to examine the motivational factors of caring behaviors

and the ontological perspectives of the process of transformation of a nurse. Ontological

assumptions assert that human beings have their own thoughts, interpretations, and means

6
(Ahmed, 2008). This study provided new knowledge on how well nursing students understood

the concept of caring and their role transition into caring nurses at the completion of their nursing

education. Thus, the study was worth performing to fill the gap in the literature as recommended

by Sokola and Sandvik et al to add knowledge to the body of nursing education, which would

benefit both practitioners and the scientific community.

Theoretical Framework

The proposition used in this study was that a student nurse effectively matures to be a

competent and caring nurse with theoretical knowledge from the classroom, obtaining skills

competency in the skill labs, and practice during clinical experience. Thus, the phenomenon of

learning could be potentially explained through the theoretical lens of constructivism learning

theory. The basic operating processes in constructivism theory are developmental, assimilation

and accommodation, and construction (Billings & Halstead, 2012). In constructivism theory, the

learner constructs new knowledge by building on to the existing knowledge through a personal

interpretation of learning (Billings & Halstead). According to constructivism, all knowledge or

meaningful reality is contingent upon human practices, and they are constructed out of

interaction between human beings and their world (Ahmed, 2008). Thus, student nurses apply

their learned knowledge about caring in the classroom and during clinical experience, having

interaction with the patients, and construct new meanings to caring by building to the existing

knowledge and mature to a caring person. Another theory base used for this study was

Mezirows transformation theory. Mezirow redefines Habermas emancipatory domain as the

transformative process that pertains to instrumental and communicative learning (Cranto, 2006,

p.102). Malcolm Knowles adult learning theory and Mezirows transformative learning (TL)

are under the umbrella of constructivism, which could be applied in nursing education.

7
Constructivism theory has been used in similar studies and found effective in improving

students skills acquisition and critical thinking skills (Brandon & All, 2010; Hinshaw, Burden,

& Shriner, 2012).

A vital theory used in developing the framework of this study was Swansons theory of

caring. According to Swanson (1991), ones beliefs and values shape their caring nature.

Swansons theory of caring is a clear explanation of what nurses practice in a caring manner and

emphasizes that the goal of nursing is promotion of all individuals well being. According to

Swanson, the five themes that are essential for the caring actions are knowing, being with, doing

for, enabling, and maintaining belief. During clinical experience, students have the opportunity

to develop the caring actions of knowing, being with, doing for, enabling, and maintaining belief.

Nursing education is designed in such way that theoretical knowledge and clinical practice

enable the transformation of nursing students to be caring nurses (Rhodes et al., 2011). Students

develop the caring behaviors through the exposure of social, environmental, and cultural factors

(Sokuola, 2013). Swansons theory was tested and found effective in many studies in direct

patient care and other sensitive and vulnerable areas in research situations (Adolfsson, 2011;

Andersed & Olsson, 2209; Higdon & Shirey, 2012; Kavanaugh, Moro, Savage, & Mehendale,

2006; Steele-Moses, Koloroutis, & Ydarraga, 2011).

Statement of the Problem

Caring has been identified as a fundamental value of nursing (AACN, 2008; NLN, 2007).

Nursing education guides the progression from a caring person to a professional identity of

caring (Labrague et al., 2015; Rhodes et al., 2011; Watson, 2008). Studies indicate that although

the registered nurse (RN) license is the evidence of achieving the legal and professional

competence to enter nursing practice, the majority of new nurses feel that they lack the clinical

8
skills and judgment needed to provide safe and competent care (Dyess et al., 2016; Li &

Kenward, 2006). Previous studies have been conducted to measure how nursing students become

a competent and caring nurse and the perception of caring (Hanson, 2004; Khademian, &

Vizeshfar, 2008; Labrague et al; Porr, & Egan, 2013; Sandvik et al., 2014; Sokola, 2013).

The research literature on competence in caring indicates that caring is the core component

of nursing (AACN, 2008: NLN, 2007), patients expect to receive quality and compassionate care

(Farber, 2010; Tsai et al., 2014), and that nursing students are taught about caring in the nursing

school (AACN). It is not known how the nursing students are maturing into compassionate and

caring nurses. There is a gap in the literature regarding the role transition of student nurses to

caring nurses. The problem addressed in the study was a need to understand how nursing

students mature to caring nurses by examining the description of caring that was provided by the

senior nursing students (Sandvick et al., 2014; Sokola, 2013). This study finding may be vital for

faculty to develop effective teaching strategies that promote the professional identity of caring

among nursing students so that the future nurses might be skillful in providing safe and

competent caring in their practice as soon as they enter the profession.

Purpose of the Study

The purpose of this basic qualitative study was to explore how senior nursing students

describe caring and the motivational factors that influenced their caring behaviors so that nursing

educators could understand the extent to which the student nurses were acquiring the knowledge

of caring and caring behaviors during their nursing education. The information gained from this

study was anticipated to assist nursing educators in developing methodologies for teaching

caring among nursing students.

9
 Research Questions

Central Research Question

How do senior nursing students describe the components of caring and the motivational

factors that influence their caring behaviors?

Sub-Questions

How do senior nursing students describe the components of caring such as: maintaining

beliefs, knowing, being with, doing for, and enabling towards caring?

How are the senior nursing students motivated to be a caring person?

Rationale, Relevance, and Significance

Together the rational, relevance, and significance of the study provided the justification

for the need for the basic qualitative research. The rational explains the need for the research and

its importance to nursing education. The relevance of the study describes the value of the study

findings to the practitioners in nursing education. The significance of the study affirms the

purpose and provides benefits of the research that explored the description of caring by the

senior nursing students and the motivational factors that influenced their caring behaviors. The

rationale, relevance, and significance of this study will contribute to the body of knowledge in

nursing education.

Rationale

The rational for this study arose from the reports that new nurses lacked the clinical skills

and judgment needed to provide safe and competent care and the frustration of lacking

competency in caring led many new nurses to leave the profession (Diaz, Clarke, Gatua, &

Wairimu, 2015; Dyess et al., 2016). New nurses constitute 10% of the nursing workforce in

many acute care settings. Currently 31% of new graduates leave their job in the first two years of

10
service due to the lack of guidance and support and lack of self-confidence (Dyess et al). About

574,400 RN job shortages are predicted by the year 2022 (McMenamin, 2014). Nursing faculty

members have a significant responsibility to prepare more nurses, as well as to retain new nurses

to continue in nursing practice. One of the solutions for this need is to prepare competent nurses

who can provide and demonstrate compassion and caring attributes to patients, which will

improve patient satisfaction as well as nurse satisfaction and help hospitals survive and

encourage new nurses to continue in the nursing profession. The patient dissatisfaction is directly

related to caring behaviors of nurses. Therefore, nursing students must develop caring attributes

before they graduate. Examining the description of caring by senior students may be helpful in

examining whether they acquired the caring attributes and are ready to function as professional

nurses. This study was based on the recommendation of Sandvick et al. (2014) and Sokola

(2013) and study findings might help in closing the gap in the literature.

Relevance

The information provided by the study may be relevant to educators and administrators in

the specialization of nursing education. The findings were anticipated to have potential value to

nurse educators to develop teaching strategies and methodologies to train nursing students to be

competent and caring nurses. Nursing educators teach nursing students in the classroom and

clinical settings, and prepare and mentor future nurse leaders in nursing profession. Nursing

educators hold roles as mentor, teacher, and role models for nursing students. In a descriptive

study, Zamanzadeh, Shohani, and Palmeh (2015) found that when students perceived the caring

behaviors of instructors, they were able to develop professional roles, caring attitudes, clinical

self-confidence, clinical competency, and interpersonal caring interactions. Nurse caring is a

quality outcome and targeted as a priority for all health care organizations. Fostering nurses

11
internal motivation to caring increased the frequency of caring behaviors and thus, improved

patient satisfaction (Burtson & Stichler, 2010). Student nurses should be well prepared to face

the challenges of nursing practice. Twibell et al. (2012) reported that new nurses leave the

profession due to heavy workloads, inability to ensure patient safety, dissatisfying inter-

professional relationships, and insufficient time with patients.

Significance

Nursing education guides student nurses to progress from a caring person to a

professional identity of caring (Labrague et al., 2015; Rhodes et al., 2011; Watson, 2008). All

patients expect to receive competent and compassionate caring during hospitalization. Recent

studies indicated that new graduate nurses lack the clinical skills and judgment needed to provide

safe and competent caring in their practice (Dyess et al., 2016: Li & Kenward, 2006). Previous

descriptive, non-experimental survey, and phenomenological studies have been conducted to

measure the perception of caring by nurses (Hanson, 2004; Khademian & Vizeshfar, 2008;

Labrague et al; Porr & Egan, 2013; Sandvik et al., 2014; Sokola, 2013). There is a gap in the

literature regarding how nursing students describe caring and the motivational factors that

influence them to be caring. Little is known regarding how nursing students mature to be a

caring person by the end of their nursing education. As the healthcare environment is getting

fast-paced and complex, caring, the core of nursing essence can be lost (Adamson & Dewar,

2015). Sandvick et al and Sokola recommended for more research to examine how nursing

students are maturing in caring behaviors. This study is anticipated to help in filling the gap in

the literature and benefit the nursing educators to develop strategies and methodologies to train

the students with caring attributes.

12
 Nature of the Study

A basic qualitative method was used for this study. A basic qualitative study focuses on

meanings, understandings, and processes of phenomenon being studied. A basic qualitative study

will bring rich descriptive meanings of phenomenon and the result is presented as themes and

categories (Merriam, 2009). In a basic qualitative study, the researchers are interested in (1)

how people interpret their experiences, (2) how they construct their worlds, and (3) what

meaning they attribute to their experiences (Merriam, 2009, p. 23). Consistent with a

constructivist worldview, the aim of this basic qualitative study was to explore how senior

nursing students describe caring and the motivational factors that influence their caring behaviors

so that nursing educators could understand the extent to which the student nurses were acquiring

the knowledge of caring and caring behaviors during their nursing education. The information

gained from this study was anticipated to assist nursing educators in developing methodologies

for teaching caring among nursing students.

Non-probability and purposive sample selection was limited to students who were in the

final semester (role transition) and did not repeat any courses in the nursing program. After

obtaining consents from participants, face-to-face interviews were performed to collect data. The

location, date, and time for the interview were chosen as per participants convenience. When

face-to-face interviews were not possible, Skype was utilized to conduct interviews. Detailed

information regarding sampling, recruitment, data collection, and data analysis is included in

Chapter 3.

According to Merriam and Tisdell (2015), interviews with open-ended questions are the

best way to obtain the desired information and description of phenomena. Semi-structured open-

ended questions were used to interview senior (role transition) nursing students from an

13
associate-degree nursing (AND) program in the Midwest of Ohio. Interview questions were field

tested prior to the interview. The interviews were audio recorded, transcribed verbatim, and field

notes were written during the interviews. Member check was performed to maintain accuracy of

data information. An interview protocol was utilized to maintain consistency in obtaining

information (Cresswell, 2012). Continuous data collection and analysis were done throughout the

study until data saturation was obtained (Merriam & Tisdell). Then, the findings were interpreted

in a narrative form.

Definition of Terms

Definition of terms will provide clarity and shared understanding of this manuscript.

Clarification through clear definitions of important terms used in the manuscript may help

readers to better understand the research project (Cresswell, 2012). Therefore, the terms specific

to this study are defined to provide better understanding of this research study.

Associate Degree Nursing (ADN)

Associate degree nursing program provides basic education to students to obtain a

registered nurse (RN) license to practice nursing. ADN programs are offered generally in

community colleges and the program takes two years to complete (Department of Labor, 2014).

Being With

Being with means being emotionally present to the other which includes being there in

person, conveying availability, and sharing feelings without burdening the other cared for

(Swanson, 1991, p. 162).

Caring

Caring is a nurturing way of relating to a valued offer toward whom one feels a personal

sense of commitment and responsibility (Swanson, 1991, p.162). Nurse caring begins with a

14
fundamental belief in people and their capacity to find meaning in their health experiences.

According to Swansons (1991), caring is demonstrated by maintaining belief, knowing, being

with, doing for, and enabling them to achieve well being based on the practice of self-caring and

self-healing.

Caring Behavior

Caring behaviors are verbal and nonverbal caring actions based on the caring theory of

Swanson (1991), demonstrated by nursing students while taking care of patients. Caring

behaviors help student nurses to learn the role of a professional nurse and enable them to provide

competent care to patients.

Competency

According to Axley (2008),

Competency refers to an individual who exhibits the ability to act prudently in given
circumstances, including the ability to act prudently in given circumstances, including the
ability to perform a job or an occupation or to reason or make decisions. (p. 216)

Doing for

Doing for means to do for others what one should do for self at all possible, including

anticipating needs, comforting, performing skillfully and competently and protecting the one

cared for while preserving his or her dignity (Alligood, 2014, p. 690).

Enabling

Enabling is facilitating the others passage through life transitions and unfamiliar events

by focusing on the event, informing, explaining, supporting, validating feelings, generating

alternatives, thinking things through, and giving feedback (Alligood, 2014, p. 690).

15
Knowing

Knowing is thriving to understand the meaning of an event in the life of the other,
avoiding assumptions, focusing on the person cared for, seeking cues, assessing
meticulously, and engaging both the one caring and the one cared for in the process of
knowing. (Alligood, 2014, p. 690)

Maintaining Belief

Maintaining belief is sustaining faith in the others capacity to get through an event or
transition and face a future with meaning, maintaining a hope-filled attitude, offering
realistic optimism, helping to find meaning, and stand by the one cared for no matter
what the situation. (Alligood, 2014, p. 690)

Motivation

Motivation is a value-based, psycho-biologically stimulus-driven inner urge that

activates and guides human behavior in response to self, others, and environment (Porr & Egan,

2012, p. 2).

Professional Nurse

Professional nurse is a registered nurse (RN) who has an independent, a dependent, and a
collaborative role in the care of individuals of all ages, as well as families, groups, and
communities to the sick or well person and holds and dedicates to the standards,
guidelines, and principles of nursing profession. (Department of Labor, 2014, para 1)

Senior Nursing Students

Senior nursing students are in the final semester (role transition) of an associate degree-

nursing (ADN) program and completed all their theory classes and competency skills checks.

During the final semester, nursing students spend their clinical hours (at least 120 hours) under

the direct supervision of a preceptor in a clinical setting. During the final semester, student

nurses are expected to synthesize the knowledge gained in preceding years and focus on the care

of individuals, families, and communities and role transition to graduate nurses (University of

16
Pittsburgh, 2015). In this study, senior nursing students are referred to ADN students in the final

or role transition semester of their nursing education.

Assumptions, Limitations, and Delimitations

This section includes a discussion of the assumptions, limitations, and delimitations that

define the study credibility. In order to support the understanding of the topic and the results of

the study, researcher must identify the assumptions, limitations, and delimitations of the study

(Merriam & Tisdell, 2015). Assumptions are beliefs that are held to be true but have not

necessarily been proven, which may be explicit or implicit (Nieswiadomy, 2012). Study

limitations are weaknesses in a study that are not controlled by the researcher. Delimitations are

the definitions a researcher set as boundaries of the study (Simon, 2011).

Assumptions

The assumptions underlying this study include the potential honesty and candidness of

the participants. Since the data collection was through participant interviews, it was assumed that

the participants were honest with their answers. It was assumed that protecting confidentiality

and anonymity would allow the participants to share their stories openly and without fear.

Participation in this study was voluntary and participants had the freedom to withdraw from the

study at any time without ramification or penalty was appropriate in sample selection. There was

the assumption that the topic selection was worthy of investigation. The descriptions of caring by

the role transition students were unique and assumed trustworthy. The interview protocol was

field tested by three experts in the field. Therefore, it was assumed that the interview protocol

was effective in answering the research questions (Merriam & Tisdell, 2015). Another

assumption was that interviewing senior students would provide sufficient information for

17
content saturation (Merriam, 2009). It was assumed that reflective journaling and member checks

minimized the potential researcher biases.

Limitations

One of the limitations of the study was the difficulty of replicating the study due to small

sample size. The knowledge obtained from the study might not be generalized to other people

because the findings might be unique to the participants description. Another limitation was the

use of non-probable purposive sampling in the study. Use of a random sampling would provide

more reliable results. In a qualitative research, the researcher is the primary instrument for data

collection and analysis. Research reliability is heavily dependent on the skills of the researcher

(Merriam, 2009). The researcher being a novice in this study might raise some reliability issues,

as well as personal biases and shortcomings could affect the data collection and analysis. In order

to minimize personal biases, a qualitative researcher should identify and monitor personal biases

or subjectivities and shortcomings as to how they might be shaping the collection and

interpretation of data (Merriam & Tisdell, 2015).

Delimitations

Senior nursing students from an ADN program were chosen for the study because

towards the last semester, senior nursing students should have received all the theoretical

knowledge, competency checks, and clinical experiences which were required by the nursing

program, and they were expected to know and express the components of caring (AACN, 2008;

Rhodes et al., 2011). Nursing students from any semester prior to senior year were excluded

from participating in the study because they were still learning and getting experience in caring

nursing actions. Nursing students from any other nursing program than ADN program were

excluded from the study because Bachelors of Science in Nursing (BSN) or Accelerated

18
Masters in Nursing students would have had more educational background than the ADN

students, which might affect the understanding of caring. Students who were repeaters in any of

the semesters in the nursing program were also excluded because their perceptions on caring

could have changed over time, and subtle changes in the educational program could have

impacted their perceptions on caring.

Organization of the Remainder of the Study

Chapter 1 included the introduction, background and statement of the problem, purpose

and nature of the study, definitions of the terms, assumptions, limitations, and delimitations of

the study. Chapter 2 will present the theoretical framework for the study, present, analyze,

synthesize, and critique the appropriate literature related to the problem described in Chapter 1.

Chapter 3 will include a description of the research methodology selected to respond to the

problem and answer the research questions. Detailed descriptions of the design, target

population, sampling method and procedure, data collection, field testing, and data analysis will

be included in Chapter 3. Chapter 4 will present an analysis of the data. The completed

dissertation will conclude with Chapter 5, which will include summary of the findings, the

conclusions drawn from the data presented in Chapter 4, the implications to practice, the

relationship of findings to the literature review, and the recommendations for practice and future

research.

19
 CHAPTER 2. LITERATURE REVIEW

The purpose of this basic qualitative study was to explore how senior nursing students

described caring and the motivational factors that influenced their caring behaviors so that

nursing educators could understand the extent to which the student nurses were acquiring the

knowledge of caring and caring behaviors during their nursing education. The information

gained from this study was anticipated to assist nursing educators in developing methodologies

for teaching caring among nursing students and to prepare competent and compassionate future

nurses to fit the 21st century nursing workforce. Chapter 2 starts with a discussion of the

theoretical framework of the study, which includes constructivism and Swansons theory of

caring. Chapter 2 continues with a review of the research literature and methodological literature

pertaining to the research problem described in Chapter 1.

An extensive literature search provided a great deal of information pertaining to this

study. Literature searches included the use of the electronic journal library through Capella

University and conventional means. Searches were conducted through CINAHL, Medline,

OVID, Academic Search Premier, ProQuest Dissertations & Theses (PQDT), ProQuest,

Education Research Complete, and ERIC. Keywords used for searches included: caring, caring

behaviors, role transition, nursing education, patient satisfaction, and new nurses. Articles from

peer-reviewed journals were extensively reviewed.

Theoretical Framework

The role of theory in qualitative research is important in developing research design and

methodology and research questions (Merriam & Tisdell, 2015). A detailed literature review

20
provided assistance in developing research design, research questions, and methodology. A

detailed explanation about the use of theories in a study provides transparency about the research

(Kelly, 2010). Theory enables a more sophisticated approach to the data so that different

questions can be asked about the research design and research questions. The proposition used in

planning this study was that a student nurse effectively mature to be a competent and caring

nurse with theoretical knowledge from the classroom, skills competency check in skills

laboratory, and clinical practice in clinical settings. Thus, the phenomenon of learning can be

potentially explained through the theoretical lens of constructivism. Another theory used for the

theoretical framework for the study was Swansons theory of caring, which was helpful in

answering the research questions and study findings.

Constructivism

Constructivism, a theory founded on observation and scientific study about how people

learn has roots in philosophy, psychology, sociology, and education (Brandon & All, 2010). It

equates learning with creating meaning from experience. The learner constructs new knowledge

by building on to the existing knowledge through a personal interpretation of learning (Billings

& Halstead, 2012). According to constructivism, learning is an active contextualized process of

constructing knowledge rather than acquiring it. The learner brings past experiences and cultural

factors to a situation and constructs new knowledge (Jia, 2010). Constructivism stems from the

similarities of Socrates philosophy leading students through a Socratic dialogue by asking series

of questions. In line with this view, knowledge results from a process of mental operations and

priori judgments. Socrates Hippocrates was a successful model for constructivism teaching

(Jia). Kant proposed that reason is automatically constructed rather than passively recognized.

Kantian constructivism endorses the respect for individuals as rational agents who engage in

21
rational deliberation, which is structured not by self-interest, but by a reasonable agreement on

principles that consider the interest of all (Jia). As a branch of cognitivism, constructivism views

the learner as being actively engaged in the process of learning and normal judgments are arrived

through reasonable agreements (Jia).

Psychologists Dewey, Piaget, and Vygotsky contributed a great deal to the formation of

constructivism. Dewey proposed that learning is an active process in which the learner constructs

knowledge from real experience (Billings & Halstead, 2012). Central to Deweys experiential

learning theory was the need for doing and then reflecting on the generation and reconstruction

of experiences. Piaget, the forerunner of individual constructivism, put forward the concepts of

assimilation, a process of incorporating new information into existing ideas, then changing those

existing patterns through accommodation to explain new experiences (Piaget & Inhelder, 1969).

During the 70s and 80s, Russian psychologist Vygotsky added to constructivism by proposing

that learning is a social construction (Billings and Halstead).

DeCoux Hampton (2012) conducted a qualitative study to explore the effectiveness of a

constructivism-based learning project to achieve clinical learning outcomes in mental health

nursing. DeCoux Hamptons five-stage project lasted for 10 weeks. During stage one, students

selected a friend, family member, or acquaintance with a diagnosis of mental illness. In the

second stage, students investigated the current care needs and financial resources available.

Following the second stage, students conducted a literature search and examined the best

practices available for the management of the symptoms, which constituted stage three. During

stage four, students watched a documentary or movie on mental illness and completed a

reflective journal. In the final stage of the project, students provided a brief informal presentation

of the data obtained from each stage of the project. Forty-one students participated in the study

22
(DeCoux Hampton). The study illustrated that the use of a constructivism-based learning activity

enabled students to collect pertinent information, had personal relevance, and increased problem-

solving ability with minimal oversight by supervisors. DeCoux Hampton confirmed that

constructivism-based learning could be used to supplement clinical hours to teach mental health

nursing and it could produce positive learning outcomes.

According to Abbas, Lai-Mei, and Ismail (2013), constructivism is based on social

cognitivism, which uses philosophical and psychological approaches. Learning happens in

contexts and learners construct new knowledge from their experience. Abbas et al experimented

with the use of constructivism as the theoretical framework for integrating technology use in the

classroom and asserted that the use of constructivism theory had a positive effect on the learner

when used to introduce new concepts in teaching. In a quantitative study, Hinshaw et al. (2012)

examined post-graduates skill acquisition using the components of constructivism and social

learning theory in designing, developing, and implementing professional development

workshops. One hundred and fifty post-graduate teachers participated in a 3-day workshop. The

researchers incorporated components of constructivism as a KWL chart (what you Know, what

you Want to know, and what you Learned) for participants acquisition of learning skills. The

study confirmed that the KWL chart could be used successfully to promote students skills

acquisition (Hinshaw et al).

In an action research, Adamson and Dewar (2015) utilized a constructivists approach as

the theoretical framework to capture what compassionate care means in practice and its use in

nursing education. Researchers developed a Leadership in Compassionate Care Program (LCCP)

module and examined the use of stories in the curricula to develop compassionate care in nursing

students. The sample size included 37 undergraduate nursing students. After listening to stories

23
selected from clinical practice, participants were asked to reflect on the scenario. The study

findings revealed that reflective learning and the use of stories about the experience of giving

and receiving could contribute to the acquisition of knowledge, skills, and confidence in

providing compassionate care (Adamson & Dewar). Brandon and All (2010) conducted an

analysis of constructivism theory and its application to curricula. The researchers confirmed that

use of constructivism theory in nursing curricula was effective in developing critical thinking

skills, and nursing education could make a paradigm shift towards concept-based curricula using

constructivism theory. The researchers asserted that constructivism theory could be integrated

into clinical education of nursing (Brandon & All).

Malcolm Knowles adult learning theory and Mezirows transformative learning (TL) are

under the umbrella of constructivism, which could be applied in nursing education. One of the

assumptions of andragogy is that the learners prior experiences create a basis for new

knowledge (Knowles, Holton, & Swanson, 2012). Both, andragogy and TL theory agree that the

learners prior experience is inevitable in fostering new learning. Mezirow described how the

transformation process begins with a disorienting dilemma and progresses to self-examination

and critical assessments. The learner then develops new knowledge by disclosing and listening to

others (Billings and Halstead, 2012). Though, Mezirow identified 10 steps required for

transformative learning, Taylor (as cited by Ssegawa & Kasule, 2015) condensed these 10

processes to three steps of disorienting dilemma, critical reflection, and action. The limitation of

students current knowledge takes place in the disorienting process. During the second reflection

process, students critically assess and analyze their assumptions to understand the problem. In

the third process of action, students disclose their opinion with others to examine alternative

24
ideas and approaches. As a result, the learner has the opportunity to test and apply the new

perspective caused by the transformative learning (Ssegawa & Kasule).

Constructivism utilizes interactive teaching strategies and helps students to construct new

knowledge based on their own experience. Student-centered learning and fostering clinical

thinking skills characterize nursing curricula. Thus, constructivism helps the students to

construct new knowledge upon their prior knowledge. Students come to nursing with innate

caring behaviors (Sokola, 2013), then develop new knowledge about caring through their

education in the classroom and clinical settings where they mature to caring nurses by the time

they graduate. Constructivism transforms the student from a passive recipient of knowledge to an

active participant in the learning process (Brandon & All, 2010). Constructivism often creates

higher order thinking skills, which are quite needed in nursing education. Constructivism

learning theory requires studying in the real or semi-real world. It emphasizes students prior

knowledge and experience and student nurses clinical practice provides them with real world

experience.

Swansons Theory of Caring

Kristen Swansons theory of caring has been chosen over Jean Watsons human caring

theory for this study after a detailed review of both theories. Both theories address caring

concepts in nursing practice. Watsons theory consists of ten major concepts and the concepts are

lengthy phrases that should be read multiple times for complete understanding (Alligood, 2014).

For example, one of the lengthy concepts of Watsons theory is, provision of supportive,

protective, and corrective, mental, physical, sociocultural, and spiritual environment (Alligood,

2014, p. 81). Another drawback of Watsons theory is that it does not provide explicit directions

25
to obtain authentic caring-healing relationships (Alligood). Nurses who rely on concrete

guidelines may not feel secure to apply Watsons theory.

In comparison, Swansons theory of caring consists of five concepts: knowing, being

with, doing for, enabling, and maintaining belief. These actions are simple but elegant and easy

to understand. In Swansons theory, the importance of caring is in the forefront and it

exemplifies the nursing professions value (Alligood, 2014). The simplicity of the language and

the clarity of the description of concepts make it easy for anyone to understand about caring. In

this study, it was expected that nursing students would be able to provide the best description

about caring from their experience.

According to Swanson (1991), caring is a nurturing way of relating to a valued other

towards whom one feels a personal sense of commitment and responsibility (p.165). The

ultimate goal of nurse caring is to enable patients to achieve well-being status. Swansons theory

of caring is a middle-range theory, which was empirically derived and developed inductively

following several investigations (Alligood, 2014). As a result of the phenomenological

investigation of women who experienced miscarriages, Swanson developed the Caring Model

and the Human Experience of Miscarriage Model (Alligood). The Caring Model became the

foundation of Swansons middle-range theory of caring. Swanson developed her theory after

conducting three phenomenological inquiries: the experiences of women who had miscarriages,

the experiences of healthcare providers who cared for the vulnerable infants in the neonatal

intensive care units, and the experiences of socially at-risk mothers who received long-term care

(Alligood). Swanson also drew from the literature of philosophy and ethics to develop her

middle-range theory of caring to explain the unique phenomena of a caring relationship between

the individual and others (Kavanaugh et al., 2006).

26
 Higdon and Shirey (2012) conducted a descriptive correlated study to measure patient

and family perception of nurses caring behaviors and found significantly higher levels of

nurses caring behaviors in those who received education on caring behaviors. Swansons caring

professional scale (CPS) was used to measure patients perception of nurses caring behaviors

before and after receiving education on Swansons theory and caring process. Four multihospital

healthcare systems successfully used Swansons theory of caring to implement patient-centered

care in anticipation of Magnet status preparation. The study affirmed that the education on caring

theory improved caring behaviors in nurses (Higdon & Shirey).

In relation to the ethical principles of respect, beneficence, and respect, Kavanaugh et al.

(2006) utilized Swansons theory of caring as a framework for recruitment and retention of

research participants and found it effective. In three separate studies, Swansons theory of caring

presented a way to conceptualize the meaning and components of caring far beyond the

traditional nurse-patient interactions. Swansons theory could be applied wherever caring

attributes were needed; in personal, professional, or patient-nurse relationships. Though

Swansons theory of caring was rooted in research with perinatal loss or threatened loss, it could

be applied to any sensitive and vulnerable areas (Kavanaugh et al).

Andershed and Olsson (2009) conducted a literature review from international journals to

identify and describe how Swansons middle-range theory had been used in nursing practice. The

researchers reviewed 120 studies and asserted that Swansons theory of caring was developed

from empirical phenomenological studies. Many authors applied Swansons theory in practice

and confirmed that Swanson continued her work by developing, implementing, and testing the

theory (Andershed & Olsson, 2009, p. 609). In a qualitative study, Roscigno (2016) used

Swansons theory of caring to categorize parents descriptions of nurses caring attributes when

27
their children suffered from traumatic brain injury (TBI). The researcher was convinced that all

the caring attributes described by Swanson, knowing, doing for, being with, enabling, and

maintaining belief, were appropriate to meet important family needs of parents whose children

suffered with TBI.

According to Andershed and Olsson (2009), if people are guided through discussions of

their experiences and feel understood, informed, provided for, validated and believed in, they

would be better prepared to integrate difficulties into their lives (p. 609), which is in accordance

with Swansons theory of caring. Brilowski and Wendler (2005) also conceptualized the five

attributes of caring: relationship, action, attitude, acceptance, and variability, which were in line

with Swansons theory of caring. In two quantitative studies, Adolfsson (2011) confirmed that

Swansons theory of caring was effective in improving the well-being of women who

experienced miscarriage and lost. For a mixed method study by Hanson (2004), Swansons

theory was the theoretical framework. The researcher asserted that critical care nurses

demonstrated various life experiences congruent with Swansons theory.

According to Swanson (1991) beliefs and values shape ones caring nature. Swansons

theory of caring is a clear explanation of what nurses practice in a caring manner and emphasizes

that the goal of nursing is promotion of an individuals well-being. The five themes of

Swansons theory of caring that are essential for the caring actions are knowing, being with,

doing for, enabling, and maintaining belief. Knowing is the intention to understand the meaning

of an event in ones life by looking at the cues and avoiding assumptions by meticulous

assessments (Swanson). Nurses understand their patients through thorough assessments to

identify problems and initiate appropriate plan of care. Staying with the patient and comforting

when the patient is in emotional distress can demonstrate being with. Doing for is what one

28
would do for the other as he or she would do for self if it were at all possible (Swanson, 1991,

p. 162). When patients are unable to perform their activities of daily lives due to illnesses, nurses

provide all the care needed to maintain health and promote healing. Enabling is empowering,

which consists of informing, coaching, assisting, and supporting another person (Swanson).

Nurses assist and enable patients to regain self-care by encouraging and assisting during

rehabilitation and facilitating the capacity of patients and families to care for them. Maintaining

belief can be attained through believing in the patients capacity, maintaining a hope-filled

attitude, offering realistic optimism, helping to find meaning, offering support, and standing by

them irrespective of their situations (Swanson). Constructivism and Swansons theory provided

the foundation and theoretical framework for this basic qualitative study on senior nursing

students description of caring and the motivational factors that influenced their caring

behaviors.

Review of the Research Literature and Methodological Literature

The literature review pertinent to this study is organized by topics related to the caring

attributes of nurses and nursing students transition to caring nurses. The literature is abundant

with research on the perceptions of caring by nurses and patients. However, little is known

whether nursing students are maturing to caring nurses who meet the needs of the community,

once they complete nursing education. The available and relevant research utilized to build a

foundation for this study is presented thematically; a brief history of caring in nursing, the

importance of caring in nursing practice, the relationship of caring and patient satisfaction, the

focus of nursing education, current trends and driving forces, caring behaviors and motivational

factors, nursing students role transition to graduate nurses, importance of professional

socialization, and seminal work for the study.

29
A Brief History of Caring in Nursing

Caring for the sick was documented since the early Christian era. Initially, the role of

deaconess gave women participating church activities the opportunity to provide care to those

who were sick (Egenes, n.d). Florence Nightingales devotion to caring for those who could not

care for themselves is well known from the 19th century. In 1854, the Crimean war broke out and

Nightingale made remarkable changes in nursing practice by taking care of wounded soldiers

and laying the foundation for the nursing profession (Alligood, 2014). Nightingale documented

the results of her care during the Crimean war and used this work as the basis for further

interventions. Nightingale emphasized the need for holistic nursing care because she believed in

the connection between person and environment. Through her work, she laid down the

foundation of modern evidence-based practice (Alligood). In 1860, Nightingale established the

Nightingale School of Nursing and students experiences were well planned and proper

education was given (Egenes). Florence Nightingale argued for an educated workforce with

standards of practice instead of apprenticeship in hospitals (Domrose, 2012).

The work of the Civil War (1861-1865) nurses laid the foundation for the nursing

profession in the U.S.A. Civil War nurses recognized the value of education in the care of the

sick, and they established schools of nursing for training nurses (Egenes, n.d). From the World

fair meeting in 1893 through the 2010 Institute of Medicine (IOM) report, there was a call for

more changes in the nursing field and full partnership with physicians and others in redesigning

health care in the U.S.A (Domrose, 2012). Hospital nurses went from supporting people after

simple surgeries and providing comfort care to those with incurable conditions to caring for

patients with complex treatments (Domrose). Illness can strike down the mightiest person. At

that time, everyone needs caring actions, especially from nurses, to recuperate. A glance through

30
the history of nursing evidences the stunning developments happening in nursing, one of the

fastest growing professions. Once, nurses were considered the hand maids of doctors (Egenes),

whereas, today, nurses (advanced practice nurses) can diagnose, prescribe, and treat patients.

However, the concept of caring did not change from the time of Nightingale to the 21st century.

Rather, today, caring is the hallmark of nursing. Hospital businesses run primarily on patient

outcomes and patient evaluations, which are deeply immersed in the caring, which people

receive in hospitals (Johnson et al., 2012). Although, nurses in the past took care of sick

individuals, modern nurses expanded their focus to deliver care to individuals, families, groups,

and communities who are well as well as sick.

The Importance of Caring in Nursing Practice

Caring is the hallmark of professional nursing practice. According to Porr and Egan

(2012), caring is not about the vague internal feeling of others; rather caring is required to

fulfilling high quality nursing practice standards and competencies. Caring actions can be small

things that make patients feel comfortable such as offering water to drink, turning the pillow,

holding the hand, listening, smiling, encouraging, and turning and repositioning. Complex caring

acts include making clinical decisions on patient care after performing a thorough assessment,

contacting a physician and obtaining new orders, being a patient advocate, helping the patient to

relieve his or her pain, and having a peaceful and dignified death (Swanson, 1999). Even though,

caring has been conceptualized as a human trait, an affect, and a moral imperative, it is

philosophically grounded and demands that the nurse be fully attentive to the patients holistic

care (Porr & Eagan). The act of caring causes nurses to attend to the salient needs of patients

such as: to question, attain in-depth understanding, seek best practices, and apply critical

reasoning skills (Porr & Eagan). Caring is inherent to nursing practice (Watson, 2008).

31
Papastavrou et al. (2011) defined caring as acts, conduct, and mannerisms demonstrated by

nurses that convey concern, safety, and attention to patients. Nurses spend considerable time

with patients; basically nurses are with the patients 24/7, meeting their needs and demonstrating

expected caring behaviors with each interaction. Caring is a complex phenomenon and it lies at

the heart of nursing. According to Milinar (2010), caring consists of two key components. They

are instrumental and expressive. The instrumental component of caring refers to the physical and

technical aspect of care and the expressive component refers to meeting psychosocial and

emotional needs (Mlinar).

Health care providers have the responsibility of providing holistic and cultural specific

health care to all patients (Al Mutair, Plummer, OBrien, & Clerehan, 2014). The ANA code of

ethics provides guidelines for carrying out nursing responsibilities. According to ANA (2015),

the code ethics for nurses provision 1 states, The nurse practices with compassion and respect

for inherent dignity, worth, and unique attributes of every person (p. 1). Again in ANA code of

ethics for nurses, provision 8 emphasizes reducing health disparities in the U.S.A. The

International Council of Nurses (ICN) also provides guidelines for nursing practice. According

to ICN (2012), there are four fundamental responsibilities of nurses. Those responsibilities are to

promote health, prevent illness, restore health, and alleviate suffering. In order to adhere to those

responsibilities, nurses must provide compassionate nursing care. Nursing care is respectful and

unrestricted by considerations of age, color, creed, culture, disability or illness, gender, sexual

orientation, nationality, politics, race, or social status (ICN, p. 1).

Nurses make countless decisions about patient care on a daily basis including what,

where, when, why, whom, and how care is being given to patients (Mlinar, 2010). In every step

of the decision-making process, nurses require a thorough assessment of the patient in the

32
context of values (personal, patients, cultural, and professional) to determine the appropriate and

unique care for the selected patient (Mlinar). According to ANA (2015), nurses have the primary

responsibility to patients. Nurses caring behaviors promote patients wellbeing. Health care is a

business as well as a human service. Thus, caring remains the soul of nursing practice. Nursing

theorists and other scholars remind the nursing profession of the importance of caring because of

its pivotal role in the importance of nursing practice and its centrality to preserve human dignity

and sustainability of human life (Wang, & Hus, 2014).

The Relationship of Caring and Patient Satisfaction

Hospitals are becoming more competitive and they are under pressure to attract patients

to their facilities (Modic, Siedlecki, Quinn Griffen, & Fitzpatrick, 2014). The values of caring

that are exhibited by healthcare professionals while dealing with sufferings of human beings is

paramount to running the hospital business (Burtson & Sticher, 2010). Nurse caring is a quality

outcome for all healthcare organizations. Health care executives prime focus is to create optimal

positive patient experience so that patients may return to their facility when needed (Modic et al).

The quality of care mainly depends on the caring behaviors that are demonstrated by nurses.

Patient satisfaction is at the core in measuring outcome of healthcare delivery (Farber, 2010). As

per the guidelines of Centers for Medicare and Medicaid Services (CMS) acute care hospitals are

required to submit patient satisfaction scores to receive reimbursement (Farber).

A hospitals Magnet status is widely regarded as a stamp of approval for nursing

excellence and retention and improved patient outcomes (Tinkham, 2014). The American Nurses

Credentialing Center (ANCC) is responsible for issuing the Magnet status to hospitals (AACN,

2008). According to the new release from ANCC, starting April 1, 2016, they are considering

patient and nurse satisfaction when hospitals are applying for the Magnet status or recertification

33
of the Magnet status (Tinkham). At the same time CMS (Centers for Medicare and Medicaid

Services) is also looking for patient and nurse satisfaction for reimbursement purposes

(Tinkham). Press Ganey (PG) is a consulting service that conducts many surveys every year and

provides benchmark reports regarding patient satisfaction. In order to have an improved PG

score, patients should receive compassionate caring during their hospitalization. The PG survey

contains a 31-question survey tool for assessing nurse engagements, which is approved by

AACN. According to Tinkham, high levels of job satisfaction among nurses have been linked to

high levels of patient satisfaction. Patient dissatisfaction occurs due to inadequate information

provided by the nurse, information about what is being done, what will be done, what the patient

can expect, and other basic information about the care process (Ervin, 2006, p. 129).

Patient satisfaction is the new marketing tool for hospitals to attract patients (Cocchi,

2012). Medicares reimbursement is tied to patient satisfaction scores. According to Cocchi,

maintaining patient satisfaction was highly important in the health care system and it was

directly related to the care they receive from nurses. In contrast, Johansen (2014) argued that

while patient satisfaction was important, it was not necessarily an indicator of quality of care in

the emergency department due to the conflicting priorities in the emergency department.

Johansen affirmed that viewing patients as customers in the emergency department and rendering

care could improve the patient satisfaction. Tsai et al. (2014) conducted a cross sectional study in

Taiwan and confirmed that nurses with high nursing competency maintained high career self-

efficacy and professional commitment. Professionally committed nurses demonstrated caring

attributes (Tsai et al). In another quantitative study, Modic et al. (2014) identified listening as

reflective caring among nurses and patients. However, patients did not perceive teaching as a

caring behavior. Patients identified caring behaviors as providing information, surveillance or

34
monitoring, and listening. Health care executives strive to create the priority of optimal patient

experience during hospitalization (Modic et al). Communication and caring behaviors such as

comfort measures, nursing rounds, and provision of engaging activities could improve patient

satisfaction (Wright et al., 2013), which are directly related to nurses caring attributes. Nurse

caring is the most influential dimension of patient advocacy and is predictive of patient

satisfaction (Burtson & Sticher, 2010).

In an attempt to explore what constituted nurse-patient interactions and patients

perceptions of nurse-patient interactions, Henderson et al. (2007) performed a mixed method

study. The researchers selected 35 samples using convenience and purposive sampling and data

were collected via observation of nurse-patient relationships and patient surveys. They

performed simultaneous analysis of the findings from both observations, which assisted them in

comparing and contrasting nurse-patient care activities. The study findings revealed that patients

had some dissatisfaction regarding the care they received. Patients perceived that nurses were not

readily available to respond to their specific needs. The researchers asserted that patient

satisfaction could be improved if nurses could respond to patient needs and communicate

effectively with them (Henderson et al). In a descriptive correlational study, Azizi-Fini, Mousavi,

Mazroui-Sabdani, and AdibHajbaghery (2012) affirmed that the caring behaviors of nurses and

patient education increased the patient satisfaction scores.

In another qualitative study, Murphy et al. (2009) aimed to examine the perception of

caring behaviors in first year and third-year nursing students and found a contradictory finding

that third-year nursing students scored less in the perception of caring behaviors than the first

year nursing students, which was opposite to what was expected. The researchers assumed that

35
the educational process might have reduced third year nursing students perception on caring

behaviors (Murphy et al).

The Focus of Nursing Education

Nursing education is aimed to expose nursing students to an overall view of caring

science so that they can be grown as caring individuals (Labrague et al., 2015). The aim of

nursing education is to help students to become beginning practitioners who are able to make

right clinical judgments and provide patient safety. Nursing education is designed in such a way

that theoretical knowledge and clinical practice enables the transformation of nursing students to

be caring nurses (Rhodes et al., 2011). Students develop the caring behaviors through the

exposure to social, environmental, and cultural factors (Sokola, 2013). When students interact

with patients, faculty, and peers, their innate caring behavior will be matured by education and

clinical practice. The nursing practice literature is replete with references to caring. All nursing

theories are in some way or another connected with the concept of caring. Nursing students

identity as caring professionals is developed as they graduate from a nursing program (AACN,

2008). Nursing students learn about the significant values and essence of the nursing profession

during their nursing education. Nursing education nurtures the caring attitude in nursing students

(Ma, Li, Liang, Bai, & Song, 2014). Nursing education guides the progression from a caring

person to a professional identity of caring (Labrague et al., 2015; Rhodes et al., 2011; Watson,

2008).

The Institute of Medicine (IOM) and other major organizations have been reporting

significant threats to the quality and safety of patient care for more than 10 years and

recommended for the Quality and Safety Education for Nurses (QSEN) (Disch, 2012). The

QSEN is a national initiative to identify the competencies and knowledge, skills, and attitudes

36
(KSAs) needed by all nurses to continually improve health care quality and safety (Barnsteiner et

al., 2013; Disch, 2012). The six QSEN competencies are safety, patient-centered care, teamwork

and collaboration, evidence-based practice, quality improvement, and informatics. QSEN

focuses critically on nursing education and nursing students are evaluated on the QSEN

competencies (Johnson et al., 2012) so that future nurses might be competent in providing

quality care.

Nursing programs are required to maintain an accreditation status from any of the

accreditation agencies to demonstrate that the program is providing substantial education to

students. One of the goals of Accreditation Commission for Education in Nursing (ACEN) is to

foster educational equity, access, opportunities, mobility, and preparation for employment based

upon type of nursing education (ACEN, 2015, p. 1). Most graduate schools will not accept

students who graduated from non-accredited schools. In order to maintain accreditation status,

programs should provide evidence of hiring agencies satisfaction with new graduates from that

institution. When newly qualified nurses from a particular institution do not perform caring

attributes, the hiring agencies express reluctance to hire graduates from such institutions and it

affects the accreditation status of that program and places the program in jeopardy (ACEN). The

quality of nurses reflects the type of education they receive. Unprepared new nurses can be

perilous to patient safety and competent patient care. This sets them up for professional

dissatisfaction (Shipman et al., 2012). Thus, nursing education is focusing and striving hard to

educate and prepare new nurses to meet the 21st century health care needs.

Current Trends and Driving Forces

Advancement of scientific and technological innovations caused tremendous changes in

the health care system and nursing practice (Neal-Boylan, 2016). In spite of all the drastic

37
changes in the health care system, the concept of caring is still the soul of nursing practice.

Studies have shown that patient satisfaction in nurse caring is paramount in the health care

system whether to achieve Magnet status, run the business, or to receive reimbursement

(Cocchi, 2012; Johansen, 2014; Modic et al., 2014; Tinkham, 2014; Tsai et al., 2014). Due to the

technology advancement and health care reforms, new nurses are compelled to assume full RN

responsibilities as soon as they obtain the RN license (Tsai et al).

Recent studies demonstrated that patients and their families were not receiving

compassionate caring from nurses (Adamson & Denwar, 2015; Blackmore, 2011). New nurses

entering the nursing practice lacked the clinical decision making skills to provide competent care

(Dyess & Sherman, 2009). Currently, new nurse graduates can take NCLEX-RN State Board

examination even within a week of their graduation and they can start practicing nursing and

assume the full RN responsibilities (Dyess & Sherman). Studies indicated that although the

registered nurse (RN) license is the evidence of achieving the legal and professional competence

to enter nursing practice, new nurses lacked the clinical skills and judgment needed to provide

safe and competent care and the frustration of lacking competency in caring led many new

nurses to leave the profession (Diaz et al., 2015; Dyess et al., 2016). Many hiring agencies

reported that many new nurses fail to meet the expected level of competency in providing patient

care (Kelton, 2014; McSherry, Cottis, Rapson, & Stringer, 2015).

New nurses constitute 10% of the nursing workforce in many acute care settings.

Currently 31% of new graduates leave their job in the first two years of service mainly due to the

lack of guidance and support and lack of self-confidence (Dyess et al., 2016). According to

Grochow (2008), new graduate turnover ranged from 55% to 61%. About 574,400 RN job

shortages are predicted by the year 2022 (McMenamin, 2014). Thus, the need for preparing more

38
nurses with compassionate and caring attributes to serve the community is paramount. The

prediction of a nursing shortage and new nurses leaving the profession puts undue pressure on

nursing faculty members to prepare more nurses as well as to help retain new nurses in nursing

practice.

There was a growing concern that patients are not receiving adequate basic care (Kitson,

Muntlin, Athlin, & Conroy, 2014). After conducting a study in the United Kingdom (UK),

Kitson et al argued that there should be substantial evidence of previous nursing assistant work

experience in order for new graduates to obtain a job as RN because the experience would

provide them with basics of nursing care. Many hospitals in UK are mandating that the new

nurses have at least three months experience as a nursing assistant to obtain a job as an RN

(Kitson et al) so that those nurses could provide compassionate nursing care.

Caring Behaviors and Motivational Factors

Students come to the nursing profession with an innate ability to care others (Sokola,

2013). Students develop the caring behaviors through the exposure of social, environmental, and

cultural factors. Sokola conducted a descriptive correlational study to examine the relationship

between caring ability (innate caring) and competency with caring behaviors (professional

learning) of student nurses and confirmed that nursing education significantly impacted the

development of professional caring behaviors in nursing students. When students interact with

patients, faculty, and peers, their innate caring behaviors will be developed by education and

they get the opportunity to practice caring. Researchers recommend further studies on identifying

factors that motivate students to incorporate caring in practice, which is the basis for this study

(Sokola). Nurse caring takes place within interactions with patients as rapport is developed. In

order to develop a nurse-patient relationship, the nurse must be motivated to attend to the needs

39
of patient. Thus, the nurses intentions to attend to the needs of patient are the driving force for

caring behaviors (Porr & Egan, 2012).

Labrague et al. (2015) conducted a descriptive non-experimental design to determine the

correlation between instructors and students caring behaviors and to understand the impact of

instructors caring on students perceptions of their caring behaviors. The researchers used two

standardized questionnaires: the Nursing Students Perception of Instructor Caring (NSPIC) and

Caring Behavior Inventory (CBI). A convenience sample of 586 international nursing students

participated in the study. Pearson r correlation and regression analysis were used to determine

the correlation between variables. The study results demonstrated significant correlation between

NSPIC and CBI (r = .587, p = <.001). The researchers concluded that the instructors caring

behaviors influenced positively the development of nursing students caring behaviors. Nursing

students could be professionally trained to develop the competence of caring when faculty

members demonstrated positive role modeling. Researchers suggested that simulation,

educational games, writing reflective journal, and nursing care plans could foster caring in

student nurses.

Nursing is a caring profession and it is deeply rooted in ethics. A descriptive study by

Clarke, Kane, Rajacich, and Lafreniere (2012), found that nursing students experienced bullying

behaviors from nursing faculty and staff nurses in clinical settings, which negatively impacted

the developments of caring behaviors in them. When a nursing shortage is looming, efforts must

be taken to increase the retention of competent nurses. Nursing students who experienced verbal

and academic abuse expressed the intention to leave the profession (Clarke et al). At the same

time, nurses who experienced bullying in the workplace failed to demonstrate caring attributes to

patients.

40
 Minnesota Baccalaureate Psychomotor Skills faculty group conducted a non-experimental

study to examine how psychomotor skill learning promotes caring behavior (Nursing student

caring behaviors, 2008). Students were videotaped while they performed blood pressure

measurement on a role-player. The role-player rated the students caring behaviors. Students

learned about caring through analysis of videotaped activity. Researchers found that students

demonstrated improved caring behavior after consistent teaching interventions.

Ma et al. (2014) conducted a qualitative descriptive study using focus group interviews in

China to explore baccalaureate-nursing students perspectives on learning about caring. The

themes emerging from the study were learning by model, conducive learning environment as the

incentive to learning about caring, lack of directive way of learning as the hindrance to learning

about caring, and lack of cultural competency as the barrier to the learning about caring (Ma et

al). The researchers concluded that by teaching nursing students the caring theory, knowledge,

skills, attitudes, and the art of caring, they would benefit from learning of caring behaviors. In a

caring environment students could get support from the team members and positive staff

relationships, which would facilitate caring behaviors (Ma et al). Informal and hidden curriculum

such as role modeling, reflective practice, critical thinking, and conducive learning environments

play important roles in developing caring attributes (Ma et al). When students establish a

student-patient relationship they learn about caring. Papastavrou et al. (2011) defined caring as

acts, conduct and mannerisms demonstrated by nurses that convey concern, safety, and attention

to patients. Nurses spend considerable time with patients; basically nurses are with the patients

24/7 meeting their needs and expected to demonstrate caring behaviors with each interaction.

Nursing students can learn professionalism from the caring education they receive during nursing

education (Ma et al).

41
 Zamanzadeh et al. (2015) performed a descriptive study to determine nursing students

perceptions of instructors caring behaviors. Through a random sampling 240 students took part

in the study. The study revealed that clinical facultys caring behaviors motivated students to be

caring; student caring abilities developed as much as the instructors attention to caring got

deeper (Zamanzadeth et al., p. 56). The researchers affirmed that students could learn

professionalism during clinical education. Nursing instructors caring behavior positively

contributed to the development of caring attributes in nursing students. Nursing instructors can

instill caring behaviors by fostering a supportive learning climate, demonstrating appreciation of

life meaning, control versus flexibility, and respectful sharing (Zamanzadeh et al). At the same

time, instructors non-caring behaviors could develop humiliation, rudeness, and negligence in

nursing students. Nursing instructors caring behaviors influenced student learning positively and

reduced their anxiety, increasing self-confidence, and interpersonal relationships (Zamanzadeth

et al).

Pai et al. (2013) conducted a cross-sectional study to explore the relationship between

caring behaviors and the disposition towards the critical thinking of nursing students in clinical

practice. The study results showed that individuals with a higher frequency of caring behaviors

had a higher score on critical thinking about nursing practice ( = .44, t = 5.14, p < .001) (Pai et

al). The researchers asserted that caring behaviors could stimulate critical thinking skills. Dewar

and Nolan (2013) used appreciative inquiry (AI) approach along with action research for

identifying strategies to promote compassionate relationship-centered care for older adults in

acute care settings. The researchers used purposive sampling (n=57), which included RNs,

nonregistered care staff, medical staff, patients, and families. Data were collected from

participant observation, interviews, storytelling, and group discussions. The researchers used a

42
process of immersion crystallization for data analysis. In order to perform the study, researchers

developed a model called 7 Cs to promote appreciative caring conversations during patient

care. The factors included in the 7 Cs model were being courageous, curious, collaborative,

connecting emotionally, considering, compromising, and being celebratory (Dewar & Nolan).

The researchers asserted that engaging in appreciative caring conversations could promote

compassionate and relationship-centered care.

In a phenomenological and hermeneutical study, Scheckel and Nelson (2014) explored

undergraduate-nursing students lived experience in regards to caring for suicidal patients. The

researchers chose 12 students who completed a mental health course for the study. Data were

collected using unstructured interview questions. Data analysis was performed using Benners

phenomenological and hermeneutical data analysis (Scheckel & Nelson). The study findings

indicated that nursing students experienced fear when they read the documentation about suicidal

patients mental status and those fears disrupted their ability to provide nursing care. The

researchers acknowledged that using unstructured questions for the interview limited their

opportunity to ask specific questions about other sources of student experiences (Scheckel &

Nelson). Patients with suicidal ideations are commonly seen in any healthcare settings. Thus,

nurses may have to deal with such patients on a daily basis.

Papastavrou et al. (2011) conducted a descriptive survey to understand the perceptions of

nurse caring behaviors from six European countries. The researchers used convenience sampling

with surgical patients (n = 1659) and their nurses (n = 1195) from 88 wards and 34 hospitals. The

researchers used Caring Behavior Inventory-24 tool to collect data and used SPSS for data

analysis. The study found significant differences in the perception of caring between patients and

nurses. The researchers reported an alarming finding that patients provided a lower evaluation in

43
the items of supporting the patient, respecting individuality, being empathetic, giving

opportunities to express feelings, and satisfying patient needs. The study conducted by

Papastavrou et al provided the perception of caring behaviors but not the actual experience of

caring. However, it pinpointed the need to improve the caring attributes of nurses.

When nurses experienced bullying behaviors they tend to demonstrate such behaviors with their

juniors (Cocchi, 2012). About 74% physicians and 82% nurses reported having experienced

bullying experience in the workplace where there was an association with poor performance,

depression, and violent behaviors (Ekici & Beder, 2014). When nursing students and nurses

experience bullying in workplace, they fail to demonstrate caring attributes with patients who

expect nurses to be competent in providing compassionate care as well as demonstrating

professional behaviors. Bullying in nursing affect patient care and patient outcomes. Studies

have shown that bullying behaviors among nursing staff increased the occurrences of medication

errors in hospital settings (Clarke et al., 2012).

Role modeling influences the development of professionalism in nursing students so that

they can meet the expectations of the public (Felstead, 2013). Role modeling by clinicians

assisted in the development of medical students professional competencies, values, and attitudes

(Burgess, Goulston, & Oates, 2015). Clinical tutors played an important role in socializing and

supporting new students to develop professional identity (Burgess et al).

Previous studies revealed that patients rated nurses professional knowledge and skills as

caring behaviors whereas the patients families reported nurse caring behaviors as treating the

patient as an individual, knowing what you are doing, knowing how to give medication and

treatments on time, and knowing how to handle equipment (Modic et al., 2014). The

consequences of non-caring behaviors were identified as anger, lack of control, despair,

44
helplessness, vulnerability, and loneliness (Clukey, Hayes, Merrill, & Curtis, 2009). In order to

provide effective care, nurses need to acquire skillful application of the theoretical knowledge

and ethical conduct (Mlinar, 2010). When the faculty members demonstrate negative role

attitudes, the nursing student may develop an aversion to nursing and he or she may leave the

profession or it may negatively affect the students academic success (Cocchi, 2012). A tsunami

of nursing shortage is predicted by 2022 (McMenamin, 2014). Nursing faculty should be

teaching and demonstrating the value of caring in the nursing profession to keep the students

interested in completing the nursing program. Azizi-Fini et al. (2012) identified the themes of

caring behaviors as responding when needed without being prompting, demonstrating respect,

maintaining positive communication, following through, and taking care of patient needs.

A faculty being a good role model to nursing students can promote students competence

and confidence (Klunklin, Subpaiboongid, Keitlertnapha, Viseskul, & Turale, 2011). Klunklin et

al conducted a descriptive study in exploring the role model behaviors of nursing faculty in

Thailand and found the highest rated role models characteristics of faculty were: respect for

students, enthusiastic and high-quality teaching activities, showing the value of nursing practice

and the profession, social appropriateness, and ongoing professional development. Nursing

students learn a great deal of professional socialization from their clinical experiences. The

researchers recommended that nursing faculty could facilitate the development of professional

socialization by being a role model and showing respect to students by giving them opportunities

to clear their doubts rather than getting annoyed by their questions (Klunklin et al).

Nursing Students Role Transition to Graduate Nurses

During the role transition period, senior nursing students assume the responsibilities of an

RN under the direct supervision of a senior nurse or a preceptor. The preceptors play an

45
important role in the transition of nursing students from classroom to clinical practice (Staykova,

Huson, & Pennington, 2013). The transition from student to registered nurse can be stressful and

related to preparedness, confidence in clinical skills, decision-making, and professional

socialization (Doody, Tuohy, & Deasy, 2012). Duchscher (2009) suggested that educational

institutions should focus on preparing senior nursing students for role transition and the dynamic,

highly intense, and critical-laden context of professional practice. New nurses experience

transition shock from anxiety, insecurity, inadequacy, and instability (Doody et al). Researchers

have found an unpleasant preceptorship experience was one of the main reasons for lower work

productivities, decrease in job satisfaction, and burnout or leaving nursing in the first year after

graduating (Doody et al., 2012; Kim, 2007). Martin, Brewer, and Barr (2011) asserted that a

preceptorship program was helpful for nursing students to role transition to graduate nurses.

Professional organizations such as: Institute of Medicine (IOM) and AACN recommend that

nursing students should demonstrate proficiency in nursing competencies (Staykova et al) so that

they would be able to assume the responsibilities of an RN as soon as they receive their RN

license. Senior students have to spend at least 120 hours under the preceptorship of a staff nurse

for role transition.

The expense of recruiting and orienting a professional nurse may range from $ 8,000 to $

50,000 (Kim, 2007). Grochow (2008) identified that the higher turnover of new graduate nurses

was due to the stressful transition from students to practicing professional. A high turnover may

drain hospitals. Tiwaken, Caranto, and David (2015) found that a healthy and positive preceptor-

student interaction promoted nursing students confidence in role transitioning into graduate

nurses. In a phenomenological study, Tiwaken et al examined nursing students point of view

and their lived experiences of clinical practice. The researchers found that clinical practice was

46
as an essential component of their learning process, which provided them an opportunity to apply

the learned skills and to become proficient and confident in their skills and to become competent

in taking care of patients. Tiwaken et al asserted that the clinical environment and the

characteristics of the clinical instructors play important roles in empowering learning,

emphasizing their sense of responsibilities, and helping them to be competent nurses.

Chung et al. (2008) used a mixed method to find out the learning experience and

outcomes of pre-graduation clinical placement. The participants included 37 students and 33

preceptors. The data included students and preceptors appraisal of pre and post inventory of

nursing competencies, interviews, and students reflective journals. The themes emerging from

the study were: learning to work with a ward nurse preceptor, learning total aspect of care, and

acting as RN helped them to demonstrate competency in taking care of patients (Chung et al).

The researchers affirmed that during the senior semester (role transition period) nursing students

receive optimal opportunity to mature to be `caring nurses with the help of their preceptors.

Duchscher (2009) conducted a study to find out the process of new graduate nurse role

transition into a competent nurse. The researcher chose 14 females graduates from 4-year

baccalaureate nursing program and six face-to-face interviews were conducted and the study

lasted for 18 months. The study results revealed that the experience of new graduates entering

professional practice was a process of making significant adjustments to personal and

professional roles. In a survey study, Doody et al. (2012) tried to explore the perceptions and

expectations of role transition students from a bachelors degree in nursing program at an Irish

University. The sample size was 116. The participants filled out 28 items pertaining to their

perceptions of role transition such as demographic data, role preparation, role competence,

organization, and support issues. Students from different disciplines had contrasting views of

47
their preparedness to take RN responsibilities. Half of the participants felt they were well

prepared to take the RN responsibilities and half of them did not feel that way. The participants

generally perceived themselves as competent, managing workload, prioritizing care delivery,

interpersonal skills, time management skills, ethical decision making, and providing health

information, and health education. Half of the participants did not feel confident about their

knowledge and expected their transition would be problematic (Doody et al). This study shows

that half of the nursing students do not perceive themselves as competent enough to take care of

the RN responsibilities.

Whitehead and Holmes (2011) conducted a literature review to investigate whether newly

qualified nurses feel prepared for practice. The transition from student to qualified nurse was a

major concern for nurse managers. Themes that emerged were transition and preparation,

accountability and responsibility, and support and learning to cope. The researchers

recommended giving students the options to choose their role transition site in a mandatory

preceptorship program. Students develop nursing skills from clinical experience. Students

acquire the knowledge of critical thinking skills and clinical decision-making skills through their

practice in clinical settings (Jan & Popescu, 2014).

Kaihlanen et al. (2013) conducted a qualitative descriptive study to find out how the

mentor guided students progression to a nurse. Sixteen nursing students were asked to write

their experience with their clinical mentor and the data was analyzed using content analysis. The

three categories emerged from the study were role change support, mentors action, and the

qualities of the mentor. The study demonstrated a significant role of mentoring to help students

to grow as a nurse. Through a Heideggerian Hermeneutic study, Kumaran and Carney (2014)

explored the experiences of role transition for newly qualified nurses. Ten new nurses were

48
interviewed and data were analyzed using Van Manens thematic analysis. The researchers found

that new nurses felt excited upon qualification but professional responsibilities and

accountability associated with the new role were overwhelming for participants. Student nurses

got frustrated when no support was received (Kumaran & Carney).

Many new nurses expressed that they were not well prepared to care for dying patients

(Gilliland, 2015). Nurses are present at the time leading up to death, during dying, and

immediately after the death. Nurses should demonstrate caring attributes during such instances.

A two-day planned experience with dying patients in a hospice setting improved students

attitude towards taking care of dying patients (Gilliland). The researcher suggested continuous

support and ongoing continuous education to prepare a novice nurse to an expert nurse.

Importance of Professional Socialization

Professional socialization is the process in which people learn new roles, values,

behaviors, and knowledge, pertaining in a special group or profession (Dinmohammadi, Peyrovi,

& Mehrdad, 2013). The socialization process has a great influence on the nature of care a nurse

provides. Even though caring is considered as an innate human trait, it has moral duty and

involves mutual relationships, which are physical or expressive in nature and learned from

experiences (Dimitriadou, Pizirtzidou, & Lavdaniti, 2013). The care that is provided by nurses is

shaped by their socialization experience as students and young workers. Educational institutions

have the responsibility of helping nursing students develop professional socialization. Nursing

students professional socialization starts as soon as they enter the nursing program and

continues with their role as nurses (Dinmohammadi et al). According to Dinmohammadi et al,

socialization is both intended and unintended consequences of the education process and work

experience (p. 27). Student nurses encounter many stresses and challenges during their

49
education, which have a significant role on their development of professional socialization

(Dinmohammadi et al).

Mosalanejad, Parandavar, and Javadpour (2013) conducted a cross-sectional study to

investigate the different dimensions of a hidden curriculum from the viewpoints of the professors

and students. They confirmed that a hidden curriculum was more important than the formal one

because students learned a great deal through non-academic dimensions of the environment. A

hidden curriculum had a close relationship with professionalism and formation of professional

ethics and self-esteem. Mosalanejad et al asserted that a hidden curriculum was the strongest way

for transmitting professionalism and values to students. Students acquire the knowledge of

critical thinking and clinical decision-making skills through their practice in clinical settings (Jan

& Popescu, 2014). Clinical practice is very important in nursing for helping students to acquire

the skills as well as developing personal and professional socialization process. Clinical

experience is important in reinforcing the principles learned in the classroom. A positive and

supportive environment is essential for students to develop skills, knowledge, and professional

socialization (Jan & Popescu). Senior nursing students description of caring might be helpful in

understanding how they were developing professional socialization.

Seminal Work for the Study

In order to examine the relationship between caring ability (innate caring) and

competency caring behaviors (professional caring) of first and fourth semester students, Sokola

(2013) conducted a descriptive correlational study. Through convenience sampling, 153 students

were recruited for the study. Data was collected using the Caring Ability Inventory (CAI) and

Caring Nurse-patient Interaction (CNPI) tools. The researchers analyzed the data using SPSS

version 18.0. The study showed a significant difference in caring ability (innate) and competency

50
caring behaviors (professional) of first and fourth semester nursing students and CAI and CNPI

tools were useful in assessing a students growth in relation to caring behaviors. Sokola asserted

that nursing students entered into a patient relationship using their innate caring skills and

behaviors. As they accrued more professional knowledge and clinical practice, they gradually

assimilated behaviors that demonstrated professional caring attributes into their interactions with

patients. Sokola (2013) recommended for a study to investigate factors that motivate students to

incorporate caring in practice and factors that contribute to adjustments in caring behaviors (p.

53).

Additionally, Sandvik et al. (2014) conducted a phenomenological hermeneutical study to

elucidate the meaning and understanding of students in the development of becoming a nurse. A

purposeful sampling was done (n = 21) and data were collected from focus group interviews. The

researchers completed data analysis using phenomenological hermeneutical data analysis. The

two constituents emerged from the study were prerequisites and items for learning and

development in becoming a nurse. The researchers found that a strong student-preceptor

relationship was the foundation for learning and development of a nurse. Sandvik et al asserted

that caring relationships promoted warmth and trust. When students experienced caring, they

could develop and demonstrate caring behaviors. Sandvik et al affirmed that nursing students

were transformed by what they learned in caring and it helped them to grow in professional

identity. The researchers asserted that a caring student-preceptor relationship was pivotal to their

transformation to be a nurse. Sandvik et al strongly recommended further studies to focus on the

ontological perspectives on the process of transformation of a nurse. Ontological assumptions

believe that human beings have their own thoughts, interpretations, and means (Ahmed, 2008). A

basic qualitative study about how senior nursing students described caring and the motivational

51
factors that influenced their caring behaviors were real truth and it could be better understood

through interviews.

Review of Methodological Issues

Research is defined as a systematic inquiry that justifies the existing knowledge and

developing new knowledge (Merriam & Tisdell, 2015). Research can be considered as a link that

connects theory, education, and practice. All research begins with a research question.

Intellectual curiosity is the foundation of any research. There are mainly two types of research:

quantitative and qualitative. Quantitative research is concerned with objectivity, tight controls

over the research situation, and the ability to generalize findings. Qualitative research focuses on

subjective meaning and understanding of how people make sense of their lives and how people

interpret what they experience (Merriam & Tisdell). Methodology is the logical link to how to

conduct a research (Neuman, 2014). A basic qualitative research methodology was chosen for

this study. In a basic qualitative study, the researchers are interested in (1) how people interpret

their experiences, (2) how they construct their worlds, and (3) what meaning they attribute to

their experiences (Merriam, 2009, p. 23). The purpose of a basic qualitative study is to

understand how people make sense of their lives and experiences. A basic qualitative study

focuses on meanings, understandings, and processes of the phenomenon being studied

(Merriam).

Since the purpose of this study was to explore how senior nursing students describe

caring and the motivational factors that influenced their caring behaviors, a basic qualitative

study provided rich descriptions of caring and caring attributes from their experience. Other

qualitative studies such as: phenomenological, ethnographic, grounded theory, case study, or

narrative analysis were not the right choice for the proposed study. A phenomenological study

52
focuses on intense human experiences such as love, anger, and betrayal (Merriam, 2009).

Ethnographic studies focus on human society and cultures, grounded theory research focuses on

building theory, case study investigates a bounded system, and narrative analysis uses peoples

stories to understand their stories (Merriam; Merriam & Tisdell, 2015). The research question of

this study was: How do senior nursing students describe the components of caring and the

motivational factors that influence their caring behaviors? Only a basic qualitative study could

provide thick and rich descriptions of caring and the motivational factors that influence caring

behaviors in nursing students so that nursing educators can understand the extent to which

student nurses were acquiring the knowledge of caring and caring behaviors during their nursing

education. The information gained in this study was anticipated to assist faculty in developing

effective teaching strategies that promote the professional identity of caring among nursing

students so that future nurses might be skillful in providing safe and competent caring in their

practice as soon as they enter the profession.

Data was collected through face-to-face interviews with eligible ADN senior nursing

students. Semi-structured questions in interviews explore the views, experiences, beliefs, and

motivations of the participants (Gill, Stewart, Treasure, & Chadwick, 2008). When using semi-

structured interview questions, the researcher has the flexibility and opportunity for the

discovery or elaboration of information that is important to participants (Gill et al; Merriam,

2009). A face-to-face interview or a Skype interview, whenever participants were not available

for face-to-face, was performed and the conversation was audio recorded for verbatim

transcription and accuracy of information (Merriam & Tisdell, 2015).

53
Synthesis of Research Findings

Studies indicated that although the registered nurse (RN) license is the evidence of

achieving legal and professional competence to enter nursing practice, new nurses lack the

clinical skills and judgment needed to provide safe and competent care (Diaz et al., 2015; Dyess

& Sherman, 2009: Dyess et al., 2016; Li & Kenward, 2006). Prior studies affirmed that new

nurses were not well prepared to take full RN responsibilities immediately after graduation

(Doody et al., 2012; Gilliland, 2015). Review of the literature confirmed that patient satisfaction

is directly associated with the care they receive (Burtson & Sticher, 2010; Henderson et al.,

2007; Modic et al., 2014; Wright et al., 2013). Tsai et al. (2014) asserted that professionally

committed nurses demonstrate caring attributes. Health care system continuously focuses on

improving the quality of care (Barnsteiner et al., 2013; Disch 2012).

The American Association of Colleges of Nursing (AACN) and National League for

Nursing (NLN) have identified caring as a fundamental value of nursing (AACN, 2008; NLN,

2007). The ANA Code of Ethics for Nurses provides guidelines for nursing practice, which

includes promoting health, preventing illness, restoring health, and alleviating suffering (ANA,

2015). In order to adhere with those responsibilities, nurses must be providing compassionate

nursing care. Nursing education guides the progression from a caring person to a professional

identity of caring (Labrague et al., 2015; Rhodes et al., 2011; Watson, 2008). In order to graduate

from nursing school, students need to demonstrate their competency in theoretical knowledge

and clinical skills to provide safe and competent care (Kelton, 2014). Studies have shown that

education on caring attributes improved nurses caring behavior (Azizi-Fini et al., 2012;

Labrague et al., 2015; Ma et al., 2014). Many hiring agencies reported that many new nurses fail

to meet the expected level of competency in providing patient care (Kelton, 2014; McSherry et

54
al., 2015). Patients expect to receive quality care (Farber, 2010; Tsai et al., 2014). Previous

descriptive, non-experimental survey, and phenomenological studies have been conducted to

measure the perception of caring and how nursing students become a competent and caring nurse

(Hanson, 2004; Khademian & Vizeshfar, 2008; Labrague et al., 2015; Nursing student caring,

2008; Porr & Egan, 2013; Sandvik et al., 2014; Sokola, 2013). However, little was known

whether nursing students were maturing or obtaining the competency of a nurse upon completion

of their education. Role transition provided smoother transition to graduate nurses (Whitehead &

Holmes, 2011). Duchscher (2008) documented that nursing students got optimal opportunity to

mature to be caring nurses during the role transition semester of nursing education. However, no

studies have been traced to know what the role transition students have to say about it.

According to Labrague et al. (2015), about caring can be read, taught, and learned but it

has to be experienced to understand what it is and caring will be understood by self-reporting.

Obtaining the description of caring and the motivational factors that influence caring behaviors

from senior nursing students may help the researcher to understand the extent to which student

nurses are acquiring the knowledge of caring and caring behaviors during their nursing

education. Clark and Holmes (2007), Sandvik et al. (2014), and Sokola (2013) identified a gap in

the literature and recommended more research to find out how nursing students are maturing in

caring behaviors. With greater understanding of the description of caring and the motivational

factors of caring behaviors, recommendations to facilitate the transition of competent nurses with

caring attributes may be revealed. This study finding may be helpful in filling the gap in the

literature and add knowledge to the body of nursing education.

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Critique of Previous Researches

A review of the literature revealed 71 studies related to nurse caring, caring behaviors,

and the motivational factors that influence caring behaviors of nurses and nursing students. Of

those studies, 35 were qualitative, 24 were quantitative, nine of them were mixed method, and

three were literature reviews. The qualitative studies included phenomenological research,

participant observations, grounded theory, and focus groups. The quantitative designs used

surveys, quasi-experimental, descriptive, and correlational studies. Overall, the studies were

found legitimate and sound. However, most of the studies focused on baccalaureate nursing

students and only a few on ADN students. Hardly any studies could be identified, which used a

basic qualitative study regarding the research topic. Studies from 2006 to 2016 were included in

the literature review to obtain the results of the landmark studies of caring.

The review of the literature established the need to investigate the description of caring

and the motivational factors that influence ADN students caring behaviors. Prior research

focused on the perception of caring, but no studies were identified regarding what the nursing

students had to say about caring. Little is known about whether nursing students are acquiring

the full concept of caring as they role transition to graduate nurses. The competency of caring

would better be obtained through basic qualitative studies (Merriam, 2009). The study

recommendation of Clark and Holman (2007), Sandvick et al. (2014), and Sokola (2013)

provided confirmation for the need for the study. The information gained in this study was

anticipated to help nursing educators and faculty members to develop teaching strategies to train

nurses to possess caring behaviors.

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 Chapter 2 Summary

The literature review included a discussion of the theoretical framework used for this

study, brief history of caring, and various themes emerging regarding the caring attributes. The

theories that were used for this study were constructivism and Swansons theory of caring.

Constructivism was found best to explain the process of student learning. Swansons theory of

caring has been chosen over Jean Watsons human caring theory because it is easier to

understand the concepts. In Swansons theory, the importance of caring is in the forefront, and it

exemplifies the nursing professions values (Alligood, 2014). The five themes of Swansons

theory of caring that are essential for the caring actions are knowing, being with, doing for,

enabling, and maintaining belief, which could easily be understood by nursing students.

Swansons theory of caring is a clear explanation of what nurses practice in a caring manner and

emphasizes that the goal of nursing is promotion of an individuals well-being. Swansons theory

of caring was effective in answering research questions and explaining the study findings.

The literature review revealed that nursing students role transition to graduate nurses

was a complex process (Dyess et al., 2016). Patient satisfaction and nurse caring have been

highly interrelated (Burtson & Sticher, 2010; Modic et al., 2014). Patient satisfaction is highly

related to the care patients receive in the hospital (Cocchi, 2012; Modic et al., 2014; Tsai et al.,

2014; Wright et al., 2013). However, Johansen (2014) argued that while patient satisfaction was

important, it was not necessarily an indicator of quality of care in the emergency department due

to the conflicting priorities in the emergency department. Johansen affirmed that viewing

patients as customers in the emergency department and rendering care could improve the patient

satisfaction.

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 The literature review affirmed that nursing programs are required to provide program

outcome reports to accreditation agencies for maintaining accreditation status and thus, it affects

the programs existence (ACEN, 2015). When new nurses from a particular program fail to

demonstrate caring behaviors, the hiring agencies express reluctance to hire any more nurses

from such institutions. The prediction of nursing shortage and the number of new nurses leaving

the profession are serious issues to consider by the nursing profession (Dyess et al., 2016;

McMenamin, 2014). The current situation is pressurizing nursing education to prepare more

competent nurses to meet the needs of 21st century workforce. Previous qualitative, quantitative,

and mixed method studies have been conducted to examine the perception of caring of nurses

and nursing students. However, little is known whether nursing students are acquiring the

knowledge of caring by the time they role transition to nurses. The literature review enabled an

identification of the gap in the literature. Clark Holmes (2007) recommended for an in depth

study of caring attributes. Sokola (2013) recommended a study to investigate factors that

motivate students to incorporate caring in practice and factors that contribute to adjustments in

caring behaviors (p. 53). Sandvick et al. (2014) recommended further studies to focus on the

ontological perspectives on the process of transformation of a nurse. The basis of this study was

based on previous studies (Clark & Holmes; Sandvick et al; Sokola). The aim of this study was

to fill in the gap in the literature by obtaining the description of caring and the factors that

influenced the ADN senior nursing students, which aided in the knowledge of how senior

nursing students are maturing and preparing to demonstrate caring attributes when they role

transition to graduate nurses. The study findings might be helpful for nurse educators to develop

appropriate curriculum and strategies to foster caring behaviors in nursing students and transform

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them to be caring nurses, which might help to add knowledge to the body of nursing education

and benefit both practitioners and the scientific community of nursing education.

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 CHAPTER 3. METHODOLOGY

A basic qualitative study was employed to examine senior nursing students descriptions

of caring and the factors that influenced their caring behaviors. Methodology explains the steps

of a research in detail so that other researchers can replicate the study (Neuman, 2014). Chapter 3

includes a detailed description of the research methodology. In Chapter 3, the purpose of the

study is presented followed by the descriptions of research question, research design, target

population, sampling method and related procedures, data collection, field tests, and data

analysis. The limitation of the research design, study credibility, transferability, and expected

findings are explained in Chapter 3. This chapter concludes with the presentation of ethical

considerations related to the research methodology and the chapter summary.

Purpose of the Study

The purpose of this basic qualitative study was to explore how senior nursing students

described caring and the motivational factors that influenced their caring behaviors so that

nursing educators could understand the extent to which the student nurses were acquiring the

knowledge of caring and caring behaviors during their nursing education. The information

gained from this study was anticipated to assist nursing educators in developing methodologies

for teaching caring among nursing students and to prepare competent and compassionate future

nurses to fit the 21st century nursing workforce.

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 Research Questions

Central Research Question

How do senior nursing students describe the components of caring and the motivational

factors that influence their caring behaviors?

Sub Questions

1. How do senior nursing students describe the components of caring such as:

maintaining beliefs, knowing, being with, doing for, and enabling towards caring?

2. How are the senior nursing students motivated to be a caring person?

Research Design

The method for exploring senior nursing students description of caring and the factors

that influenced their caring behaviors was a basic qualitative study. In a basic qualitative study,

the researchers are interested in (1) how people interpret their experiences, (2) how they

construct their worlds, and (3) what meaning they attribute to their experiences (Merriam, 2009,

p. 23). The purpose of a basic qualitative study is to understand how people make sense of their

lives and experiences. Basic qualitative study focuses on meanings, understandings, and

processes of the phenomenon being studied. A basic qualitative study was appropriate to explore

the study purpose. Other qualitative studies such as phenomenological, ethnographic, grounded

theory, case study, or narrative analysis were not the right choice for this study. A

phenomenological study focuses on intense human experiences such as love, anger, and betrayal

(Merriam, 2009). Ethnographic studies focus on human society and cultures, grounded theory

research is focused on building theory, case study investigates a bounded system, and narrative

analysis uses peoples stories to understand their stories (Merriam; Merriam & Tisdell, 2015). A

basic qualitative study is the best fit for the research question because the question asks for

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the description of caring. Only a basic qualitative study could provide thick and rich descriptions

of caring and the motivational factors that influence caring behaviors in nursing students. The

research questions, data collection, and data analysis guided the research design. Qualitative

research questions are open-ended and usually begin with how, what, or why (Merriam &

Tisdell). In qualitative studies, Rogers (2010) and Kaihlanen et al. (2013) used open-ended

questions using how and what to frame the research questions and the researchers were able

to obtain thick and deeper understanding of participants experiences.

Qualitative data collection and data analysis are complex processes and require following

an expert model. The research design followed the model from experts in the field (Merriam,

2009; Merriam & Tisdell, 2015). According to Merriam and Tisdell, interviews with open-ended

questions are the best way to obtain the desired information and description of phenomena.

When using a semi-structured interview questions, the researcher gets the flexibility and

opportunity for the discovery or elaboration of information that is important to participants (Gill

et al., 2008; Merriam).

According to Merriam (2009), constant comparative method of qualitative data analysis

is inductive and comparative and so has been widely used throughout qualitative research

without building a grounded theory (p. 175). A constant comparative method of data analysis

was used, which was adopted from the grounded theory research design of Glaser and Strauss

(1967). Former studies used constant comparative analysis to analyze data for interpreting

qualitative study findings (Alipour et al., 2015; Nasiri, Taleghani, & Alireza, 2012; Wilde,

Brasch, & Yi, 2011). Through a qualitative study, Alipour et al were able to obtain the unique

viewpoints of participants who experienced social issues following an earthquake. Kolehmainen,

Francis, McKee, and Duncan (2012) explored the beliefs of childrens occupational therapists

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beliefs about caseload management through a qualitative research. A basic qualitative study

using constant comparative analysis of the data would be able to provide a thick description of

caring and the caring attributes of senior nursing students.

Target Population, Sampling Method and Related Procedure

A basic qualitative study was performed to examine senior nursing students description

of caring and the factors that influenced their caring behaviors. For any study, identification of

the target population and description of sampling methods hold high importance in evaluating

the study process, credibility and validity (Merriam, 2009). In this section, the target population,

sampling methods, and related procedure are described.

Target Population

Target population is a group of individuals who exhibit the same characteristic used for a

study (Merriam & Tisdell, 2015). The target population from which the sample was drawn for

this study included senior nursing students or final semester nursing students from an ADN

program from an urban college of nursing. The final semester of an ADN program is otherwise

known as role transition semester. During the final semester, nursing students work under the

direct supervision of a preceptor. Senior nursing students from an ADN program were chosen for

the study because towards the last semester, students should have received all the theoretical

knowledge, competency checks, and clinical experiences required by the nursing program, and

they were expected to know and express the components of caring (AACN, 2008; Rhodes et al.,

2011). At the end of final semester, students take the NCLEX-RN State Board Examination and

become a registered nurse. Once the students take the NCLEX-RN examination and obtain the

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Sampling Method

A non-probability purposive sampling was used in this basic qualitative study. Purposive

sampling is a non-probability sampling procedure in which the researcher uses certain criteria to

choose the participants depending on the central importance of the purpose of inquiry (Merriam,

2009). Previous studies used purposive sampling in qualitative studies (Marshall, Cardon,

Poddar, & Fontenot, 2013; Nasiri et al., 2012). A purposive sampling was done with the purpose

in mind to study a specific group and ADN students were a special group of people. Participants

were recruited via email and consents were obtained prior to conducting interviews. ADN

students were chosen for this study because the majority of frontline nursing workforce

represents ADNs and the study findings may help to educate future ADNs.

Inclusion criteria. The inclusion criteria for taking part in the study were that nursing

students should have been in the final semester (role transition) of an associate-degree nursing

program (ADN) and they should not have repeated any prior nursing courses.

Exclusion criteria. The exclusion criteria of this study were as follows: (1) Nursing

students from any semester prior to the final semester were excluded from participating in the

study because they were still learning and gaining experience in caring nursing actions. (2)

Nursing students from any nursing program other than ADN programs were excluded. (BSN or

accelerated MSN program students have more educational background than the ADN program

students, which may affect the understanding of caring). (3) Students who were repeaters in any

of the semesters in the nursing program were excluded because their perceptions on caring could

have been changed overtime, and subtle changes in the educational program could have impacted

their perceptions.

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Sample Size

The chosen sample was a group of senior nursing students and the plan for data collection

was through semi-structured interviews. According to Marshall et al. (2013) the most critical

best practice for determining the sample size of a qualitative study is statistical demonstration of

data saturation and the second most important best practice is, that of citing other similar studies

that have adopted similar designs with similar research problems (p. 20). Previous studies used

purposive sampling in qualitative studies and this technique was found effective (Marshall et al;

Nasiri et al., 2012). A purposive sampling was used in this study and data collection continued

until data saturation was obtained.

Setting

The research study was performed at an urban college of nursing. This college of nursing

provides both an ADN program and a baccalaureate program in nursing. For this, study, students

from the ADN program were selected. Site permission to conduct the study was obtained from

the director of the ADN program. Prior conducting the study, IRB approval was also obtained

from the site, as well as from Capella University. The research site was different from the

researchers workplace to avoid any conflict of interest.

Recruitment

For this basic qualitative study, senior nursing students from an ADN program were

selected from an urban college of nursing. After obtaining site permission and IRB approval,

participants email addresses were obtained from the Director of Nursing. Then, the participants

were contacted for recruitment through their college email.

The following steps were performed for recruiting participants:

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 1. Email invitation to all senior nursing students provided explanations about the research
topic and their voluntary participation. An inclusion criteria questionnaire and consent
forms were sent to all students along with the email invitation so that they were prepared
to ask any questions prior to signing the consent.

2. A visit to all senior nursing students provided them with a chance to clarify any questions
and enabled them to make an informed decision to take part in the study.

3. Students favorable email reply was considered as a primary consent to take part in the
study.

4. Upon receipt of the screening questionnaire from the participants, sample selection was
performed with those who met the inclusion criteria.

5. The participants contacted the researcher through emails or via phone calls.

6. An appreciation email was sent to participants who expressed willingness to take part in
the study and a date, time, and place were setup for a face-to-face or Skype interview at a
mutually agreed location.

7. Those who did not meet the inclusion criteria were sent a thank you note for their
willingness to participate in the study along with a regret note for not meeting the criteria.
The students who were not eligible for the study were not contacted again.

Data Collection

In a qualitative study, the primary instrument is the researcher and data is collected

through interviews, observations, and reviewing documents. Words, pictures, and body language

are included in qualitative study data (Neuman, 2014; Merriam, 2009; Merriam & Tisdell, 2015).

Data was collected primarily through face-to-face interview, which lasted for about 30 to 45

minutes. Prior to starting the interview, participants were given an opportunity to ask any

questions or receive clarification. Informed consent from each participant was then obtained. The

interview mainly took place in a private room at the college of nursing where both parties could

communicate well without any interruption and where participant privacy and confidentiality

was maintained. Semi-structured interview protocol was used in collecting data. A Skype

interview was performed whenever face-to-face interview was not possible. An electronic

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consent was obtained whenever Skype interview was used. However, prior to the Skype

interview, a verbal consent was obtained and it was audio recorded along with interview

conversation. In both face-to-face and Skype interviewing, the conversation was audiotaped and

transcribed verbatim for accuracy of information. There was no involvement of any

transcriptionist for verbatim transcription. The interviews were planned in such a way that there

was sufficient time for transcription between interviews. Memos were taken during the interview

to capture participants emotions and body languages while answering the questions. According

to Gill et al. (2008), interviews could be used to explore the views, experiences, beliefs, and

motivations of the participants. Using semi-structured interview questions provided flexibility

and opportunity for the discovery or elaboration of information (Gill et al; Merriam). Studies

have shown that open-ended semi-structured questions were effective in obtaining in-depth

meaning of the phenomena being studied (Alipour, 2015; Dixon, 2015; Manjunatha, Revathi

Devi, & Arpitha, 2014; Nasiri, 2012). The largest part of the interview was guided by a list of

questions and neither the exact wording nor the order of the question was determined ahead of

time. Semi-structured interviews allow the researcher to respond to situations at hand, to the

emerging worldview of the respondent, and to new ideas on the topic (Gill et al; Merriam).

Interview questions were developed based on the five concepts of Swansons theory of caring

(Swanson, 1991). Interview questions were field-tested prior to interviewing participants. The

semi-structured interview protocol included the following questions:

1. Tell me about a typical clinical day when you demonstrate caring behaviors?

2. What do you do to help you know more about your patient?

3. What does being with the patient mean to you?

4. What does doing for the patient mean to you?

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 5. Give an example of how you enable or empower patients?

6. How do you help your patient with maintaining belief to get through an event?

7. What does caring mean to you?

8. What do you think are the factors that influence and motivate you to be a caring person?

Field Tests

Field tests of interview protocol were performed to check the soundness or validity of the

data collection instrument (Merriam & Tisdell, 2015). The interview protocol was uniquely

developed for this study based on a thorough review of the literature. Three experts from the

nursing field reviewed, tested, and provided a report on the interview protocol. Two experts were

chosen because both of them were in the field for more than 34 years and held managerial

positions in the field. Moreover, they have demonstrated a passion for nursing and strived hard to

educate students about caring. Though the third expert had only eight years of teaching

experience, she has been a nurse for more than 15 years. The third expert was teaching beginner-

nursing students and had much passionate about nurses caring attributes and served as a role

model for students. All three experts affirmed that the interview protocol was appropriate to

obtain the needed answers.

Data Analysis Procedures

A constant comparative method of data analysis, adopted from the grounded theory as

proposed by Glaser and Strauss (1967), was used in this study. Constant comparative data

analysis included open, selective, and axial coding process, which was performed manually. The

memos and reflexive journaling were also analyzed during data analysis process to capture all

information pertinent to the study (Berger, 2013). To gain a deep and detailed understanding of

the phenomena, qualitative research entails continuous data collection and analysis. Through the

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constant comparative content analysis method, the code structure evolves inductively and

reflecting the ground, which was the participants experience (Glaser & Strauss).

The first step in content comparative analysis began with identifying the segments in the

data that are represented in the research questions. Category construction was the important part

of data analysis. A category is otherwise known as a theme, a pattern, or a finding (Merriam &

Tisdell, 2015). Open coding was used to identify segments and concepts of the transcribed data.

Coding was the basic tool in qualitative data analysis. Going back and forth through the data was

used in open coding process. The codes were then condensed into developing and defining of

categories. In the next step, the codes were examined for similarities and grouped together into

larger concepts through axial coding (Merriam & Tisdell). Comparisons of the categories defined

during the analysis of the second interview were compared with those defined in the first

interview. New codes were given as new categories emerged. Then, coded data were clustered

into themes. Data saturation occurred when the researcher heard repetition of themes and data

collection ceased at that point. Then, categories or themes were developed that were grounding

for the theoretical explanations of data and the findings were presented in a narrative form.

Quotes from the participant interviews were used for describing the in-depth meaning of the

phenomena being studied (Bailey, 2008; Merriam & Tisdell). Former studies used constant

comparative data analysis for interpreting qualitative study findings (Alipour et al., 2015; Nasiri

et al., 2012; Wilde et al., 2011).

Limitations of the Research Design

One of the limitations of the study was the difficulty of replicating it. The knowledge

obtained from the study might not be generalized to other people because the findings might be

unique to the participants description and limitation of the sample size. In qualitative research,

69
the researcher is the primary instrument for data collection and analysis. Research reliability is

heavily dependent on the skills of the researcher (Merriam & Tisdell, 2015). The researcher,

being a novice in this study, might raise some reliability issues as well as personal biases and

shortcomings that could affect the data collection and analysis. In order to minimize personal

biases, qualitative researchers should identify and monitor personal biases or subjectivities and

shortcomings as to how they may be shaping the collection and interpretation of data (Merriam

& Tisdell). The subjective nature of the information from a qualitative study can be open to

misinterpretation and observer biases. The common issues that are found in qualitative research

are regarding ethics, sampling, validity, reliability, and bias (Merriam, 2009).

Another limitation of the study was the use of non-probable purposive sampling. Use of a

random sampling would have provided more reliable results. According to Merriam (2009), a

non-probability, purposive sampling is accepted in a basic qualitative study because

generalization in a statistical sense is not a goal of qualitative study. A purposive or purposeful

sample is based on the assumption that the researcher wants to discover, understand, and gain

insight that the samples should be selected from which the most can be learned (Merriam, 2009,

p.77).

Credibility

Credibility of a qualitative study could be approached through careful attention to the

studys conceptualization, the way data being collected, analyzed and interpreted. Credibility

deals with reliability on how research findings match reality (Merriam, 2009; Merriam & Tisdell,

2015). One of the assumptions underlying qualitative research is that reality is holistic,

multidimensional, and ever changing (Merriam). The credibility of the qualitative research

depends on the way ethics are used to conduct the research. The audience should have the

70
confidence in the investigation and the results of the study (Merriam; Merriam & Tisdell). An

IRB approval was obtained from the responsible institution of the research site as well as from

Capella University prior to participant recruitments. In a qualitative research, the researchers are

the primary instrument of data collection and analysis. Interpretation of reality is acquired

through their observation, which is near to reality and it is a definite strength of a qualitative

research (Merriam). The research process, data collection, and data analysis were explained well

for the audience to make informed decisions. According to Maxwell (2013), the soliciting

feedback on emerging findings is:

The single most important way of ruling out the possibility of misinterpreting the
meaning of what participants say and do and the perspective they have on what is going
on, as well as being an important way of identifying your own biases and
misunderstandings of what you observed. (p.127)

Reliability refers to what extent a study could be replicated (Merriam & Tisdell, 2015).

Will it produce the same result in another study? Reliability is difficult in qualitative research

because human behavior is not static (Merriam, 2009). Strategies to ensure consistency and

dependability or reliability in a qualitative study are through triangulation, member check, peer

examination, reflexivity, and audit trail (Merriam). Writing reflexive journals can give insights

and helps one to grow as a qualitative researcher (Watt, 2007). A field note and reflexive journal

were maintained including all the vital information obtained during the interview for data

analysis (Gill et al., 2008). Peer-review was maintained throughout the research process by

ongoing communication with the dissertation committee members. A self-reflexive journal was

helpful in identifying assumptions and personal characteristics that might have influenced the

study (Creswell, 2009).

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 During the face-to-face interview, obtaining extensive field notes, which included the

description of the events, conversation, and nonverbal expressions of the participants, assisted in

understanding the clarity depth of the situation (Merriam & Tisdell, 2015). Writing expanded

field notes and memos after each interview were helpful in analyzing and interpreting data.

Memos could capture the researchers reflections on both the process and the phenomena being

studied. Reviewing the field notes and memos guided in directing the next set of interview

questions (Neuman, 2014). Bracketing interpretive comments kept the observations and

interpretations distinct. In member checks, the participants were asked to read and comment on

transcription verbatim for the accuracy of the content. According to Neuman (2014), member

checks are the single most important action that qualitative researchers can take to ensure

credibility of a studys findings (p. 84). Member checks were done with randomly selected

participants.

Transferability

Transferability or external validity refers to the extent to which the study results could be

applied to other situations. According to Lodico et al. (2010), transferability is the degree to

which the study results can be applied to other settings. In a qualitative study, this is up to the

reader to decide. The person who reads the study can decide if it is applicable to his or her

situation (Merriam, 2009). Usually, the generalizability is considered as a weakness of a

qualitative study. However, the use of small sample size might enable the researcher to obtain

thick and deeper meaning of the phenomenon being investigated, and it is assumed that a small

sample is universally true for the entire population (Merriam). Providing step-by-step

instructions or explanations of each step of the study can create transferability. When the study

provides clarity and details about the research process especially the data collection and data

72
analysis, the reader could make an informed decision whether the findings could be adapted in

other settings (Merriam). The two threats of validity are the biases and reactivity. Reactivity is

the influence of the researcher on the settings or the individuals of the study (Maxwell, 2013).

Biases and reactivity can be minimized if the researcher acknowledges them and explains it well

in the study.

The population from which the sample was chosen was the senior nursing students from

an ADN program. Purposive sample selection was limited to those who met the inclusion and

exclusion criteria. Rich description of the study findings will be presented later in this

manuscript, which may enable the reader to evaluate whether or not the results can be applicable

in other settings. Thus, it is up to the readers to decide whether the study findings can be utilized

in their settings.

Expected Findings

The aim of the research study was to explore nursing students understanding of caring

and the motivational factors that influenced their caring behaviors. It was expected that

participants would be honest in sharing their experience. The major expected finding of this

study was that it would increase the understanding of how well nursing students were acquiring

the knowledge of caring, caring behaviors, and the motivational factors of their caring behaviors.

Another expected finding of this study was that the gained information from this study might

assist nursing instructors in developing methodologies for teaching nursing students about caring

so that future nursing students may have a smooth role transition to new graduate nurses with

adequate knowledge and competency in caring and they will be able to demonstrate caring

attributes and continue in nursing practice.

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 Ethical Issues

Ethical principles used in conducting research are respect for others, beneficence, and

justice (Merriam, 2009). In qualitative research, researchers form unique relationships with their

participants. Relationships are developed through communication, trust, and respect. There is a

great possibility for ethical issues and challenges to arise. The best way to minimize the

occurrence of ethical issues is by acknowledging them and avoiding them. According to

Merriam (2009), The best a researcher can do is to be conscious of the ethical issues that

pervade the research process (p. 25). Any research should not cause any harm to participants.

Conflict of interest may occur when the researcher conducts research in his or her workplace.

Even if the research is not taking place in the researchers classroom, there could be potential

ethical issues. The ethics, validity, and reliability of a study depend upon the ethics of the

investigator (Merriam). The three essential components to ensure credibility of qualitative

research are: the credibility of the researcher depends on training, experience, track record,

status, and presentation of self (Patton, 2002), rigorous methods, and a fundamental appreciation

of qualitative inquiry. The main ethical issues that are addressed include conflict of interest due

to dual roles, personal biases, and maintaining confidentiality.

Conflict of interest assessment. Conflict of interest can compromise the objectivity with

which the research is designed, conducted, and reported (Curzer & Santillanes, 2012).

Researcher and the research supervisors disclosed any personal relationship or financial interest

that might have contributed to conflict of interest while applied for the IRB approval. An

approval was obtained from the appropriate IRB of the research site, as well as from Capella

University prior to recruiting the candidates. Selecting a different site other than the researchers

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workplace was helpful in reducing conflict of interest due to dual roles. There were no sponsors

or money involvement associated with this study.

Personal biases. Personal biases can be avoided by exploring ones own prejudices,

viewpoints, and assumptions prior to conducting a study (Merriam & Associates, 2002).

Maintaining a reflexivity journal, providing a position statement, and researchers study

assumptions can decrease the occurrence of personal biases. According to Creswell (2009), prior

to initiating the study, evaluating personal beliefs, biases, and backgrounds can minimize

personal biases. Interview questions were field tested before the start of participant interview.

Participant interview with audio recording, verbatim transcription, and member check will

increase the validity and reliability of the research findings (Creswell; Merriam, 2009). Personal

bias can happen easily in a qualitative research because the researcher is the primary instrument

in qualitative research. The researchers ideas about his or her knowledge, about the study,

assumptions, and human distractibility can cause bias in a study (Capella University, n.d). The

researcher remained open mindful, neutral, and receptive to information from the participants to

reduce personal biases.

Maintaining confidentiality. The participants were senior nursing students from an

ADN program. No vulnerable population was involved in the study. Participants were given

written and verbal information about the study for gaining information about the details of the

study. Along with the email invitation to participate in the study, a consent form was also sent,

which explained the benefits and risks for the study. No major potential risks were noted as the

data collection was through one time participant interview. Participants were informed about

their voluntary participation in the study and assured them in maintaining confidential of any

information shared. The face-to-face interviews were performed in a quiet and private room at

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the college to maintain privacy. Interviews were conducted in a mutually agreeable location.

After collecting the demographic data and member check of transcribed verbatim, numbers were

given to participants to maintain anonymity and confidentiality (Merriam, 2009). No research

assistants were involved in this study. Participants were assured of not using their names in any

reports or publications. All paper documents and recorded audiotapes were kept in a locked box

in a secured place, which will be shredded and disposed appropriately after seven years.

Electronic records were stored in a password-protected personal computer so that no one other

than the researcher had access to it.

Researchers Position Statement

The researcher holds a masters degree in nursing and has been working as a full time

faculty member, teaching medical and surgical nursing in an ADN program in a community

college. Teaching helps to understand what ADN students are taught and what they should know

about caring by the time they reach the final semester of their education. Conducting a

qualitative study on how senior nursing students describe caring could make sense to the

researcher and comprehend well when students described caring. The researchers prior

experience in conducting a quantitative research and being published in a journal gives some

confidence in conducting another research. The researcher is well aware of the ethical

considerations pertaining to any research. However, all measures were taken to decrease personal

biases or subjectivity and followed the ethical principles of respect for person, beneficence, and

justice while conducting a research. The researcher maintained a reflexive journal (Creswell,

2012) throughout the research process along with maintaining constant communication with the

mentor and following Capella Universitys guidelines. Anonymity was maintained by keeping

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confidentiality of any participant identifiers, and institutions and the data are kept under lock and

key for seven years.

Chapter 3 Summary

This study was conceptualized from the growing problem of new graduate nurses leaving

practice, as well as the complaints of hiring agencies regarding new graduate nurses lack of

competence in caring and providing safe care (Dyess & Sherman, 2009; Li & Kenward, 2006;

Diaz et al., 2015; Kelton, 2014; McShery et al., 2015). A basic qualitative study was a right fit to

answer the research question as the study explored the description of caring and the factors that

motivated the caring attributes of senior nursing students, which could only be obtained through

a basic qualitative study (Merriam, 2009). Sampling method, sample size, setting, and

recruitment procedures were presented and justified. The interview protocol was developed

based on Swansons theory of caring and it was field-tested prior to using. Only an interview

could provide a thick and deeper understanding from participants descriptions of the

phenomenon from their experience. A constant comparative data analysis was helpful in

identifying the themes that emerged from the data (Creswell, 2009; Glaser & Strauss, 1967;

Merriam). Expected study findings and ethical issues that might have occurred in this study have

been discussed and explained. This study was anticipated to add to the body of knowledge

whether nursing students were acquiring the knowledge of caring and caring behaviors during

their nursing education. The information gained in this study was anticipated to assist nursing

educators in developing methodologies for teaching caring among nursing students.

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 CHAPTER 4. DATA ANALYSIS AND FINDINGS

Caring is a core competency and the hallmark of professional nursing practice (Porr &

Egan, 2013). Although nursing has gone through many innovations and has grown as a

profession, caring still remains as the soul of nursing practice. Recent studies demonstrated that

patients and their families were not receiving compassionate care from nurses (Adamson &

Denwar, 2015; Blackmore, 2011). New nurses entering nursing practice lacked the clinical

decision making skills to provide competent care (Dyess & Sherman, 2009). The linkage

between caring, patient satisfaction with nursing care, and patient satisfaction with hospital

experience is of prime importance in todays health care system (Hooper et al., 2010). The

purpose of this basic qualitative study was to explore how senior nursing students describe caring

and the motivational factors that influenced their caring behaviors so that nursing educators

could understand the extent to which student nurses were acquiring the knowledge of caring and

caring behaviors during their nursing education. The information gained from this study was

anticipated to assist nursing educators in developing methodologies for teaching caring among

nursing students so that future nurses might be skillful in providing safe and competent caring in

their practice as soon as they enter the profession. Data were collected through face-to-face

participant interviews and analyzed thematically using the constant comparative data analysis

method (Merriam, 2009; Merriam & Tisdell, 2015). Chapter 4 is divided mainly into three

sections: description of the participants, research design and introduction to the data analysis,

and the summary of findings.

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 Description of the Sample

The participants were selected from an associate-degree nursing program senior nursing

students (role transition) from an urban college in the United States of America. The

convenience sample of participants was purposefully selected for this study anticipating to obtain

in-depth information to answer the research question. The senior nursing students from the ADN

program were a special group of students and it was appropriate to use a purposive sampling in

studying the description of caring and the factors that influenced their caring behaviors

(Merriam, 2009). Each sample was identified by the following criteria:

Nursing students were from an ADN program

Nursing students were senior nursing students who were in the final semester of an ADN
program and who were ready to take the NCLEX-RN State Board Examination after this
semester.

Participants were excluded from the study on the basis of the following criteria:

Nursing students from any semester prior to final semester

Nursing students from any other nursing program than ADN programs

Students who were repeaters in any of the semesters in the nursing program

Study participants were recruited through an email invitation sent out to the whole class

of role transition students. Out of 23 students enrolled in the role transition semester, 15 students

responded to the invitation and 10 students met the inclusion criteria. Each participant completed

a demographic questionnaire. The questionnaire information included whether the student was

enrolled in the role transition semester, any repeat of previous nursing courses, and the highest

education obtained as well as ethnicity, gender, and age. The participants were from different

ethnic groups representing: Caucasians (8), African American (1), and Asian (1). Eight

participants had only high school education, one participant had a bachelors degree, and another

79
participant had an associate degree, prior to the nursing program. There were eight females and

two male students who took part in this study. Participants represented from different age

groups: 20 to 25 years (n= 6), 26 to 30 years (n= 1), 31 to 35 years (n= 1), 36 to 40 years (n=1),

and over 40 years (n=1). In this document, participants are represented as P1, P2, P3, and so on.

Table 1 provides the demographics for the participant population.

Table 1. Demographic Data

Participants Highest Ethnicity Gender Age

Education
Obtained
P1 HS AA F Over 40 years

P2 HS Caucasian F 20-25 years

P3 HS Caucasian F 20-25 years

P4 HS Asian F 31-35 years

P5 HS Caucasian F 20-25 years

P6 HS Caucasian F 20-25 year

P7 Bachelor Caucasian F 36-40 years

P8 HS Caucasian F 20-25 years

P9 HS Caucasian M 20-25 years

P10 Associate Caucasian M 26-30 years

Note: HS = High School; AA = African American; F = female; M = male

Research Design and Introduction to the Data Analysis

A basic qualitative study was chosen for the study that aimed to gain understanding of the

phenomenon of caring by the senior nursing students from an ADN program and to answer the

80
research question: How do senior nursing students describe the components of caring and the

motivational factors that influence their caring behaviors? The research question was designed to

uncover the meaning and experience (Merriam, 2009) of caring by the senior nursing students

and the motivational factors that influenced their caring behaviors. The anticipated outcome was

to gain information on how well nursing students were prepared to be caring nurses as soon as

they completed their nursing education.

Data was collected using semi-structured interview questions, which included eight open-

ended guided questions and those questions that were field tested prior to data collection. All 10

participants signed an informed consent form prior to being interviewed. All interviews were

conducted face-to-face with participants. The interview conversations were audio recorded and

the researcher performed manual verbatim transcription and data analysis.

A constant comparative method of data analysis was used, which was adopted from the

grounded theory research design of Glaser and Strauss (1967). According to Merriam (2009),

constant comparative method of qualitative data analysis is inductive and comparative and so

has been widely used throughout qualitative research without building a grounded theory (p.

175). The first step in content comparative analysis began with an open coding system,

identifying the segments in the data that were represented in the research questions. A process of

going back and forth through the data was used in open coding process. Open coding started with

writing notes or codes in the margin that included words phrases, or statements from the

participants (Merriam). The same pattern was followed after each interview. The codes were

then condensed into the development and defining of categories. As the next step, the codes

were examined for similarities and grouped together into larger concepts through axial coding

(Merriam & Tisdell, 2015). Comparisons of the categories defined during the analysis of the

81
second interview were compared with those defined in the first interview. New codes were given

as new categories emerged. Then, coded data were clustered into themes that were grounding for

the theoretical explanations of data. The findings were presented in a narrative form. Quotes

from the participant interviews were used for describing the in-depth meaning of the phenomena

being studied (Bailey, 2008; Merriam & Tisdell). Member check was performed with all

participants. Five participants responded to member check. In responding to member check, P3

made a correction for the error of misspelling presses for professors, which was immediately

corrected and reported back to P3. Other participants reported, I agree with the transcript that

you sent me (P5). The interview protocol is attached in Appendix A.

Summary of Findings

Each participant was interviewed to provide information related to the topic of caring

behaviors and the factors that influence caring behaviors among ADN students. The interview

protocol was developed to obtain answers for the research questions. The research questions

answered by this study were as follows:

Central research question. How do senior nursing students describe the components of

caring and the motivational factors that influence their caring behaviors?

Research sub-question 1. How do senior nursing students describe the components of

caring such as: maintaining beliefs, knowing, being with, doing for, and enabling towards

caring?

Research sub-question 2. How are the senior nursing students motivated to be a caring

person?

The findings were summarized and organized based on the themes that arose and on the

theoretical framework upon which the study was based. In order to answer the research

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questions, the study findings were categorized under the headings of meaning of caring,

components of caring behaviors such as: knowing, being with, doing for, enabling or

empowering, and maintaining beliefs, and the motivational factors of caring behavior.

Participants were able to sufficiently describe knowing the patient, being with the patient, doing

for the patient, and enabling the patient in relation to their caring attributes. However, the study

participants had only limited knowledge in maintaining patients beliefs to help them overcome

the crisis situation during their illness. Participants were unable to clearly identify the need and

the importance of incorporating patients religious, spiritual, and cultural practices, which are

essential in providing competent caring. Participants also described the motivational factors that

influenced their caring behaviors that included innate behavior, how one was being raised,

experience with faculty members and staff, personal desire, and religious practices. Detailed

study findings are described below supported with quotes from the participants.

Meaning of Caring

Participants explained what they meant by caring. In analyzing the data for the meaning

of caring, the following themes emerged: maintaining wellbeing, selfless service to others, being

empathetic and sympathetic, demonstrating simple gestures, and care for self. All participants

identified the need of maintaining wellbeing of patients by meeting their individualized physical,

emotional, spiritual, and intellectual needs and spending extra time with them. P9 explained the

meaning of caring, You have patients physical needs, you have their emotional needs, you

have their spiritual needs, you have their intellectual needs, so, there are a lot of different kinds

of caring. Another participant said, I am concerned about their physical thing, about their

mental being. They are sick and they are in the hospital; they try to get better (P1).

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 The second theme that emerged in response to the meaning of caring was selfless service

to others. Nursing students expressed that they provided selfless service to their patients. One

participant (P2) reported the meaning of caring as, willingness to kind of take yourself out of

your own perspective and put somebody elses need first. Being empathetic and sympathetic

was the third theme identified. According to P3, I think caring means being able to put others

before you. Just being able to have empathy and sympathy for people when suffering.

The fourth theme was demonstrating simple gestures that meant caring. Participants in

this study reported that demonstrating simple gestures such as: staying with patient, explaining

about their care, bringing water, providing a warm blanket, listening to their concerns and

complaints, making sure that their nutritional needs and other basic needs are met, respecting

them, and providing them the needed medicines and treatments on time. For example, P3 said,

The simple things to help with for what they are there for. Making sure, they are getting their

meds, making sure they are clean. Care for self was another theme that emerged while

analyzing the meaning of caring. Participants asserted that unless the nurse cared for self, he or

she would not be able to take care of patients. P4 said,

Caring to me also includes the nurse herself, you know? She needs to care about herself
as well, because if you dont you are not going to care about others. Caring in a nutshell
means care of yourself, and your patient and being there for whole.

All participants were cooperative and showed enthusiasm to express their understanding of

caring and all asserted the importance of demonstrating caring behaviors in nursing practice.

Components of Caring Behaviors

Swansons theory of caring was utilized as the theoretical framework for this study. The

five concepts of Swansons theory of caring are: knowing, being with, doing for, enabling, and

84
maintaining belief (Swanson, 1991). Each concept was analyzed deeply and separately to obtain

in-depth information of the experiences of ADN students on the components of caring.

Knowing. In an analysis of the data pertaining to knowing, the following themes

emerged: assessing patient condition and seeking cues. All participants verbalized that in

assessing patient condition, they gathered patient information from the computer, from the

nurses, and collected more information from the patients themselves by asking questions and

spending time with them. They collected information by listening and speaking with patients, not

hurrying, and engaging with them and also through observations. For example, P1 reported, I

look it up in the computer and research my patient. In addition to research, I go to the nurse just

assigned to the patient and ask them pertinent questions. Another participant said,

I start looking in the chart, just speaking with the patient, listen to their stories, really
getting that relationship with them where they feel like they can share stuff with you,
speaking with family, kind of just the patient-centered care. (P8)

Another theme emerged for knowing the patient was seeking cues from patients.

Participants sought out cues from patients for knowing more about them. For example, P5

specified, I like to spend time with them because whats always on the chart isnt exactly what

is going on. Sometimes it is more perceived than what the patient really say. Another

participant reported, Not just rushing the conversation, sitting and actually listening and then

asking them more questions about themselves to just kind of seeing what they are telling me

(P2). Another participant said,

Well, aside from consulting with the chart, I think the most important thing is to just
communicate with them. So many things you learn from communicating with them. Even
the things they dont tell you, you can learn about them, know about them without even
having verbal cues. (P9)

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 Being with. Two themes were identified in relation to being with associated with the

components of caring. They were physical presence and emotional presence. The participants

described physical presence by being personally present with the patient, maintaining eye

contact, and listening to cues without jumping to conclusions. According to P4, You just have

to perceive with the patient that you are there for them. . . touch of the back, holding of their

hands like, its just let them know that you are there for them. For emotional presence,

participants described providing support for physical, emotional, and spiritual needs and

anticipating any problems beforehand and acting accordingly to prevent complications. P4 said,

Patients are scared and anxious, so, being there means, just listening to them, because it really

does calm them down. Another participant said, I think, it is definitely like physically being

with them and mentally being with them and really understanding what they are going through

(P6). Another participant said, Being with the patient means not just being in there. It means,

engaging with them and not just, oh, I am talking to you but looking at my computer. Its,

giving your full attention and really engaging with them (P8).

Doing for. All participants explained in detail about what they would do for their patients

during clinical rotations. Four themes emerged during the data analysis in regards to the caring

component of doing for. They were physical needs, support and comfort, anticipating needs,

and preserving dignity. Providing physical needs included making sure that patients received

care in relation to activities of daily living, administering medicines and treatments, being a

patient advocate, and demonstrating simple gestures such as: providing a warm blanket, fluffing

their pillows, offering some coffee and snacks to patients families while they are waiting for

their loved ones to return from surgery, and providing customer service. P4 explained how she

advocated for a patient,

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 I had a patient who was in a hypertensive crisis. Her doctor always didnt order, prn
meds, she was going off 179 / 103. So, its like doing for the patient, going to the resident
that was there, getting meds for them, and making them feel like you are going for what
they want.

Another theme that emerged for doing for was support and comfort. Participants identified

providing selfless service, active listening, holding their hands, pat on the back, and alleviating

anxiety and pain included in demonstrating caring. P5 reported, I mean to taking care of them,

the simple things to help with for what they are there for. Making sure, they are getting their

meds, making sure they are clean. Another participant explained about doing for was, touch of

the back, holding of their hands like, its just letting them know that you are there for them. In

anticipating needs, the participants reported assessing the patient and identifying problems in

advance to help them to get better and recover faster. Student nurses anticipated the need to

provide basic care for patients who had self-care deficit. P1 said, I try to word of problems

before they start, like when you go in there, say, are you experiencing any pain?

Preserving dignity was identified as the fourth theme when analyzing participants

interview details about doing for. In response, P3 reported, the simple things to help with what

they are there for. Making sure, they are getting their meds, making sure they are clean. When

patients have a self-care deficit, they lose their dignity. Keeping patients clean would help them

in preserving their dignity.

Enabling. Through constant comparative analysis of data, the following themes emerged

for enabling the patient in association with the components of caring: teaching and informing,

encouraging, reassuring, and feedback, and promoting self-care. Teaching and informing

included helping patients to express their concerns freely and providing patient education to help

them understand their power in improving their health care outcomes, and getting them through

87
the difficult times of hospitalization. For example, P9 said, I think education is the biggest way

to empower people because a lot of people dont really know how much power they really have

over their own health outcomes. Another participant said,

I go by enabling or empowering them by giving them a machine, write down all your
questions, you are empowered to know from the doctor, what is going on, write down
your question, when the doctor comes in, you go in with them like Here you go. (P5)

When patients are in the hospital, they go through a difficult time. The participants expressed

that when patients had difficult times in the hospital, encouraging their attempts, reassuring hope,

and providing positive feedback could enable them to get through the crisis situation and get

better rather than losing hope and getting worsening of the condition. For example, P2 said, Just

kind of positive reinforcement and speaking with them and saying, Yesterday you walked only

this far, but today, you made it that much further and that is kind of encouraging them and

letting them know their strength.

Another theme that emerged in enabling the patient was promoting self-care. Interview

participants reported that they came across patients who were not able to perform self-care due to

surgery or other chronic conditions. In such occasions, they enabled patients to get back on track

by promoting self-care. For example, P4 said,

I do a lot of encouraging like, for example, if they say, I cant do this, I cant, ok, do
you want to try, and you know? If they are adamant that they cant do it, I will say,
well, why dont we try this by sitting up, if it is uncomfortable, Ill put you back down.

Maintaining belief. All participants appeared stuck in their thoughts when asked to

describe how to maintain beliefs in their patients. Out of 10 participants, only four were able to

identify a few factors to support maintaining beliefs. Probing questions such as, Suppose you

are getting a Muslim patient or Christian patient; how do you help them to get through their

crisis situation? enabled three themes to be obtained pertaining to maintaining belief. They were

88
a hope-filled attitude, respecting individuality, and realistic optimism. Participants explained that

they provided a hope-filled attitude to maintain patients beliefs during a crisis by being positive,

open to their suggestions and providing them needed referrals to support groups or to a chaplin.

Two participants reported praying with the patient and providing provision for receiving

communion or any pastoral services. One participant said, I think, you let their belief shine

through like you dont let them, you dont belittle their beliefs, you let them bring out their

belief. That is going to help them with their healing (P3).

Respecting individuality was another theme that emerged in analyzing the maintaining

belief component. The interviewee recognized that each patient was unique and care must be

individualized. According to P4, I realize everybody is different. I am different. So, if they have

certain things that they believe or need, I encourage whatever they believe. I mean, I even ask

questions about their religion. Another identified theme was realistic optimism. One participant

identified, being a patient advocate also would help them maintain their belief. For example, P5

said,

It is honest and very situational. Its what the patient really means. I just tend to help
them with belief by bringing them what they need. Just bring them what they need to
make them happy. If happy, they are going to be in a positive mind frame, if they are sad,
upset, then, you need to be there with them to help them to get back to be happy.

Another participant said, If they want special food or something that we have, as long as there is

no restriction for them to have it, then, I can obtain those things for them (P1). According to P2,

Just seeing what they like to do, if they meditate, or if they kind of silence, or they want to talk,

or however their hope and just going with their coping mechanism. Another participant said that

maintaining belief was hard. P9 said, It is hard because if it was just me and the patient it would

be easy. According to P10, First you have to understand what their beliefs are. Then, I think,

89
you have to make up your own mind about what your beliefs are about their beliefs. Another

participant said, Just a smile. Just working with the presence (P5) for maintaining belief, which

showed the participants limited understanding of the concept. Although the participants

provided information on how to maintain belief, it appeared that they paid very little attention to

that component while providing care.

Motivational Factors of Caring Behavior

In order to seek an answer to the research question, data was analyzed for the

motivational factors that influenced participants caring behaviors. The following themes were

identified: innate behavior, how one was being raised, experience with faculty members and

staff, personal desire, and religious and spiritual practice. A few participants very clearly

asserted that they had an innate nature towards caring. For example, P5 said,

I always wanted to help people. Like even when I was a little kid. That is the way I am.
Even in like, middle school, and whenever I thought what I want to be when I grow up? It
was always that something to help someone else. So, something was, my guess was my
DNA.

P3 said,

Actually my mom, couple of years ago, she is like looking back through her old school
work, preschool and kindergarten, and she found like, they give out this little piece of
paper, say what you want to be when you grow up? I wrote a nurse twice when I was
four or five years old. I did not know what it was at that time.

All participants agreed that their caring behaviors had been influenced by how they had

been raised. P1 said, It has a lot to do with how I was raised. I was raised with both parents

My parents raised me to be kind to people. They raised me to care about their wellbeing. Care

about their physical thing. For one participant, the neighborhood where she lived with disabled

children caused a great influence in developing her caring behaviors. For example, P 8 said, We

90
are around a lot of kids with down syndrome and stuff like that, I think, being exposed to

something like that so young kind of embodies or make you more caring. P4 reported,

I watch my mom going through a lot. She was in and out of emergency room. And
actually the nurses, there kind of, you know? I never seen people like that. People who
are actually like intelligence up here and then also vey compassionate and empathetic
about whats going on.

Another emerged theme was the experience from faculty members and staff. Almost all

participants expressed that they had many caring faculty members that they could approach at

anytime and they would get an answer. P3 said, I think, a lot of our faculty here are doing a

very great job with. They are encouraging us, and wanting us to be better and to learn. Another

participant said,

The faculty, I am kind of naggy, not naggy, but I ask them a lot of questions and I always
email and going to their office hours and they are always been there and answer my
questions. Sometimes, they tell, you have to figure it out. (P2)

P2 responded,

The difference between my first clinical rotation and that clinical rotation was night and
day because the 2nd floor that I was on, they were so welcoming, like I would eat lunch
with them, they just treat you like another nurse and the other floor was not like that.

One participant expressed her fear and concern about caring behaviors. She joined the nursing

program with a caring attitude, but she was afraid that her caring attributes had been diminished

in the final semester. The participant reported, I almost feel like Im in the opposite of caring

right now because I am so afraid of that I am going to kill them because of there is so much

responsibilities (P7). P7 reported her negative experience with a patient, The minute my

professor walked in the door and we are supposed to tube feed her and give her meds, she starts

crying, and tells my professor that I was mean to her (P7).

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 Participants expressed that their personal desire to care for others had great influence on

their caring behaviors. P3 said, I just couldnt see myself doing something else. Another

participant said,

I always wanted to help people. Like even when I was a little kid. That is the way I am.
Even in like, middle school and whenever I thought what I want to be when I grow up? It
was always that something to help someone else. (P5)

One participant identified that her education helped her to be more caring. Participant (P6) said,

Understanding what is going on with like, pathophysiology of the body and knowing why the

stuff is happening in this patient. It definitely has given me a huge advantage of being more

caring and empathetic towards patients. Another participant said, I dont know, I was always

told, I was like the mother of my friends group. So, I am always there for everyone (P3).

Religious and spiritual practice was another theme that emerged while analyzing the factors that

influenced caring behaviors. According to P4, I am spiritual but not religious, but if we are here

for a short period of time, just let us make the best of it for everybody. P1 said, In addition to

this, my religion that is what the basis of Christianity. Im Baptist. So, religion is very important

to us.

Chapter 4 Summary

A basic qualitative research methodology was utilized to explore ADN students

description of caring and the factors that influenced their caring behaviors from their experience.

Chapter 4 included a detailed description of the sample. The sample included 10 senior nursing

students from an ADN program. Study participants included two male and eight female students.

Qualitative data was collected through in-depth face-to-face interviews. Chapter 4 included a

detailed description of the data analysis procedure that was used to examine the interview

transcript. The interview protocol was effective in obtaining answers to the research questions.

92
The emergent themes revealed in the data were supported by quotes that came directly from

participants.

In order to answer the research questions, three areas were examined and categorized for

the emerged themes. They were meaning of caring, components of caring behaviors such as:

knowing, being with, doing for, enabling or empowering, and maintaining beliefs, and the

motivational factors of caring behavior. The themes that emerged for meaning of caring

included: maintaining wellbeing, selfless service to others, being empathetic and sympathetic,

demonstrating simple gestures, and care for self.

The components of caring that emerged respectively were:

Knowing assessing patient condition and seeking cues

Being with physical presence and emotional presence

Doing for physical needs, support and comfort, anticipating needs, and preserving
dignity

Enabling teaching and informing, encouraging, reassuring, and feedback, and promoting
self-care

Maintaining belief a hope-filled attitude, respecting individuality, and realistic

optimism

Themes that emerged for motivational factors of caring behaviors included: innate behavior,

how one was being raised, experience with faculty members and staff, personal desire, and

religious and spiritual practice. Chapter 5 will present a summary and discussion of the data as

well as provide recommendation for the application of the findings and for further research.

93
 CHAPTER 5. CONCLUSIONS AND DISCUSSION

The purpose of this basic qualitative study was to explore how senior nursing students

describe caring and the motivational factors that influenced their caring behaviors so that nursing

educators could understand the extent to which the student nurses were acquiring the knowledge

of caring and caring behaviors during their nursing education. The information gained from this

study was anticipated to assist nursing educators in developing methodologies for teaching

caring so that the future nurses might be skillful in providing safe and competent caring in their

practice as soon as they enter the profession. A basic qualitative study was chosen for the study

that aimed to gain an understanding of the phenomenon of caring by the senior nursing students

from an ADN program and to answer the research question. The research questions were

designed to uncover the meaning and experience (Merriam, 2009) of caring by the ADN senior

nursing students, which was anticipated to gain information on how well nursing students were

prepared to be caring nurses when they complete their nursing education. The research questions

answered by this study were as follows:

Central research question. How do senior nursing students describe the components of

caring and the motivational factors that influence their caring behaviors?

Research sub-question 1. How do senior nursing students describe the components of

caring such as: maintaining beliefs, knowing, being with, doing for, and enabling towards

caring?

Research sub-question 2. How are the senior nursing students motivated to be a caring

person?

94
 Data was collected using eight semi-structured interview questions, which were field

tested prior to data collection. All 10 participants signed an informed consent prior to the

interview. All interviews were conducted face-to-face with participants. Ten participants

provided a thick description about their understanding of caring, the five components of caring,

and the motivational factors that influenced their caring behaviors. The interview conversations

were audio recorded and transcribed verbatim for accuracy. There was no involvement of any

personal assistance for verbatim transcription or data analysis. A constant comparative method of

data analysis was used, which was adopted from the grounded theory research design of Glaser

and Strauss (1967). A constant comparative method of data analysis started with an open coding

and proceeded with axial coding, grouping into categories, and developing themes (Merriam &

TIsdell, 2015). Verbatim transcription was sent to all 10 participants for member check and five

participants responded: four participants reported of no changes and one participant requested a

change in spelling, and it was immediately corrected and reported back to the participant.

Chapter 5 consists of the summary and discussion of the research findings, discussion of

the research findings in relation to the literature, study limitations, implications of the findings

for practice, recommendations for further research, and conclusion. The relationship between the

need for the study and study findings are also discussed in Chapter 5. The study findings were

examined in light of Swansons theory of caring to identify and understand the components of

caring (Swanson, 1991) and are discussed in detail in Chapter 5.

Summary of the Findings

The data was gathered through a convenience sample of 10 participants who were in the

final semester (role transition) of an ADN program in the Midwest. Study participants were

selected using inclusion criteria to answer the research questions. Participants in this study

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provided a thick description about caring and the factors that influenced their caring behaviors

from their experience. In order to answer the research questions, the study findings were mainly

grouped into three categories: the meaning of caring, the components of caring, and the

motivational factors of caring. The emerged themes for all those categories were analyzed,

discussed, and presented in detail. The study findings provided answers to the research questions.

Participants were able to sufficiently describe knowing the patient, being with the patient, doing

for the patient, and enabling the patient in relation to their caring attributes. However, the study

participants had only limited knowledge in maintaining patients beliefs to help them overcome

the crisis situation during their illness. Participants were unable to clearly identify the need and

the importance of incorporating patients religious, spiritual, and cultural practices, which are

essential in providing competent caring. Participants also described the motivational factors that

influenced their caring behaviors that included innate behavior, how one was being raised,

experience with faculty members and staff, personal desire, and religious practices.

Meaning of Caring

In analyzing the data for the meaning of caring, the following themes emerged:

maintaining wellbeing, selfless service to others, being empathetic and sympathetic,

demonstrating simple gestures, and care for self. All participants identified the need of

maintaining wellbeing of patients by meeting their individualized physical, emotional, spiritual,

and intellectual needs and spending extra time with patients. Selfless service to others was

another theme that emerged in response to the meaning of caring. Nursing students expressed

that they provided selfless service to their patients by spending extra time engaging genuinely

with their patients. All participants identified the need to be empathetic and sympathetic in

helping patients get through a crisis situation. The study participants identified the importance of

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demonstrating caring through simple gestures such as: explaining about their care, bringing

water, providing a warm blanket, staying with the patient, listening to their concerns and

complaints, making sure that their nutritional needs and other basic needs were met, respecting

them, and providing them the needed medicines and treatments in time. Care for self was another

theme that emerged while analyzing the meaning of caring. Participants asserted that unless the

nurse cares for self, he or she would not be able to take care of patients.

Components of Caring Behaviors

Swansons theory of caring was utilized as the theoretical framework for this study. The

five concepts of Swansons theory of caring: knowing, being with, doing for, enabling, and

maintaining belief (Swanson, 1991) were analyzed deeply and separately to obtain in-depth

information and meaning on the components of caring from the experiences of ADN students.

Knowing. The following themes pertaining to knowing were identified: assessing patient

condition and seeking cues. The first theme that emerged for knowing was assessing patient

condition. All participants verbalized that in assessing patient condition, they gathered patient

information from the computer, from the nurses, and collected more information from the

patients themselves by asking questions and spending time with them. They collected

information by observation, listening and speaking with patients, not hurrying, and engaging

with them. The second theme that emerged for knowing the patient was seeking cues from

patients. Participants sought out cues from patients for knowing more about them. Participants

verbalized that they would sit with the patient and listen to them and collect cues to ask more

questions and obtaining a full picture of them.

Being with. The physical presence and the emotional presence were two themes that

emerged for the caring component of being with the patient. Participants described physical

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presence as personally being present with the patient, maintaining eye contact, and listening to

cues without jumping to conclusions. For emotional presence, participants described providing

support for physical, emotional, and spiritual needs and anticipating any problems before hand

and acting accordingly to prevent complications.

Doing for. All participants explained in detail what they would do for their patients

during clinical rotations. Four themes emerged during data analysis in regards to the caring

component of doing for. They were physical needs, support and comfort, anticipating needs,

and preserving dignity. Providing physical needs included making sure that patients received

care in relation to their activities of daily living, administering medicines and treatments, being

patient advocates, and demonstrating simple gestures such as providing a warm blanket, fluffing

their pillows, offering some coffee and snacks to patient families, and providing customer

service. Another theme that emerged for doing for was support and comfort. Participants

identified providing selfless service, active listening, holding patients hands, patting them on the

back, and alleviating anxiety and pain as demonstrating caring. In anticipating needs,

participants reported assessing the patient and identifying problems in advance to help them to

get better and recover faster. Student nurses anticipated the need to provide basic care for

patients who had a self-care deficit. Participants reported that when patients have a self-care

deficit, they lose their dignity. Keeping patients clean would help them in preserving their

dignity.

Enabling. The themes that emerged for enabling included teaching and informing,

encouraging, reassuring, and feedback, and promoting self-care. Teaching and informing

included helping patients to express their concerns freely. Providing patient education assisted

patients in understanding their power in improving health care outcomes, and helped them to get

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through the difficult times of hospitalization. Giving them choices also would enable them to

have control and power over their care, which would also help them to overcome the crisis

situation. Study participants expressed that when patients had difficult times in the hospital,

encouraging their attempts, reassuring hope, and providing positive feedback could enable them

to get through the crisis or situation rather than losing hope and experiencing a worsening of

their condition. Interview participants reported that they came across patients who were not able

to perform self-care due to surgery or other chronic conditions. On such occasions, they enabled

patients to get back on track by promoting self-care.

Maintaining belief. Maintaining belief was the other component of caring (Swanson,

1991). All participants appeared stuck in their thoughts when asked to describe maintaining

beliefs in their patients. Out of 10 participants, only four were able to identify a few factors to

support maintaining beliefs following probing questions. The themes that emerged for

maintaining belief were hope-filled attitude, respecting individuality, and realistic optimism.

Participants explained that they provided a hope-filled attitude to maintain patients beliefs

during a crisis situation by being positive and open to their suggestions as well as by providing

them needed referrals to support groups or a chaplain.

Respecting individuality was another theme that emerged in analyzing the maintaining

belief component. The interviewees recognized that each patient was unique and care must be

individualized. Participants supported patients with realistic optimism by being honest and

situational with them to get through their difficult times in the hospital. Although the participants

provided some information on how to maintain patient beliefs and those themes were emerged, it

appeared that they paid very little attention to that component while providing care. Participants

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did not mention conducting an assessment of their spiritual, religious, or cultural background in

order to assist patients to get through their difficult times in the hospital.

Motivational Factors of Caring Behaviors

In order to answer the research question, data was analyzed for the motivational factors

that influenced participants caring behaviors. The identified themes were: innate behavior, how

one was being raised, experience with faculty members and staff, personal desire, and religious

practice. The first theme that emerged for the motivational factors of caring behavior was

innate behavior. Participants recalled when they started demonstrating caring, and they

recognized it as an inborn instinct to take care of little things with a caring attitude from a very

young age. The participants recognized how they were being raised had great influence in their

caring behavior. All participants agreed that their caring behaviors had been influenced by their

parents, how they had been raised, and their past experience with others. Another emerged theme

was the experience with faculty and staff members they encountered. Participants reported that

they had positive and negative experiences with faculty and floor nurses. However, those

positive and negative experiences helped them to be caring persons.

Participants expressed that their personal desire to care for others had a great influence

on their caring behaviors. A few participants could not verbalize well what caused them to be

caring, but they felt like they had a personal desire to help others from childhood. Participants

confidentially verbalized that their religious and spiritual practices played important roles in

influencing their caring behaviors.

Discussion of the Findings

The themes that arose based on input from participants assisted in answering the research

questions. In particular, a deep understanding was gained regarding the meaning of caring,

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components of caring behaviors, and the motivational factors of caring behaviors of senior ADN

students from their experience. The new knowledge generated during the study was that ADN

students may need more education on how to maintain patient beliefs. Participants identified the

meaning of caring as maintaining wellbeing, selfless service to others, being empathetic and

sympathetic, demonstrating simple gestures, and care for self. The participants were passionate

about nursing.

Swansons theory of caring was utilized to examine whether nursing students were

demonstrating the components of caring behaviors and maturing to be competent and caring

nurses. This study could not support that the participants were maturing as competent nurses

with all the five components of caring attributes as per Swansons theory of caring. Participants

were able to identify the components of caring such as: knowing, being with, doing for, and

enabling the patients during their practice. However, the study revealed that the participants

lacked sufficient knowledge in maintaining patients beliefs to get through their difficult times in

the hospital. Participants were unable to clearly identify the need and the importance of

incorporating patients religious, spiritual, and cultural practices, which are essential in providing

competent caring.

The participants identified that innate behavior, how one was being raised, experience

with faculty and staff, personal desire, and religious and spiritual practices were the influential

factors of their caring behaviors. Participants reported that they had positive and negative caring

experiences from faulty members and floor nurses influenced their caring behaviors. Participants

revealed that nursing education helped them to develop their caring behaviors. The study

findings were suggestive that senior nursing students are not prepared well to provide holistic

care to patients as they are nearing graduation.

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 Discussion of the Findings in Relation to the Literature

The need for the study originated from the practice problem of new nurses entering

nursing practice and lacking clinical decision making skills to provide competent care (Dyess &

Sherman, 2009). Caring has been identified as a fundamental value of nursing (AACN, 2008;

NLN, 2007). Nursing education guides the progression from a caring person to a professional

identity of caring (Labrague et al., 2015; Rhodes et al., 2011; Watson, 2008). Many hiring

agencies reported that many new nurses failed to meet the expected level of competency in

providing patient care (Kelton, 2014; McSherry et al., 2015).

Dyess et al. (2016) and Li and Kenward (2006) indicated that although the registered

nurse (RN) license was the evidence of achieving legal and professional competence to enter

nursing practice, the majority of new nurses felt that they lacked the clinical skills and judgment

to provide safe and competent care. New nurses constitute 10% of the nursing workforce in

many acute care settings. Currently 31% of new graduates leave their job in the first two years of

service mainly due to the lack of guidance and support and lack of self-confidence (Dyess et al).

According to Grochow (2008), new graduate turnover ranged from 55% to 61%. About 574,400

RN job shortages are predicted by the year 2022 (McMenamin, 2014). Thus, the need for

preparing more nurses with compassionate and caring attributes to serve the community is

paramount. Previous studies have been conducted to measure how nursing students become

competent and caring nurses and the perception of caring (Hanson, 2004; Khademian, &

Vizeshfar, 2008; Labrague et al., 2015; Porr & Egan, 2013; Sandvik et al., 2014; Sokola, 2013).

However, little was known regarding how nursing students were maturing into compassionate

and caring nurses. There was a gap in the literature regarding the role transition of student nurses

to caring nurses. The problem addressed in the study was a need to understand how nursing

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students mature to caring nurses by examining the description of caring that was provided by the

ADN senior nursing students. This study finding may assist faculty in developing effective

teaching strategies that promote the professional identity of caring among nursing students so

that future nurses might be skillful in providing safe and competent caring in their practice as

soon as they enter the profession.

The answers to the research questions are presented in relation to the current literature on

the topic of caring in nursing practice. Constructivism and Swansons theory of caring (Swanson,

1991) formed the conceptual framework for the themes that emerged from the data analysis. The

relationship between the findings and the conceptual framework are presented in detail. The

discussion of the findings are categorized under meaning of caring, components of caring, and

the motivational factors of caring.

Meaning of Caring

The importance of caring has been well established in the literature (AACN, 2008;

Adamson & Dewar, 2015; Mlinar, 2010; NLN, 2007; Pai et al., 2013; Papastavrou et al., 2011;

Porr & Egan, 2013; Swanson, 1991; Watson, 1997). According to Swanson, Caring is a

nurturing way of relating to a valued offer toward whom one feels a personal sense of

commitment and responsibility (p. 162). Porr and Egan clearly described the simple gestures

that can demonstrate caring and the act of caring that causes nurses to attend to the salient needs

of patients such as: to question, attain in-depth understanding, seek best practices, and apply

critical reasoning skills. Milinar asserted that caring consisted of instrumental and expressive

components. The instrumental component of caring referred to the physical and technical aspect

of care and the expressive component referred to meeting psychosocial and emotional needs.

Papastavrou et al described the four factors of caring as assurance of human presence,

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knowledge and skills, respectful differences to others, and the positive connectedness between

participants. In this study, the senior nursing students (role transition) identified the meaning of

caring appropriately. This led to the emerged themes of maintaining wellbeing, selfless service to

others, being empathetic and sympathetic, demonstrating simple gestures, and the care for self.

The emerged themes in this study were undeviating with what was being identified in the

literature. This study provided sufficient evidence that final semester ADN students were

obtaining the meaning of caring by the time they were in the final semester.

Components of Caring

In this study, Swansons theory of caring was used as the theoretical framework and used

as the lens to analyze the caring components in nursing students caring attributes. According to

Swansons (1991) theory of caring, the components of caring are demonstrated by knowing,

being with, doing for, enabling and maintaining beliefs of patients. Each component of caring is

separately analyzed in this study.

Knowing. According to Alligood (2014),

Knowing is thriving to understand the meaning of an event in the life of the other,
avoiding assumptions, focusing on the person cared for, seeking cues, assessing
meticulously, and engaging both the one caring and the one cared for in the process of
knowing. (p. 690)

Previous studies have utilized Swansons theory of caring and asserted that knowing the patient

was a component of caring attributes demonstrated by performing a complete assessment,

listening to patients, staying with them, having a nurse-patient relationship, looking for cues, and

avoiding assumptions (Adolfsson, 2011; Andershed & Olsson, 2009: Hanson, 2004; Higdon &

Shirey, 2012; Kavanaugh et al., 2006; Roscigno, 2016; Wright et al., 2013). In this study, themes

emerged for knowing the patient included assessing patient condition and seeking cues which

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were in accordance with Swansons (1991) definition and themes of avoiding assumptions,

centering on the one centered-for, assessing completely, seeking cues, and engaging the self of

both (p. 162). The participants provided a clear description about how they could obtain the

details to care for their patients in a caring manner through the emerged themes.

Being with. According to Swanson (1991), being with means, being emotionally present

to the other. This includes being there in person, conveying availability, and sharing feelings

without burdening the other cared for (Swanson, p. 162). Previous studies affirmed that being

with the patient could be achieved by spending extra time with the patient, actively listening,

sitting quietly alongside them, conveying respect, providing support, and consoling them

(Adolfsson, 2011; Andershed & Olsson, 2009: Hanson, 2004; Higdon & Shirey, 2012;

Kavanaugh et al., 2006; Roscigno, 2016; Wright et al., 2013). In this study, the participants

articulated stories in which they described what it meant by being with and the emergent themes

were physical presence and emotional presence, which were in congruence with Swansons

theory of caring and the themes that were found in the literature.

Doing for. According to Alligood (2014), doing for means to do for others what one

should do for self if at all possible, including anticipating needs, comforting, performing

skillfully and competently and protecting the one cared for while preserving his or her dignity

(p. 690). Swanson defined doing for as comforting, anticipating, performing competently

/skillfully, protecting, and preserving dignity (Swanson, 1991, p. 163). Previous studies

identified the process of doing for as initiating caring dialogues (Dyess et al., 2010), providing

comfort and supporting the value of communication (Wright et al., 2013), treating patients with

dignity and respect, and performing tasks with competency (Adolfsson, 2011). Other studies

identified the simple gestures of caring such as painting patients toenails, providing a backrub, a

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warm blanket, and meeting hygiene needs in relation to the process of doing for aspect of caring

(Hanson, 2004; Higdon & Shirey, 2012; Roscigno, 2016). In this study, all participants identified

appropriately the caring acts they provided to patients on a daily basis and the themes that

emerged were physical needs, support and comfort, anticipating needs, and preserving dignity,

which were supported by the literature and what had been reported by Swanson.

Enabling. According to Swanson (1991) enabling was, informing/explaining,

supporting/allowing, focusing, generating alternatives/thinking it through, and validating/giving

feedback (p. 163). Hanson (2004) included informing, coaching, assisting, and supporting

another person in the process of enabling the patient. Previous studies described enabling as

giving feedback, validating family strengths, actively supporting (Adolfsson, 2011; Roscigno,

2016), providing prompt information on the updates with usual and intervention care (Wright et

al., 2013), and educating with return demonstrations (Higdon & Shirey, 2012). Most of the

participants described personal experiences where they made significant commitment in enabling

patients to come out of their crisis situation. The themes that emerged were teaching and

informing, encouraging, reassuring, and feedback, and promoting self-care. The emerged

themes were consistent with the information available in the literature.

Maintaining belief. Swanson (1991) explained maintaining belief as, believing

in/holding in esteem, maintaining a hope filled attitude offering realistic optimism, and going the

distance (p. 163). Adolfsson (2011) asserted that providing support with a hope-filled attitude

with women who experienced miscarriages helped them to overcome their grief period. Prior

studies identified maintaining beliefs as sticking with patients beliefs and conveying hope and

optimism (Hanson, 2004; Hihdon & Shiery, 2012), helping patients and families to find positive

personal meanings (Roscigno, 2016), and helping patients to accept the reality of their situation

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and actively engaging to recover faster in a crisis situation (Adolfsson). Gillespie (2012)

affirmed that caring could sustain faith when people go through challenging times and nurses

caring behaviors and attitudes could enable patients and their families find their own inner

capacity for hope and healing. Health care providers have the responsibility of providing holistic

and cultural specific health care to all patients (Al Mutair et al., 2014). During the data

collection, with probing questions, four participants were able to provide a description of

maintaining beliefs in the process of demonstrating caring. The study participants did not

identify the need to provide culture specific care to patients. The themes that emerged for

maintaining belief were hope-filled attitude, respecting individuality, and realistic optimism.

Participants tried to take care of issues such as dietary concerns with Jewish people. However,

most of the participants did not express the need to perform an assessment on patients cultural,

spiritual, or religious practices in anticipating their needs and maintaining their beliefs. Although

the emerged themes were consistent with what was found in the literature, most of the

participants could not verbalize something to explain their experience about maintaining beliefs.

From the study findings, it was clear that the participants paid little attention in meeting patient

needs related to their cultural practices, which plays an important role in patients recovery

(Cope, 2015).

Motivational Factors of Caring Behaviors

Nurses caring behaviors are described as creating a culture in which patients regain

their health and will to live, where nursing staff have the prerequisites for excellent nursing care

(Mlinar, 2010, p. 498). Dewar and Nolan (2013) asserted that compassionate caring and

promoting dignity were the key priorities and they were central to the quality of care for patients,

families, and job satisfaction for staff. Sokola confirmed that students came to the nursing

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profession with an innate ability to care others (2013). Students develop caring behaviors

through the exposure of social, environmental, and cultural factors. Studies have shown that

nursing education helped tremendously in the development of caring behaviors in nursing

students (Sokola). When students interact with patients, faculty, and peers, their innate caring

behaviors could be developed by education and they get the opportunity to practice caring during

clinical practice and become competent in caring (Labrague et al., 2015; Rhodes et al., 2011).

Previous studies have shown that ones personal background, positive and negative

experiences of caring from faculty members, floor staff, friends, and family members could

influence ones caring attributes (Burgess et al., 2015; Clarke et al., 2012; Felstead, 2013;

Labrague et al., 2015; Sandvik et al., 2013; Zamanzadeth et al., 2015). Nursing students learn a

great deal about caring behaviors during their clinical rotation (Zamanzadeh et al). According to

Watson (2008), caring relationships and caring environments preserve dignity, wholeness, and

integrity of people. In this study, all participants agreed that their family background, religious

practices, and previous experiences had great influence on their caring behaviors. Clarke et al,

Ekici and Beder (2014), and Ma et al. (2014) reported that negative experiences could be a

motivation for some people to become caring persons, for others, it could be a discouraging

experience and led them to leave the nursing profession. One participant reported that her caring

attributes were decreased from the time she started nursing due to a negative experience from a

patient, which supported the findings of Murphy et al. (2009). Murphy et al revealed that third-

year nursing students scored less in the perception of caring behaviors than the first year nursing

students. In this study, one participant voiced the concern of losing the motivation for caring by

the final semester of education.

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 In a study, Burtson and Stichler (2010) concluded that nurses were motivated to caring by

the satisfaction they receive from caregiving for others. This finding was evident in the current

study as well. Porr and Eagan (2012) affirmed that a nurse-patient relationship and the intentions

to attend to the needs of patient were the driving force to caring behaviors. Although, people

have innate behavior in caring, structured teaching could be beneficial in training student nurses

to prepare them to be competent and caring nurses (Higdon & Shirey, 2012). Burgess et al.

(2015) revealed that faculty role modeling and a hidden curriculum would promote developing

students professionalization, professional competencies, values, and attitudes. Prior researchers

have found that preceptors and clinical faculty members greatly influenced caring behaviors in

nursing students (Doody et al., 2012; Grochow, 2008; Tiwaken et al., 2015). Previous studies

revealed that patient satisfaction was directly related to the caring behaviors of nurses (Ervin,

2006; Clukey et al., 2009; Shipman et al., 2012). In this study, the themes that emerged for the

motivational factors of caring behaviors were innate behavior, how one was being raised,

experience with faculty members and staff, personal desire, and religious practices, which were

well supported by the literature. The nursing practice literature is replete with references to

caring. All nursing theories emphasize the concept of caring, which signifies the importance of

caring in nursing.

Discussion of Findings in Relation to Theoretical Framework

The theories of constructivism and Swansons theory of caring were utilized to explain

how ADN senior nursing students described caring, the components of caring behaviors, and the

motivational factors of caring behaviors from their experience. In constructivism theory, the

learner constructs new knowledge by building on to the existing knowledge through a personal

interpretation of learning. According to constructivism, learning is an active contextualized

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process of constructing knowledge rather than acquiring it (Billings & Halstead, 2012). Ahmed

(2008) confirmed that all knowledge or meaningful reality is contingent upon human practices,

constructed out of interaction between human beings and their world. Jia (2010) asserted that the

learner brings past experiences and cultural factors to a situation and constructs new knowledge.

Student nurses come to nursing education with their innate caring attributes, and they further

learn more about caring in the classroom where they construct new knowledge. Then, they apply

their learned knowledge about caring during clinical practice. Having interaction with patients,

they construct new meanings to caring by building on the existing knowledge as they mature to

being caring persons. Constructivism theory has been used in similar studies and found effective

in improving students skills acquisition and critical thinking skills (Brandon & All, 2010;

Hinshaw et al., 2012). In analyzing the data, it was evident that the participants joined the

nursing program with innate caring attributes and their classroom education and clinical practices

helped them to improve skill acquisition and critical thinking on caring as well as the

demonstration of caring attributes during clinical practice. Nursing education is designed in such

way that theoretical knowledge and clinical practices enable the transformation of nursing

students to be caring nurses (Rhodes et al., 2011).

Swansons theory of caring was the other theory utilized for the theoretical framework

for this study. According to Swanson (1991), caring is a nurturing way of relating to a valued

other towards whom one feels a personal sense of commitment and responsibility (p. 165). The

ultimate goal of nurse caring is to enable patients to achieve well-being status. Swansons theory

of caring consists of five concepts: knowing, being with, doing for, enabling, and maintaining

belief. These actions are simple but elegant and easy to understand. In Swansons theory, the

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importance of caring is in the forefront and it exemplifies the nursing professions value

(Alligood, 2014).

Previous studies have asserted the effectiveness of using Swansons theory to understand

the perceptions of nurses caring (Hanson, 2004; Higdon & Shirey, 2012; Kavanaugh et al.,

2006). Brilowski and Wendler (2005) also conceptualized the five attributes of caring:

relationship, action, attitude, acceptance, and variability, which were in line with Swansons

theory of caring. In two quantitative studies, Adolfsson (2011) confirmed that Swansons theory

of caring was effective in improving the well-being of women who experienced miscarriage and

loss. Kavanaugh et al utilized Swansons theory of caring as a framework for recruitment and

retention of research participants and found it effective. Kavanaugh et al asserted that Swansons

theory could be applied wherever caring attributes were needed; in personal, professional, or

patient-nurse relationships. Swansons theory of caring is a clear explanation of what nurses

practice in a caring manner and emphasizes that the goal of nursing is promotion of an

individuals well-being. In this study, each concept of Swansons theory of caring were explored

and detailed descriptions of caring were obtained from all participants. Nursing students were

able to provide clear and in-depth information of their experience and how they demonstrated

caring in most of the components of caring. All participants provided sufficient information

about how they demonstrated the caring attributes of knowing, being with, doing for, and

enabling their patients. These attributes were well supported by the literature. However, their

answers pertaining to maintaining patients beliefs were not satisfactory to affirm that they were

maturing to be competent nurses with caring attributes. It was evident that the participants did

not pay much attention to patients cultural, religious, or spiritual needs when they were in their

most vulnerable time in hospital. Four participants were able to provide information about

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maintaining patients beliefs with probing questions only. Swansons theory of caring was very

helpful in understanding and analyzing the caring attributes of the participants.

Limitations

The use of a basic qualitative research in this study was appropriate to answer the

research question (Merriam & Tisdell, 2015). However, qualitative research has inherent

limitations. One of the limitations related to qualitative research was the potential for

researchers assumptions, perceptions, and biases to pose undue influences on the findings. In

generating credible findings of the study, strategies such as peer review, member checks, and

reflective journaling were used. Another limitation of the study was the difficulty of replicating it

due to a small sample size of 10 participants. The knowledge obtained from the study might not

be generalized to other people because the findings might be unique to the participants

description and limitation of the sample size. However, in this study, students from different

ethnicities (Caucasian, African American, and Asian) provided perspectives of caring from

different cultures. Eight females and two males representing various age groups provided a broad

picture of caring. Another limitation of the study was the use of non-probable purposive

sampling. Use of random sampling would have provided more reliable results. According to

Merriam (2009), non-probability, purposive sampling is accepted in a basic qualitative study

because generalization in a statistical sense is not a goal of qualitative study.

Implication of the Findings for Practice

The need for this study arose from the reports that new nurses lacked the clinical skills

and judgment needed to provide safe and competent care and the frustration of lacking

competency in caring led many new nurses to leave the profession (Dyess et al., 2016; Diaz et

al., 2015). The new nurses leaving the profession (Dyess et al) and the prediction of an upcoming

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huge nursing shortage (McMenamin, 2014) places undue pressure on nursing faculty to prepare

more nurses, as well as to retain new nurses to continue in nursing practice. The intent of this

study was to examine if the nursing students were maturing to be competent nurses by the

completion of their nursing education so that they might be able to provide competent and

compassionate caring upon graduation. It was expected that by the time students are in role

transition (final semester), they should be able to demonstrate holistic care so that they can

assume the full RN responsibilities upon graduation.

This study findings revealed that although the participants were able to demonstrate

competency in demonstrating caring behaviors in knowing the patient, being with, doing for, and

enabling the patient, they lacked knowledge how to maintain patients beliefs and assisting them

to get through their difficult times in the hospital. According to Swanson, maintaining belief is,

sustaining faith in the others capacity to get through an event or transition and face a future of

fulfillment (p. 162), which is congruent with attending to spiritual, religious, and cultural

patient needs. In this study, the participants did not attempt to pay attention to patients religious,

spiritual, or cultural needs, meaning, they may not be competent enough to care for the patients

when they pursue RN responsibilities. The lack of knowledge in providing holistic care might

cause frustration in new nurses and they might leave the profession as reported by Dyess et al.

(2014). Moreover, all patients expect competent caring during their difficult times of sickness

and patient satisfaction is paramount in hospital business. When nurses are not competent in

providing holistic care, patient satisfaction will be affected and jeopardizes hospital business.

This amplifies the need for nurses to be competent and caring in nursing practice. When AACN

(2015) and QSEN (Kohlbry, 2016) emphasized the need for patient-centered care nursing,

education should be preparing competent nurses to meet the needs of 21st century population.

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Nursing educational institutions will be in jeopardy when they do not prepare competent nurses,

which affects their accreditation status or even the institutions existence. If nurses are

unprepared, it may cause negative impact on the nursing education, health care settings, as well

as the community itself.

As the U.S population is getting more and more diverse, nurses must be capable of

meeting the diverse needs of people (Hines, 2012). ADNs represent the majority of the frontline

nursing workforce. They should be competent in providing culturally congruent care. Patient-

centered care includes meeting the holistic needs of all patients and families across all settings.

Because of the ever-growing diversity of patient population, cultural sensitivity and cultural

competence in nursing have dramatic implications in practice. The suggestions based on this

study include faculty members to review the nursing curriculum and examine whether ADN

students are obtaining the theoretical knowledge as well as the clinical practice for the

development of culturally sensitive skills to provide holistic care to patients and include cultural

competence in theory and clinical practice in the ADN curriculum.

Recommendations for Further Research

The recommendation for further research arose from the study findings. This study was

conducted in one ADN group with a small sample size. A recommendation for further research

will be to conduct a replication study with other ADN groups and BSN groups and compare how

each group describes the components of caring behaviors from their experiences. Another

recommendation stems from the finding that the participants had positive and negative caring

experiences from faculty members and floor nursing staff. When students experience non-caring

attributes from faculty and other nursing staff, it may have positive or negative influences on

114
their caring behaviors. Further exploration is needed to examine how faculty members

demonstrate caring attributes when teaching nursing students.

Conclusion

The aim of this qualitative research was to examine how well ADN students were

prepared to provide competence in caring as they graduate from a nursing program. Although,

many studies have been conducted to measure how nursing students become competent and

caring nurses, a gap existed in the literature as to whether nursing students are maturing to be a

caring person by the completion of their education. In order to examine whether ADN students

were acquiring the knowledge of providing competent caring by the completion of nursing

education, participants descriptions of their experience with caring were analyzed for the five

components of caring described by Swanson (1991). The study findings revealed that ADN

students had sufficient knowledge about knowing the patient, being with the patient, doing for the

patient, and enabling the patient in relation to their caring attributes. However, the study

participants had only limited knowledge in maintaining patients beliefs to help them overcome

the crisis situation during their illness. This lack of knowledge might hinder the provision of

holistic caring when students assume RN responsibilities after obtaining an RN license.

Based on the findings of this study, nursing schools are recommended to review the ADN

curriculum and include cultural competence in theory and clinical practice in the ADN

curriculum. Another recommendation to practice is to include service-learning opportunities with

diverse communities in the ADN curricula. Cultural competency education is paramount in

nursing education as evidenced by the AACN and QSEN mandates (Kohlbry, 2016). When

nursing students graduate with cultural competency they might be able to provide competent

caring, which might improve patient satisfaction as well as nurse satisfaction. Having job

115
satisfaction might inspire new nurses to continue in the profession and may be a solution to

having sufficient people in the workforce. The insight gained from this study may benefit

primarily nursing educators or nursing faculty members in developing appropriate nursing

curriculum and teaching methodologies in developing caring attributes in nursing students who

can provide holistic care to their patients. Ultimately it may benefit nursing education in

preparing and supplying competent nurses to meet the 21st century nursing workforce needs.

Thus, the findings of this study benefit both practitioners and the scientific community of nursing

education.

116
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 APPENDIX A. INTERVIEW QUESTIONS

1. Tell me about a typical clinical day when you demonstrate caring behaviors?

2. What do you do to help you know more about your patient?

3. What does being with the patient mean to you?

4. What does doing for the patient mean to you?

5. Give an example of how you enable or empower patients?

6. How do you help your patient with maintaining belief to get through an event?

7. What does caring mean to you?

8. What do you think are the factors that influence and motivate you to be a caring person?

Demographic Information

Study Title: Senior Nursing Students Description of Caring From Their Experience: A
Qualitative Research

Student initial: ____________ Assigned Number: ________

Please complete this questionnaire.

1. Are you enrolled in the final semester (role transition) in an associate-degree nursing
program?
a. Yes
b. No

2. Have you repeated any courses in nursing?

a. No
b. Yes

3. Your highest education:

a. High school
b. Associate degree
c. Bachelors: Masters degree
d. Others

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4. Ethnic background
a. Caucasian
b. African American
c. Asian
d. Middle Eastern
e. Others

5. Your Gender
a. Male
b. Female
c. Other

6. Your age
a. 20 25 years
b. 26 30 years
c. 31 - 35 years
d. 36 40 years
e. Above 40 years

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