Caring Science Education: Measuring Nurses' Caring Behaviors

International Journal of Caring Sciences January-April 2019 Volume 12 | Issue 1| Page572
Special Article
Caring Science Education: Measuring Nurses’ Caring Behaviors
Linda Ackerman, MSN, RN

Kaiser Permanente, Oakland, CA, USA
Corespondence: Linda Ackerman MSN, RN, Kaiser Permanente, Oakland, CA, USA E-mail:
Linda.Ackerman58@gmail.com
Abstract
This article focuses on reviewing research and evidence-based practices related to Caring Science educational
programs, utilizing Caring Science theory as an intervention to inform and impact the nurses caring behaviors while
caring for patients within a heathcare environment. While there are multiple survey tools directed at patient’s
assessing the caring behaviors based on the patient’s perception, there are limited surveys that examine the nurse’s
perception of their caring behaviors and their personal, professional practice relating to Caring Science or
relationship-based care and, the impact on their clinical practice post education intervention.
The purpose of this article is to better understand the impact and measurement of nurses’ self-perception of caring
behaviors following the co-creation of the Caring Science/Heart Science standardized educational series in a large
multi-site organization and, patient’s perception of being “treated with loving kindness.” Advancing the art and
science of the nursing staff through deepening their understanding of the theory of human caring, engaging their
hearts and minds, deepening their understanding of the theory as the foundation for all professional nursing practices
within the organization.
Keywords: nurse, caring theory, education, caring attributes, patient, perception.
Introduction families and practice caring behaviors. When

nurses are challenged to engage in authentic caring
The healthcare landscape has changed. Social,
behaviors with their patients and families due to
political, and economic forces of healthcare reform
increased technology and complexity of patient
are challenging organizational viability. As
care, their professional identity diminishes leading
hospital systems merge, creating mega systems,
to decreased job satisfaction (Amendolair, 2012).
caring and administrative practices are often in
conflict. To compete for viability in this new Dr. Jean Watson, nurse theorist, originator of the
landscape, hospitals have moved from caring Theory of Human Caring, calls on nurses and
healing-environments to business or economic nurse leaders to transform hospitals and healthcare
models of caring institutions that focus on census systems from the dominant medical techno-cure
instead of patients and, technology instead of touch system of today often viewed as biocidic (life
or human connection (Watson, 2006). The largest depleting or toxic) to a biogenic (life-giving, and
workforce within the healthcare system, nurses are life receiving for patient and practitioners alike)
torn between the economic direction of the healthcare environment (Watson, 2010). Shifting
organization and the needs of the patient and their our caring to authentic intention, a nursing practice
family. Caring is central to the nursing profession; that is based in ethics and values, thus restoring the
it is through the act of caring and engaging in human spirit for the patient and the practitioner
authentic caring, humanistic encounters that nurses (Schlagel & Jenko, 2015). Caring science
find their professional identity. Nurses’ find connects the nurse, patient, family, and members
purpose and satisfaction in their work when they of the healthcare team by engaging in authentic
have the opportunity to engage with patients and human caring relationships and honoring the very
www.internationaljournalofcaringsciences.org
humanity of the patient and their family (Watson, Science/Heart Science nursing education
2008). In 2010 a multi-site organization located in program (T).
Northern California adopted Dr. Jean Watson’s
The PICOT question guided a systematic search
Theory of Human Caring (Caring Science) as the
(November, 2018) using the keywords nurse,
foundation for the nurses’ professional practice.
caring theory, education, and job satisfaction. The
Literature Review: Cumulative Index of Nursing and Allied Health
Literature (CINAHL), PubMed, and Joanna Briggs
Reviewing literature focusing on research and
Institute Library were searched, yielding 76
evidence-based practices, it was found that limited
articles. Two studies were reviewed based on
research specifically focusing on caring science
impact of caring cultures within the organization
educational programs utilized as an intentional
and the job satisfaction of the nursing staff and,
intervention to inform and influence and measuring
two studies examined the nurses’ perception of
the caring behaviors of the nursing staff while
their work environment and the patients’
caring for patients within a healthcare environment
perceptions of the nurses caring behaviors prior to
is available. Although multiple survey tools exist
the launch of relationship-based care within the
that assess the caring behaviors based on the
organization as a foundation for future learnings.
patient’s perception, there are limited tools that
As noted above, there are limited research study
examine the nurses’ perception of their caring
articles available specifically focusing on
behaviors and their personal, professional practice
educational interventions to assist staff in
as it relates to caring science or relationship-based
examining their personal, professional practice as
care and the change in clinical practice post-
it relates to Caring Science or relationship-based
intervention. This gap is being addressed as the
care and the change in clinical practice post-
organization continues to advance the art and
intervention.
science of the nursing staff through deepening their
understanding of the theory of human caring, Persky, Nelson, Watson, and Bent (2008)
engaging their hearts and minds, and deepening conducted a psychometric study examining the
their understanding of the theory as the foundation profile of nurses’ caring effectiveness. Patients
for all professional nursing practices. A desire to and nurses who were selected to participate in the
understand the impact of this work on a large study were from eight pre-identified medical-
multi-site organization and the currently limited surgical units and one mental health unit preparing
literature examining nurses’ perceived caring to implement relationship-based care. The purpose
behaviors following an intentional caring science of the study was to establish baseline data for the
education program led to the co-creation and nurses caring effectiveness prior to education and
delivery of a standardized Caring Science/Heart implementation of a new practice care model.
Science education program. Health Environment Survey (HES) and the patients
The PICO question used to guide the literature completed a Caring Factors Survey (CFS). The
search was: For nurses in a medical center (P), dyad review was conducted to assess the
how does the Caring Science/Heart Science relationship of nurses’ report of care environment
education series serve as the foundation for nursing to the patients’ perception of caring received from
practice (I), compared to no intervention (C), affect the nurse. The results of the study revealed nurses
the following? of all ages who scored highest in caring behaviors
by their patients experienced the highest levels of
• Registered nurses’ intentional caring behaviors frustration on the HES due to the incongruency of
in clinical practice with their patients (O), the environment and the nurses’ values and goals
assessed within six months after completion of of caring. Both the HES and the CFS provided
Caring Science/Heart Science nursing good reliability indicated by a Cronbach alpha of
education program (T). .95 and .97, respectively.
• Patients’ perception and reporting of being
Asselin and Fain (2013) conducted a mixed
treated with loving kindness (O), assessed
methods study to examining the impact of nurse’s
within six months after completion of Caring
participation in a reflective practice continuing
education program and if the deducation made a A qualitative method of narrative inquiry was used
difference in the self-reflection, insight, and to better understand the nurses’ contextual
reflective thinking about their care in specific realities. The interviews were audio recorded, then
clinical situations. The study was a mixed method transcribed into written text. Utilizing a
pre and post-test design using a quantitative review categorical-content method of narrative analysis
using the Self-Reflection and Insight Scale (SRIS) the interviews yielded 159 detail codes that were
a 20 item self-report questionnaire measuring for placed into five structural categories: (a)
self-reflection and a qualitative approached using a descriptors, (b) conditions, (c) consequences of
reflective practice journaling exercise based on meaningful work, (d) meaningful nursing roles,
patient scenarios. The written narratives were and (e) stories of meaningful moments. The stories
developed from the participant’s own personal revealed that nurses found purpose and meaning
reflections of specific situations. Using the through the relational activities of being and
Bonferroni procedure, it was revealed that nurses connecting with patients.
did have significantly higher engagement in self- Based on the limited literature available,
reflection immediately post-program (Time 2; M = examining the impact of providing nursing staff
30.84; SD = 3.99), as compared to pre-program education focusing on developing caring behaviors
(Time 1; M = 27.32; SD = 6.01). and reflective practices and the impact on their
work satisfaction and the perceived caring
Amendoilair (2012) conducted a descriptive
behaviors from the patient’s perspective, it was
correlational study examining the relationship
identified that further exploration and research
between nurses’ perception of their caring
would be appropriate. The evidence indicated by
behaviors with their patients using the Caring
the work of Persky et al., (2008), Amendolair,
Efficacy Scale (CES) and their job satisfaction
(2012) and, Pavlish & Hunt, (2012) that nurses
using the Index of Work Satisfaction (IWS). The
have a higher job satisfaction when they engage in
study consisted of a random sample of medical-
caring healing-encounters with patients and
surgical nurses (N = 1,091) who completed the two
families.
questionnaires. The CES tool reported consistent
reliability in a variety of settings with a Cronbach’s Aim
of .85 and .88. The IWS tool reported consistency
As part of the organization’s Northern California
and validity for the nursing population with a
patient care services leadership strategic plan, the
Cronbach’s of .82 to .91. The data were analyzed
goal is to align the multiple initiatives within the
using SPSS. The surveys were tallied, and
organization establishing Caring Science as the
parametric statistics were used with all of the
foundation of all the various initiatives, essentially
summed data (Amendolair, 2012). There was an
linking the why we do, to what we do.
established correlation between the CES and the
IWS with the nurses’ ability to spend time with The aim of this work is to co-create and develop a
their patients and job satisfaction. The authors Caring Science/Heart Science education module
reported that nurses should reflect on the value of series and assessing the impacting on the nurses
expressing caring behaviors to strengthen their caring behaviors using the Caring Factor Survey-
professional identity and improve their job Care Provider Version (CFS-CPV) moving the
satisfaction. When nurses practice caring behaviors nurses’ from “being to becoming” and assessing,
with their patients, it creates a positive work the effect on the patient’s perception of being
environment, thus increasing job and patient “treated with loving kindness”.
satisfaction.
Caring Science/Heart Science Education
Pavlish and Hunt (2012) conducted a narrative
design interview study to understand the nurses’ Nurse leaders must develop creative programs and
perceptions of meaningful work and the contextual strategies that support and value a caring
factors that impact the nurses’ perceptions of environment for patients and staff so that nurses
meaning at work. The study consisted of acute will be fulfilled in their work, ensure retention, and
care hospital nurses (N=13) at two magnet improve organizational outcomes (Amendolair,
hospitals located in the southwestern United States. 2012).
and their care team (McCraty & Chilre, 2004).

A Caring Science/Heart Science experiential
The HeartMath® practices that were integrated
education program was co-created and developed
into the caring science education were the Quick
by the caritas coaches within the organization with
Coherence™, Energetics of Communication™ and
the intent to reconnect and engage the nursing staff
Freeze Frame™ tools. HeartMath® practices focus
to the essence of the professional nursing practices.
on generation of positive emotions that create an
A standardized Caring Science education program
emotional shift to one of calm, ease and presence
utilizing Dr. Jean Watson’s Theory of Human
which allows the nurses to engage in a more
Caring as the foundation of professional practice
authentic caring relationships with self, patients
provides the nursing staff the ability to examine,
and their care team. Integration and co-creating of
reflect, and discuss theory guided practices leading
a consistent and unified message, “one unified
to a deeper appreciation of connecting the “why”
voice,” for clinical nursing practice throughout the
to the what”.
organization’s Northern California medical centers
To align the Caring Science/Heart Science is a key strategy to transform and empower the
innovative practice, this organization has partnered professional nurse to own their practice.
the caritas coaches with the 38 HeartMath®
This education series enables professional nurses
trainers who have been trained by the HeartMath®
to reflect on the value of expressing caring
institute in the Resilience Advantage™ workshop.
behaviors as they care for their patients and
The evidence-based practices learned in the
strengthen their own purpose and resolve. The
workshop offers self-regulation skills focusing on
Watson Caring Institute’s Caritas Coach Education
the heart connection in identifying and, sustaining
Program® (CCEP) was used as an experiential
positive emotions such as love, gratitude and,
guideline, in the design plan for the educational
appreciation and its healing capabilities for self
series to allow staff to deepen their understanding
and others (McCraty & Childre, 2004). These
and enculturating caring science into their
HeartMath® practices provide the caring healing-
professional practice framework. Educating the
modalities for staff to obtain self-care and
nursing staff in the theoretical practices based on
contribute to the development of caring healing-
human-caring values while delivering care within
environments, engaging the hearts and minds of
the professional practice framework for the
the clinical staff to move beyond task to purpose.
organization by focusing on the following:
The organization in collaboration with Dr. Watson • Care focusing on professional practice based
and HeartMath® brought the caritas coaches and
on morality-ethics-values.
HeartMath® trainers together to enhance the
• Shifting from a mechanical cure approach to
Caring Science education incorporating specific
spiritualizing of heath and healing processes.
HeartMath® evidence-based practices into the
caring science education program. The • Moving from rote, atheoretical professional
HeartMath® practices provide the staff the tools to routines to a nursing practice based on
understand the heart connection in identifying and intentional caring-theory -guided professional
sustaining positive emotions such as love, actions.
gratitude, and appreciation of the healing
capabilities for self and others (McCraty & • Moving from “institutional” environments to
Childre, 2004). The HeartMath® practices that healing environments. Understanding that the
were integrated into the caring science education nurse is part of that healing environment.
were the Quick Coherence® (McCraty & Childre, • Focusing on the covenant of caring for a
2004), Energetics of Communication® (McCraty, human soul.
2004) and, Freeze Frame® (Childre & Rozman,
2005) tools. HeartMath® practices focus on • Moving beyond industrialized “managed care”
generation of positive emotions that create an to the relationship-centered caring healing-
emotional shift to one of calm, ease and presence partnership with the patient and families.
which allows the nurses to engage in more Recognizing the whole patient and their
authentic caring relationships with self, patients
support system as part of the caring healing nursing staff to the essence of the professional
process (Watson, 2008). nurse to enhance their caring behaviors from being
to becoming, creating caring healing- practices
With an understanding the importance and impact
with their patients. Providing the nurses with a
of the integration and application of caring science
deeper understanding of caring science and
as the foundation for professional practice, the
HeartMath® practices will assist in engaging
organization has supported and funded 46 clinical
patients, families, and co-workers in creating
staff and leaders combined to become certified
authentic, caring healing-practices and
caritas coaches by attending the Watson Caring
environments. Integration and co-creating of a
Science Institute’s (WCSI), Caritas Coach
consistent and unified message, “one unified
Education Program (CCEP)®. The CCEP®
voice” for nursing clinical practice is a key strategy
program is a 6-month educational program which
to transform and empower the professional nurse
provides the nurses and other caregivers the
to own their practice. The Caring Science/Heart
foundation of the moral, ethical, philosophical
Science education program incorporates the
principles of Caring Science as a framework for
organizations national professional practice model
teaching, learning and modeling the theory in their
(Kaiser, 2015); the evidence-based fundamental of
practices (Horton-Deutsch & Anderson, 2018).
care experience and, the evidence-based practices
To align the Caring Science/Heart Science of HeartMath®, to align and “connect the dots” of
innovative practice, this organization has partnered multiple programs’ content to the primary focus,
the caritas coaches with the 38 HeartMath® the theory of Caring Science for the nursing staff.
trainers who have been trained by the HeartMath® This provides the nursing staff an opportunity to
institute in the Resilience Advantage™ workshop. enhance and reinforce their perception of
The evidence-based practices learned in the meaningful work.
workshop offers self-regulation skills focusing on
The Watson Caring Institute’s® Caritas Coach
the heart connection in identifying and, sustaining
Education Program ®(CCEP) was used as an
positive emotions such as love, gratitude and,
experiential guideline in the design plan for the
appreciation and its healing capabilities for self
educational series to allow staff to deepen their
and others (McCraty & Childre, 2004). These
understanding and enculturate caring science into
HeartMath® practices provide the caring healing-
their professional practice framework. This
modalities for staff to obtain self-care and
experiential learning series was developed to
contribute to the development of caring healing
provide the nursing staff a theoretical guide,
environments, engaging the hearts and minds of
establishing a common language allowing them to
the clinical staff to move beyond task to purpose.
see, act on and, reinforce authentic practices that
The quality improvement program that the Caritas enable the nursing staff to develop their caring
Coaches and HeartMath® trainers team agreed to attributes moving them from “being to becoming.”
engage in was the consistent use of the The 4 modules and their foci are:
standardized Caring Science/Heart Science
• Module 1: The caring connection –
education modules as the foundation for
Foundation of Caritas Process
professional practice education for the
organization. The Caring Science/Heart Science • Module 2: Being and Becoming – Taking
experiential education program was developed care of self and others
with the intent to reconnect the nursing staff to the
essence of the professional nursing practices. • Module 3: The healing environment –
Caring Science honors the whole being mind, body Providing care to our patients and members
and, spirit providing the nurses with a deeper • Module 4: Caritas Consciousness –
understanding of honoring the sacredness of caring Evolving our care environments (Appendix A)
for patients.
The Caring Science/Heart Science experiential Research has shown that when nurses are able to
education program for the registered nurse was engage in meaningful relationships with their
developed with the intent to reconnecting the patients and their families, they have purpose and
satisfaction in their jobs (Pavlish & Hunt, 2012).
The sponsoring organization supports and endorses (DiNapoli, et al., 2010). The researchers reported
this work to honor, frame, discuss, develop and the reliability for the modified 10-item tool using
advance the art and science of the professional Cronbach’s alpha used for a study of 450 nurses in
nurses within the organization (Watson, 2008). three healthcare facilities was .89 (DiNapoli, et al.,
2010). The project tool utilizes the CFS-CPV
Instruments
with permission from Dr. John Nelson which
Reviewing Caring Science literature, it was invites the RN to personally reflect and assess their
identified that there are multiple tools measuring caring attributes in relationship to Dr. Jean
the impact of caring and caring behaviors or Watson’s 10 Caritas Processes®. The modified
attributes of the nurse from the patient’s caring factor survey-care providers version
perception. The number of tools focused consists of a 10-item survey using a 7-point Likert
specifically on the nurse’s personal perception of scale.
his/her own caring behaviors is limited.
Results
Assessing and evaluating the impact of the caring
The intent of this project is to validate the impact
science/heart science education program on the
of theory-guided experiential learning to inform
nurses’ perception of their caring behaviors both
the professional practice of the nursing staff within
pre and post-intervention utilizing the Caring
the organization. Using the CFS-CPV and the
Factor Survey–Care Provider Version (CFS-CPV)
HCAHPS “Nurses treated me with loving
developed by Karen Drenkard, John Nelson, Gene
kindness” data to measure the effectiveness of the
Rigotti, and Jean Watson in 2006 (Johnson, 2012)
Caring Science/Heart Science education. The
(Attachment A). Patients’ perception of being care
focus of this work is on the nurses’ perception of
for will be assessed pre and post-intervention
their caring behaviors pre and post educational
reviewing the organizations customized Hospital
intervention. This work is intended to add to the
Consumer Assessment of Healthcare Providers and
body of knowledge needed to validate the impact
Systems (HCAHPS) question: “Nurses treated me
of human caring education for both the nursing
with loving kindness.”
staff and patients.
Caring Factor Survey-Care Provider Version
Conclusion
The caring factor survey-care provider version
Through the completion of the Caring
(CFS-CPV), originally a 20-item tool designed to
Science/Heart Science experiential learning series,
measure caring using the 10 Caritas Processes® as
the nursing staff have an opportunity to examine,
constructs by CFS instrument (DiNapoli & Nelson,
reflect, and discuss theory guided caring practices
2010). The CFS-CPV was modified to a 10-item
leading to a deeper appreciation of “what” they do
tool which was developed to measure the essential
and “why” it makes a difference in the lives of the
elements of the 10 Caritas Processes® as the
people they care for daily. The ability to measure
perception of caring concepts by employees who
the impact of this allows nurses to practice at their
interact with patients within health care (DiNapoli,
highest potential as they connect their clinical
et al., 2010). The CFS reduced item was explored
practices with the purpose of the organizations
using exploratory and principal component factor
professional and nursing vision.
analysis in 2010 by nurse researchers, P. DiNapoli,
J. Nelson, M. Turkel, and, J. Watson (DiNapoli, et References
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Appendix A:
Caring Science/Heart Science
Modules
Appendix B
Caring Factor Survey- Care Provider Tool
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https://creativecommons.org/licenses/by/4.0/(the “License”). Notwithstanding
the ProQuest Terms and Conditions, you may use this content in accordance
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International Journal of Caring Sciences January-April 2019 Volume 12 | Issue 1| Page572

Caring Science Education: Measuring Nurses’ Caring Behaviors

Linda Ackerman, MSN, RN

Introduction families and practice caring behaviors. When

and their care team (McCraty & Chilre, 2004).

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