For this assignment the topic is on Nursing and Caring Activities related to better patient outcomes.
THE ARTICLE CITATION IS:
Akansel,N., Watson, R., Vatansever, N., & Özdemir, A. (2020). Nurses’ perceptions of caring activities in nursing.Nursing open, 8(1), 506–516.
https://doi.org/10.1002/nop2.653
Received: 7 February 2020
| Revised: 4 September 2020 | Accepted: 11 September 2020
DOI: 10.1002/nop2.653
RESEARCH ARTICLE
Nurses’ perceptions of caring activities in nursing
Neriman Akansel1
| Roger Watson2
1
Department of Nursing, Bursa Uludag
University Faculty of Health Sciences, Bursa,
Turkey
2
FAAN Professor of Nursing, University of
Hull Faculty of Health and Social Care, Hull,
UK
Correspondence
Neriman Akansel, Department of Nursing,
Bursa Uludag University Faculty of Health
Sciences, Bursa, Turkey.
Email: nakansel@uludag.edu.tr
| Nursel Vatansever1 | Aysel Özdemir1
Abstract
Aim: This study aimed to determine nurses’ perceptions of caring activities in nursing.
Design: A descriptive study design.
Methods: A Turkish translation of the 25-item version of the Caring Dimensions
Inventory was completed by 260 nurses working in one university hospital. Data
were analysed using Mokken scaling.
Results: Technical aspects of nursing were highly endorsed items such as “observing the effects of a medication on a patient, measuring vital signs, being technically
competent with a clinical procedure, consulting with the doctor” except for the item
“providing privacy for a patient” which is a psychosocial item. The range of items
included in the Mokken scale with “providing privacy for a patient” (mean = 4.31) as
the most endorsed, and “exploring the patient’s lifestyle” (mean = 2.60) being the
least endorsed item. Listening to patients and involving them in their care are not
considered as caring.
KEYWORDS
caring, item response theory, Mokken scaling, nursing, Turkey
1 | I NTRO D U C TI O N
2 | BAC KG RO U N D
Nurses are unique caregivers that make a difference in patients’
Caring in the nursing profession is a challenging, universal phenom-
lives. Nurses aim to protect, promote and optimize the health of
enon yet a difficult process for nurses to understand and articulate.
individuals, preventing illness, facilitating healing, alleviate suffer-
Nevertheless, theorists agree that caring is an essential aspect of the
ing through the diagnostic procedures and advocate in the care
nursing profession (Alpar et al., 2013), and the value of nursing care
of individuals and families (American Nurses Association, https://
on positive outcomes in patients’ well-being is undeniable(Ayyub
www.nursingworld.org/practice-policy/scope-of-practice/;
ac-
et al., 2015). Nevertheless, nurse caring is considered as a quality
cessed 10 June 2020). Finkelman and Kenner (2013) underlines
indicator in healthcare organizations (Burtson & Stichler, 2010). As it
that caring relationship, attention to human responses, integrating
launched in Watson’s Caring Theory, caring occurs whenever a nurse
assessment data, application of the scientific data, advancing pro-
and patient come in to contact with each other’s. The theory empha-
fessional nursing knowledge, promoting social justice, assuring safe
sizes the interactions between the caregiver and recipient; where
and evidence-based practice are features of professional nursing.
holistic nursing care is placed in the centre of caring (Kandula, 2019).
Professional, personal, scientific, aesthetic and ethical human trans-
Holistic nursing and nursing care which is in harmony with the cul-
actions are important in nursing where a patient should be a focus of
ture are vital components of Leininger’s theory of Transcultural
practice (Kandula, 2019).
Nursing as well (Alpar et al., 2013).
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2020 The Authors. Nursing Open published by John Wiley & Sons Ltd
506
| wileyonlinelibrary.com/journal/nop2
Nursing Open. 2021;8:506–516.
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AKANSEL Et AL.
The magnitude of caring in nursing is very complex (Finkelman
who willingly choose nursing as a career and the ones’ who had
& Kenner, 2013); thus, studies conducted on caring in nursing re-
caring experience are more sensitive to patient needs (Birimoğlu &
veal different dimensions of caring as well as different descriptions.
Ayaz, 2015). Caring perceptions of nursing students are influenced
Nursing requires a range of technical and psychological dimensions
by their attitudes and experiences (Konuk & Tanyer, 2019). There is
and has other dimensions that are not clarified (Lea et al., 1998).
a need to support nursing students during their education using ap-
Finkelman and Kenner (2013) emphasizes that practising as a nurse
propriate methods of teaching and role models are essential (Culha
is far beyond the basic knowledge on how to do specific things or the
& Acaroğlu, 2019). Overall, nursing students should be taught how
ability to care for someone. Being able to care for someone requires
to care for themselves at first because being able to take care of
attentiveness, concern and knowledge and art of caring (Finkelman
the others is consuming a lot of energy and draining experience as
& Kenner, 2013; Hudacek, 2008b).
well. This is also a very important practice for qualified nurses since
The latest definition is caring provided by the American
nurses tend to ascribe different meanings to caring in nursing.
Association of the Critical Nurses’ Synergy Model for Patient Care
Although most of the studies involving nurses and patients show
is: “activities performed by nurses in a compassionate, support-
that technical aspects of nursing are an important part of their per-
ive and therapeutic environment to promote comfort and healing.
ceptions related to caring (Acaroğlu et al., 2009; Algıer et al., 2005;
Nursing care also should focus on preventing unnecessary suffer-
Ayyub et al., 2015; Geçkil et al., 2008; O’Connell & Lenders, 2008;
ing as well.” (American Association of Critical Care Nurses, https://
Özdemir & Şenol Çelik, 2010), psychological dimensions of nursing
www.aacn.org/nursi ng-excellence/aacn-stand ards/syner gy-model
care should not be underestimated (Ayyub et al., 2015), as well as
,2017; accessed 10 June 2020). According to this description, caring
providing reassurance to patients (Weyant et al., 2017) being his/
includes both attitudes and activities (actions) performed by nurses.
her advocate (Hudacek, 2008a) and providing culturally appropriate
Research shows that nurses’ caring behaviours are influenced by
care (Murphy et al., 2009). Area of practice (e.g. surgical and medi-
several factors such as working conditions; workload; management
cal) also influences nurses caring behaviours (Lea & Watson, 1999;
support; and concerns related to patients’ health (Enss & Swatzky Jo-
Walsh, 1999; Watson & Lea, 1998). Nurses who are exposed to oc-
Ann, 2016), compassion fatigue (Burtson & Stichler, 2010), cultural
cupational stress tend to have a low quality of life which can also
differences (Ian et al., 2016; Watson, 2003), patients’ expectations
influence patient outcomes (Sarafis et al., 2016). ICU nurses re-
from nurses (Özbaşaran et al., 2000; Weyant et al., 2017) and nurses’
port that working with dying patients is a stressful, draining, de-
perceptions about caring (Karaöz, 2005; Skott & Erikson, 2005).
pressing and heartbreaking experience. Also, supporting families is
Hudacek (2008a) says the personal meaning of caring for nurses
another dimension of care for ICU nurses (Kisorio & Langley, 2016).
should be questioned. In addition to personal perceptions of car-
According to critical care nurses and the relatives of critically ill
ing, compassion, spirituality, being aware of people who need health
patients, technical aspects of nursing are important (O’Connell
care, assessing patients’ comfort, providing comfort, crisis inter-
& Lenders, 2008), this aspect of nursing is also valuable for nurs-
vention, undertaking advocacy roles both for the patient and their
ing students as reported by different studies (Akansel et al., 2012
families contribute value to the nursing profession should not be
and Watson et al., 2001). Researchers report that gender has an
underestimated (Hudacek, 2008b).
influence on which caring behaviours were valued among nurses
Rego et al. (2010) indicate that high empathy levels of nurses provoke an increase in their caring behaviours. Some studies emphasize
the most (Greenhalgh et al., 1998; Lea & Watson, 1999; Watson &
Lea, 1998).
that altruistic and emotional aspects (O’Connell & Lenders, 2008),
Differences were also found between nurses’ and patients’ per-
intimacy and support aspects (Watson et al., 2001), usually comes
ceptions about caring (Geçkil et al., 2008). Nurses should be famil-
after technical aspects of nursing according to nurses and nursing
iar with patients’ perceptions of caring and instill this in improving
students. Despite the fact that nurses are taught how to care prop-
their nursing care (McCance et al., 2008). Patients have expressed
erly for patients during their education; their practice and percep-
dissatisfaction with how nurses react to their worries and fears, pro-
tions related to caring are quite different. Watson et al. (2001) report
viding comfort during hospitalization (Geçkil et al., 2008). Most of
that other aspects of nursing such as intimacy and support develop
the studies on this topic reveal different perceptions of caring by
sometime later in nursing students during their education. Another
patients and nurses. McCance et al. (2008) reveal that both techni-
study suggests that although professional values tend to increase
cal and intimacy dimensions of nursing were prioritized by nurses.
during nursing education compassion of students does not differ
Specifically, “listening to a patient” underlined as a part of nursing
greatly (Kavradım et al., 2019). Thus, clinical practice plays a signifi-
care by nurses. In the same study, patients emphasized “involving
cant role in developing caring behaviours in nursing students (Mlinar
a patient in care” and “providing privacy for a patient” as nursing
et al., 2010). Therefore, using narratives is recommended to use in
care. Consequently, perceptions of nurses and patients’ on caring
nursing education to expand awareness of nursing students on car-
are incongruent. The respectful and holistic approach provided by
ing (Hudacek, 2008a). Overall, whenever the person can meet his/
advanced practice nurses in Sweden combined with knowledge and
her caring needs in daily life, he/she tends to show sensitivity to the
skills is stressed as an important part of caring by patients (Eriksson
caring needs of others (Baykara & Şahinoğlu, 2014; Öztunç, 2013).
et al., 2018). A systematic review by Papastavrou et al. (2011) em-
One study involving nursing students emphasizes that students
phasized that instrumental nursing skills and nurses’ competency in
508
|
those skills are important for patients. However, effective nursing
AKANSEL Et AL.
3.2 | Sample and data collection procedure
care is perceived as expressive care for nurses which differs from
patients’ perspective. Visible features of nursing care are valuable
Data were collected during September 2015-February 2016 by two
to patients while invisible caring activities such as expounding the
of the researchers in one university hospital in the northwest re-
nursing care, protecting the patient and competency are underlined
gion of Turkey. Four hundred fifty (N = 450) nurses were employed
by nurses (Canzan et al., 2014).
in the hospital during the conduction of this study. Operating room
Since nurses’ perceptions of caring are influenced by numer-
nurses and outpatient clinic nurses were excluded from the study
ous facts, it is important to clarify the nurses’ understanding of the
since uninterrupted patient care is not available in those depart-
phenomenon of caring. As far as we know of no study that deter-
ments. Nurses who were on sick leave, annual leave or unpaid leave
mines the caring dimension of the working nurses using the Caring
were also excluded making. Data were collected from 280 nurses
Dimensions Inventory Turkey (CDI-25).
who volunteered to participate in this study. Since 20 participants
did not complete the forms properly (missing data on the data collection form and CDI-25 inventory), study was completed with 260
2.1 | Aim
nurses Researchers handed the forms (data collection form and CDI25 inventory) in envelopes to the nurses and collected completed
This study aimed to determine nurses’ perceptions about caring ac-
forms after one week.
tivities in nursing by using CDI-25 and compare the findings with
relevant literature.
3.3 | Mokken scaling
3 | M E TH O DS
The present study used the non-parametric item response (IRT)
theory method of Mokken scaling analysis (MSA). IRT methods offer
3.1 | Design
advantages over the more commonly applied multivariate methods
based on such as factor analysis—based on classical test theory—
Demographic variables and data on nurses working status were col-
in that they can establish item ordering in scales (hierarchies) and,
lected using a data collection form which consisted of 10 questions.
thereby, provide a more meaningful relationship between scale
-Four questions were related to demographic variables of nurses.
scores and levels of the latent trait being investigated. A non-tech-
-Five questions were related to nurses working experience, num-
nical explanation of MSA has been provided by Watson et al. (2012)
ber of patients assigned, wards they work.
where the underlying principles of the method are explained along
-One question used to determine nurses’ perception of the ef-
with the parameters whereby the qualities of a Mokken scale may be
ficiency of nursing care given to patients using the Visual Analogue
judged. These parameters include Loevinger’s coefficient (H) which
Scale (0 = not efficient, 10 = completely efficient).
is a measure of the strength of an overall scale (Hs) or the scala-
The Turkish translation of the CDI-25 (Akansel et al., 2012)
bility of individual items (Hi) and pairs of items (Hij). The minimum
self-administered questionnaire for measuring nurses’ perceptions
requirement for values of H is that they equal or exceed 0.30; the
about caring originally developed by Watson and Lea (1997) was
lower-bound 95% confidence intervals for individual items should
used for data collection. CDI-25 includes twenty-five statements of
not include 0.30 and the lower-bound 95% confidence intervals for
nursing actions. In the study of Lea et al. (1998), CDI-25 was cate-
item pairs should not include 0 (Kuijpers et al., 2013). Values of Hs
gorized into five dimensions; psychosocial, technical, professional,
equalling or exceeding 0.30, 0.40 or 0.50 indicate weak, moderate
inappropriate and unnecessary activities. There is a base question
and strong scales, respectively. Items scores should continually in-
in the inventory: “Do you consider the following aspects of your
crease as the latent trait increases (monotonicity) and items charac-
nursing practice to be caring?” CDI-25 includes statements of nurs-
teristic curves (ICC)—which describe the relationship between the
ing actions. Respondents answer the items included in the inven-
score on an item and the level of the latent trait—should not inter-
tory through a 1–5 point scale (1 = disagree and 5 strongly agree).
sect, a property knows as invariant item ordering (IIO). Monotonicity
Chronbach’s alpha value of CDI-25 was calculated as 0.91 indicat-
is judged using a “Crit” value, which is calculated from the number of
ing that it had a high degree of internal consistency (Watson & Lea,
violations of monotonicity; values should not exceed 80 (Molenaar &
1997). In the Turkish form of the instrument, the ordering of par-
Sijtsma, 2000). The existence of IIO can be established by a combi-
ticipants was supported by appropriate Mokken Scaling Parameters
nation of visually inspecting plots of ICCs and looking for significant
and scoring of items by participants was not invariant. The Turkish
violations of IIO; the strength of IIO can be estimated using Htrans
version of the Caring Dimensions Inventory is a reliable instrument
(HT ) (Watson et al., 2014) which is analogous to Hs and the values
for measuring nurses’ perceptions about caring. Mostly, endorsed
for judging the strength of IIO are the same as those for Hs reported
items were psychosocial while the professional/technical items were
above. The probability of obtaining a Mokken scale and the reliabil-
less endorsed (Akansel et al., 2012).
ity (rho) of Mokken scales can also be estimated.
| 509
AKANSEL Et AL.
3.4 | Data analysis
TA B L E 1
Data were entered into SPSS 21.0 and checked listwise for missing
values before conversion in R (public domain software available
at https://www.r-proje ct.org/; accessed 18 August 2015) using
the “foreign” package to a form suitable for analysis in R using the
“mokken” package. Data were analysed using the automated item
selection procedure (“aisp” which has a default setting of Hs 0.30,
P < .05 and which finds the item with the highest Hi and then
Demographic variables of working nurses (n = 260)
Mean ± SD (range)
Age
32.3 ± 6.1 (range
20–53 years)
Work experince as a nurse (years)
9.8 ± 6.5 (range 1–31 years)
Mean number of patients asiigned
per nurse (in one shift)
10.5 ± 7.6 (range 1–40)
Nurses’ perception on effciencey of
nursing care given to patients
7.1 ± 1.8 (range 1–10)
builds a Mokken scale until no further items fit) and inspected for
violations of monotonicity. Standard errors of Hs and Hij were
used to check 95% confidence intervals. Item pairs were plotted
and inspected for intersection and for any outlying items which
may exaggerate IIO. The data were then analysed for significant
violations of IIO and items sequentially removed until no further
violations were evident.
Numbers (percentage %)
Gender
Female
244 (93.8%)
Male
16 (6.2%)
Marital status
Married
177 (68.1%)
Single
83 (31.9%)
Degree
3.5 | Ethics
High school degree
12 (4.6%)
Associate degree
20 (7.7%)
Ethical approval was given by the University Ethical Board (2014-
Bachelor degree
205 (78.8%)
2015/10.
Msc in Nursing
23 (8.8%)
B.30.2.ULU.0.20.70.02.050.99/290)
for
this
study.
Permission was obtained from the author to use the scale (CDI-25
Turkish Version) in this study. All of the nurses were informed about
the aim of the study both verbally and in writing. They were reassured that participation is voluntary and have the right to leave the
research at any time they want to.
4 | R E S U LT S
The CDI was administered to 280 nurses and 260 completed it giving
a response rate of 92.8%. Nurses’ ages ranged between 20–53 years
Position
Staff nurse
246 (94.6%)
Head nurse
14 (5.4%)
Ward
Medical Unit
72 (27.7%)
Surgical Unit
81 (31.2%)
ICU
90 (34.6%)
ER
12 (4.6%)
Pediatric Clinic
5 (1.9%)
Working shifts of nurses
(mean = 32.34, SD 6.14). As shown in Table 1 most of the nurses
Rotating shifts (08−16/ 16–08)
were female (93.8%) and had a bachelor's degree in nursing (78.8%).
Always 08–16 shifts
49 (18.8%)
The mean working experience of nurses was 9.76 (SD 6.46) years.
Always 16–08 shifts
26 (10.0%)
185 (71.2%)
According to nurses working in different wards of the hospital, the
efficiency of care given to hospitalized patients was 7.14 (SD 1.83)
according to the Visual Analogue Scale numbered 0–10. Data from
two participants were removed due to missing data, and 18 nurses
pair plots which showed that the ICC for item 16 was positioned a
did not want to participate.
long way from the remaining cluster of items; therefore, item 16 was
The analysis showed a single scale with four items (8, 16, 17 &
removed from the analysis of IIO.
19) not scaling which means that these items did not meet the basic
Table 2 shows the outcome of sequentially removing items until
scalability requirement of having Hi ≥ 0.3 and were therefore ex-
there were no further violations of IIO—in other words that there
cluded from the analysis. Items 3, 7, 8, 17 and 18 had lower bound
were no overlapping items—leaving 19 items in 6 steps with a final
95% confidence intervals including 0.30; this means that 95% of the
HT of 0.40 indicating moderately strong IIO whereby items are rea-
time these items are included in a Mokken scaling analysis they will
sonably positioned along the span of the latent trait.
not meet the minimum requirement of Hi ≥ 0.3. Nevertheless, they
Table 3 shows all of the items ordered by the mean score with
were not removed from the analysis as the confidence interval may
those showing IIO and those with unsatisfactory 95% confidence
be related to the relatively small sample size. All item pairs with item
intervals indicated. The most highly endorsed item is “Providing pri-
16 had 95% confidence intervals including 0, and this is a clear indi-
vacy for a patient” and the least endorsed is “Exploring a patient's
cation that there may be a problem with item 16 in relation to the
lifestyle.” However, it should be noted that three of the items show-
other items in the scale. This was verified by visual inspection of item
ing IIO had 95% confidence intervals which included 0.30.
510
|
TA B L E 2
AKANSEL Et AL.
Number of significant violations of IIO and effect on Htrans (HT ) with sequential item removal steps (N = 260)
Item
Label
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
1
Assisting a patient with an activity of daily
living (washing, dressing, etc.
0
0
0
0
0
0
2
Making a nursing record about the patient
0
0
2
–
3
Feeling sorry for a patient
0
1
0
1
–
–
4
Getting to know the patient as a person
1
0
0
0
0
0
5
Explaining a clinical procedure to a patient
0
0
0
0
0
0
6
Being neatly dressed when working with a
patient
0
0
0
0
0
0
7
Sitting with a patient
0
0
0
0
0
0
8
Exploring a patient's lifestyle
0
0
0
0
0
0
9
Reporting a patient's condition to a senior
nurse
0
0
0
1
0
0
10
Being with a patient during a clinical
procedure
1
0
0
0
0
0
11
Being honest with a patient
2
–
–
–
–
–
12
Organizing the work of others for a patient
0
0
1
0
0
0
13
Listening to a patient
0
0
0
0
0
0
14
Consulting with a doctor about a patient
0
0
0
0
0
0
15
Instructing a patient about an aspect of selfcare (washing, dressing, etc.)
1
0
1
1
1
0
16
Sharing your personal problems with a
patient*
–
–
–
–
–
–
17
Keeping relatives informed about a patient
0
0
0
0
0
0
18
Measuring the vital signs of a patient (e.g.
pulse and blood pressure)
0
0
0
0
0
0
19
Putting the needs of a patient before your
own
0
1
–
–
–
–
20
Being technically competent with a clinical
procedure
0
0
1
0
0
0
21
Involving a patient with his or her care
0
0
0
0
0
0
22
Giving reassurance about a clinical procedure
0
0
0
1
0
0
23
Providing privacy for a patient
0
0
0
0
0
0
24
Being cheerful with a patient
1
0
1
1
1
–
25
Observing the effects of a medication on a
patient
0
0
0
0
0
0
*Removed following
inspection of item
pair plots
HT
0.35
0.35
0.36
0.38
0.39
0.40
5 | D I S CU S S I O N
–
–
their patients in a holistic manner, suitable for their cultural structure
and also be respectful to it (Alpar et al., 2013).
5.1 | Concepts of Caring in Nursing
Being able to give sufficient, professional and culturally sensitive care to an individual is an important aspect of nursing (Murphy
Nursing care is composed of professional understanding, knowledge
et al., 2009). While teaching these aspects of caring in nursing
and skills to practice nursing and interactions between nurses and pa-
schools, there is a great emphasis on how to provide patient care
tients (Dinç, 2010). According to Leininger's theory of Transcultural
properly. Thus, both teaching and learning nursing is a process that
Nursing, nursing is described as a science and type of art which can
requires effort both by nursing faculties and nursing students. Both
be learned. Caring is an essence of nursing and basic human need.
the definition and provision of caring activities in nursing are dif-
Every single culture has some differences and similarities in terms of
ficult and multidimensional. There is no universally accepted defi-
ethical and moral values. Thus, nurses are expected to give care to
nition of the concept of caring. Caring includes perspectives such
| 511
AKANSEL Et AL.
TA B L E 3
Mokken scale of CDI-25 items (N = 260)
Item
Label
Mean score
Hi(SE)
0.50 (0.03)*
23
Providing privacy for a patient
4.31
25
Observing the effects of a medication on a patient
4.21
0.51 (0.03)*
18
Measuring the vital signs of a patient (e.g. pulse
and blood pressure)
4.16
0.47 (0.04)*
20
Being technically competent with a clinical
procedure
4.10
0.46(0.04)*
14
Consulting with a doctor about a patient
3.99
0.49 (0.03)*
15
Instructing a patient about an aspect of self-care
(washing, dressing, etc.)
3.90
0.48 (0.03)*
24
Being cheerful with a patient
3.89
0.45 (0.04)
13
Listening to a patient
3.85
0.52 (0.04)*
21
Involving a patient with his or her care
3.75
0.40 (0.04)*
22
Giving reassurance about a clinical procedure
3.73
0.39 (0.04)*
12
Organizing the work of others for a patient
3.71
0.46 (0.04)*
5
Explaining a clinical procedure to a patient
3.71 0.49 (0.03)*
2
Making a nursing record about the patient
3.70
0.40 (0.04)
4
Getting to know the patient as a person
3.66
0.44 (0.03)*
11
Being honest with a patient
3.66
0.44 (0.04)
10
Being with a patient during a clinical procedure
3.57
0.50 (0.03)*
6
Being neatly dressed when working with a patient
3.54
0.44 (0.04)*
1
Assisting a patient with an activity of daily living
(washing, dressing, etc.
3.43
0.40 (0.04)*
9
Reporting a patient's condition to a senior nurse
3.10
0.41 (0.03)*
3
Feeling sorry for a patient
3.05
0.30 (0.04)†
19
Putting the needs of a patient before your own
2.95
0.30 (0.04)†
17
Keeping relatives informed about a patient
2.94
0.24 (0.05)*†
7
Sitting with a patient
2.69
0.35 (0.04)*†
8
Exploring a patient's lifestyle
2.60
0.26 (0.05)*†
16
Sharing your personal problems with a patient
1.36
−0.16 (0.09)
T
Note: Hs = 0.40; Rho = 0.93; * = items showing IIO (H = 0.40); † = items with lower 95% confidence intervals
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