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The impact of nurse education on the caring behaviours of nursing students

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DOI: 10.1016/j.nedt.2008.08.016 · Source: PubMed

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 Author's personal copy

Nurse Education Today (2009) 29, 254–264

Nurse
Education
Today
www.elsevier.com/nedt

The impact of nurse education on the caring

behaviours of nursing students
a,*
Fiona Murphy , Steve Jones a, Mark Edwards a, Jane James a,
Alan Mayer b

a
School of Health Science, Swansea University, Singleton Park, Swansea SA2 8PP, United Kingdom
b
School of Business and Economics, Swansea University, United Kingdom

Accepted 23 August 2008

KEYWORDS Summary This study aimed to ascertain whether nursing students’ perceptions of
Nurse education; caring behaviours as part of nursing practice change over a three-year, pre-registra-
Survey; tion, undergraduate nursing course. Students are expected to have a predisposition
Caring to care with nurse education nurturing and developing this into professional caring
behaviour. However, there is some evidence that this process inures rather than
develops these behaviours.
This was a quantitative, single cross section survey of two nursing student
cohorts from one Higher Education Institution (HEI) in Wales, United Kingdom
(UK). There were two sample groups; sample group A were 80 first year students
and sample group B were 94 third year students. Students completed a question-
naire incorporating the caring behaviors inventory (CBI) [Wolf, Z.R., Colahan, M.,
Costello, A., Warwick, F., Ambrose, M.S., Giardino, E.R., 1994. Dimensions of nurse
caring. Journal of Nursing Scholarship 26 (2), 107–111].
The key finding was a statistically significant difference in the means in caring
behaviours between first years and third years with third years scoring lower than
first years. This was exaggerated for those under 26 and increased further for those
under 26 with no previous experience of caring. Caring is a core nursing value and a
desirable attribute in nursing students, but the educational process seemed to
reduce their caring behaviours.
c 2008 Elsevier Ltd. All rights reserved.

Introduction
This paper draws on the findings of a study explor-
* Corresponding author. Tel.: +44 01792 518572. ing whether nursing students’ perceptions of caring
E-mail address: f.murphy@swan.ac.uk (F. Murphy). behaviours as part of nursing practice are subject


0260-6917/$ - see front matter c 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2008.08.016
 Author's personal copy
The impact of nurse education on the caring behaviours of nursing students
to change over a three-year, pre-registration,
undergraduate nursing course.
Caring is an important part of nursing
(Leininger, 1988; Watson, 1988; Swanson, 1999)
and although difficult to define (Brilowski and
Wendler, 2005), Woodward (1997) suggests it
might consist of two key components, instrumen-
tal and expressive. The instrumental component
relates to the physical and technical aspects of
care, whilst the expressive component relates to
meeting patient’s psycho-social and emotional
needs. Studies of nurses’ perspectives on caring,
suggest that they see the latter as important in
relating to patients on a human level and treating
them as individuals (Savage, 1995; Wilkin and Sle-
vin, 2004). However, there is a suggestion that in
contemporary healthcare this may be an unrealis-
tic aspiration (Dingwall and Allen, 2001). Nurses
may be unable to provide expressive forms of car-
ing and the process of nurse education is itself
complicit in not nurturing and developing expres-
sive modes of caring in students.
Background
To identify relevant literature, the following data-
base were accessed: Synergy, SwetsWise, CINAHL,
Medline, British Nursing Index, Web of Science,
RCN journals and Science Direct. The parameters
of the review were any English language publica-
tions between 1990 and 2007 although key relevant
literature before 1990 was also included. Search
terms included ‘caring’, ‘nursing’, ‘nurse educa-
tion’ and ‘nursing students’.
Caring and nurse education
An emphasis on care and caring in nursing was part
of an important theoretical movement in western
nursing in the 1980s. It was argued that care is at
the heart of nursing practice and synonymous with
it (Leininger, 1988; Watson, 1988). This perspec-
tive emphasised expressive care as a means of
establishing a bond between patient and nurse
(Pearson, 1988; Savage, 1995). There have been
attempts to analyse the concept of care (see
Brilowski and Wendler (2005)) and develop tools
to measure caring behaviours in nurses (Beck,
1999; Watson et al., 1999a; Watson, 2002). How-
ever, there is consensus that although caring is a
difficult concept to define (McCance et al., 1997;
Beck, 1999; Paley, 2001), it is a fundamental part
of nursing practice (Barker and Buchanan-Barker,
2004). Indeed, the UK Nursing and Midwifery
255
Council recently reiterated the importance of care
and compassion as part of their essential skills clus-
ters (NMC, 2006).
As nursing students are potential nurses of the
future, there is an expectation that in addition
to appropriate academic qualifications they will
have appropriate caring behaviours. Ideally stu-
dents should begin with a compassionate outlook
and an inclination to care, with the process of
nurse education nurturing and developing this so
students learn to behave in a caring, yet profes-
sional manner (Wilkes and Wallis, 1998; Karaöz,
2005). Building on Davis’s (1975) classic study of
the socialisation of nursing students, Day et al.
(2005) in the USA identified a movement from a
lay image of nursing to a more professional view,
shaped by exposure to the realities of practice.
However, in the UK, there has been some evidence
that while the educational process for nursing stu-
dents does modify their caring behaviours, the
direction of the change is not always positive
(Melia, 1987; Smith, 1992; Watson et al.,
1999a,b; Randle, 2003). In a case study approach
of the socialisation of nursing students in a UK hos-
pital, Smith (1992, p. 112) identified a ‘caring tra-
jectory’ in which students began the course
idealistically, eager to care for patients only to ar-
rive at the third year disillusioned, cynical and
preoccupied with getting through the work. Wat-
son et al. (1999a,b) using the caring dimensions
inventory (CDI) (Watson and Lea, 1997) with nurs-
ing students, also identified a loss of idealism at 12
months into the course.
As a possible consequence of this, there are re-
ports of nurses in some situations being uncaring
(Wiman and Wikblad, 2004; Duffin, 2005; Salvage,
2006; Rush and Cook, 2006; Tingle, 2007), and feel-
ing that they are unable to care (BJN, 2004).
Chambers (2007) further argues that the political
and economic situation in the UK National Health
Service (NHS), may adversely affect the ability of
nursing students to care. Given this, it seems
timely to investigate whether students’ views on
caring really do change over the period of their
course, and if so, from what base-line and by how
much.
Methods
Aim
To ascertain whether nursing students’ perceptions
of caring behaviours as part of nursing practice
change over a three-year, pre-registration, under-
graduate nursing course.
 Author's personal copy
256
Design
A quantitative, single cross section survey of
two nursing student cohorts from one HEI in Wales,
UK.
Sample
A population sample of two groups of nursing stu-
dents. Sample group A was 196 year one students
(135 adult, 42 mental health and 19 child branch)
entering a three-year undergraduate nursing
course of which 80 responded (41%). Sample group
B was all third year students (161) towards the end
of the course (91 adult, 35 mental health, 35 child
branch) of which 94 responded (56%).
Data collection
The difficulties of defining and hence operational-
ising the concepts of care and caring have been
well documented (McCance et al., 1997; Coates,
2002). After a careful review of the available
tools to measure caring (Watson et al., 1999a,b;
Watson, 2002), it was decided to use the caring
behaviors inventory (CBI) (Wolf et al., 1994). This
has a strong theoretical grounding in the work of
Watson (1988) with an emphasis on expressive
caring which ‘encompasses a humanitarian human
science orientation’ with an ethical–moral stance
(Watson and Smith, 2002, p. 456). This 42 item
tool (Box 1) aims to measure caring behaviours
through a series of four point Likert scales where
caring is defined as an ‘interactive and inter-sub-
jective process that occurs during moments of
shared vulnerability between nurse and patient,
and that is both both-and other directed’ (Wolf
et al., 1994).
First year students completed a web delivered
questionnaire at the beginning of the course which
included demographic details (age, gender, branch
programme and previous informal and formal care
experience) and the CBI (Box 1) (Wolf et al.,
1994). Third year students completed the question-
naire midway through year three.
Validity and reliability
The CBI is an established instrument with Beck
(1999) citing an alpha coefficient of 0.83 and a
test-retest internal consistence reliability of
r = 0.96 from a sample of 278 participants. It has
been rated highly in terms of theoretical ground-
ing, content validity and internal consistency
(Coates, 2002).
F. Murphy et al.
Pilot study
The questionnaire was piloted with a group of 29
students with all being able to complete the ques-
tionnaire without difficulty.
Ethical considerations
The study was presented to the HEI’s ethics com-
mittee where permission was given to proceed.
Verbal explanation and written information was gi-
ven to both student groups. It was recognised that
students may have felt under pressure to comply
because the request came from their teaching staff
thus they had the option to withdraw at any point
in the process.
To preserve anonymity the students were ran-
domly assigned a number on the database but this
was not linked to their name or student record
number. The data was stored on a secure database,
which only the research team had access to.
Data analysis
Initial analysis was accomplished by porting the
data from the database into Microsoft Excel. A
gross comparison of means between the two initial
sets of data and a comparison of means for each
question along with a correlation between ques-
tions in the two sets of data was made. Subsequent
analysis was performed using the statistical pack-
age for social sciences (SPSS) V. 13.0.
Results
The key finding was that although both groups
achieved high scores, there was a statistically sig-
nificant difference in the mean scores between
first and third years with third years scoring lower.
This was most marked in younger students.
Initial comparison showed an overall reduction
of the mean from 3.57 to 3.46 between intake A
(year one) and intake B (year three). Also of inter-
est is the reduced standard deviation (0.398–
0.297) between the two intakes indicating possibly
less diversity in the year three responses suggesting
a tendency for opinions in that intake to converge.
The overall mean response by item for each intake,
illustrating the differences between the two groups
and the direction of the scoring are illustrated in
Chart 1.
Whereas, the overall reduction in variance
(Table 1) is not significant (p = 0.116), the overall
reduction in the mean response at p = 0.038.
 Author's personal copy

The impact of nurse education on the caring behaviours of nursing students 257

Box 1 Caring behaviors inventory I (Wolf et al. (1994). Used with permission of the author)
Directions: Nurses do many things when they care for patients. Below is a list of responses that may
represent nurse caring. Please read each phrase and indicate if you agree or disagree that the
phrase indicates nurse caring.
Kindly use the scale provided to select your answer. Please circle the number you select after
reading each item.
1 = strongly disagree.
2 = disagree.
3 = agree.
4 = strongly agree.
1. Attentively listening to the patient.
2. Giving instructions or teaching the patient.
3. Treating the patient as an individual.
4. Spending time with the patient.
5. Touching the patient to communicate caring.
6. Being hopeful for the patient.
7. Giving the patient information so that he or she can make a decision.
8. Showing respect for the patient.
9. Supporting the patient.
10. Calling the patient by his/her preferred name.
11. Being honest with the patient.
12. Trusting the patient.
13. Being empathetic or identifying with the patient.
14. Helping the patient grow.
15. Making the patient physically or emotionally comfortable.
16. Being sensitive to the patient.
17. Being patient or tireless with the patient.
18. Helping the patient.
19. Knowing how to give shots, IVs, etc.
20. Being confident with the patient.
21. Using a soft, gentle voice with the patient.
22. Demonstrating professional knowledge and skill.
23. Watching over the patient.
24. Managing equipment skilfully.
25. Being cheerful with the patient.
26. Allowing the patient to express feelings about his or her disease and treatment.
27. Including the patient in planning his or her care.
28. Treating patient information confidentially.
29. Providing a reassuring presence.
30. Returning to the patient voluntarily.
31. Talking with the patient.
32. Encouraging the patient to call if there are problems.
33. Meeting the patient’s stated and unstated needs.
34. Responding quickly to the patient’s call.
35. Appreciating the patient as a human being.
36. Helping to reduce the patient’s pain.
37. Showing concern for the patient.
38. Giving the patient’s and medications on time.
39. Paying special attention to the patient during first times, as hospitalization and treatments.
40. Relieving the patient’s symptoms.
41. Putting the patient first.
42. Giving good physical care.
 Author's personal copy

258 F. Murphy et al.

Chart 1 All students.

Table 1 Independent samples test

Levene’s t-Test for equality of means
test for
equality of
variances
F Sig. t df Sig. (2-tailed) Mean Std. error 95% confidence
difference difference interval of the
difference
Lower Upper
Mean Equal 2.490 .116 2.094 172 .038 .11058 .05280 .00636 .21480
variances
assumed
Equal 2.047 144.163 .043 .11058 .05403 .00379 .21738
variances
not assumed

Although there is an apparent reduction in mean
response between intakes A and B for the first two
age groups (ages 17–25 and 26–35), there was a
slight increase in the 36–45 group. There is also
significantly less variation in the 17–25 age group
in intake A than in the others (combined). Using
‘‘equal variances not assumed’’, the difference in
mean response between 17–25 and others is not
significant (p = 0.157).
Investigating the possibility that the younger
students may have been out of step using one-
way ANOVA and Scheffe multiple comparisons
(omitting 46–55 group), no significant difference
was found between the mean returned by the
17–25 age groups and the other two groups. How-
ever, when the means for 17–25 age group be-
tween intake A and intake B were compared
(Table 2) a highly significant (p = 0.001) reduction
in mean response emerged.
The divergence between the mean score in this
subset is illustrated in Chart 2.
Membership of the different branches did not
seem to be a significant factor. Although, for exam-
ple the number of mental health students were
proportionally small, their mean of 3.63 in intake
A and 3.45 in intake B was close to the overall mean
of 3.63 and 3.43, respectively. The consistent
reduction in the mean response from intake A to
 Author's personal copy

The impact of nurse education on the caring behaviours of nursing students 259

Table 2 Comparison of 17–25 age groups between intakes A and B

Year N Mean Std. deviation Std. error mean
Group statistics
Mean 1 47 3.6337 .25058 .03655
3 42 3.4376 .29682 .04580

Levene’s t-Test for equality of means

test for
equality of
variances
F Sig. t df Sig. Mean Std. error 95% confidence
(2-tailed) difference difference interval of the
difference
Lower Upper
Independent samples test
Mean Equal variances .035 .852 3.379 87 .001 .19610 .05804 .08073 .31146
assumed
Equal variances 3.347 80.685 .001 .19610 .05860 .07950 .31269
not assumed

Chart 2 Students aged under 26 years.

intake B, for age 17–25, for all branches seemed
only affected by prior experience in caring.
The group mean response for students with lay
care (informal care) experience was slightly higher
at 3.71, than for other sorts of previous experi-
ence. There were no students with lay care experi-
ence in the year three sample (intake B), and in the
year one (intake A) sample, four of the seven peo-
ple with previous experience of lay care were in
the 17–25 age group. This had the effect of exag-
gerating the difference between the means for
the 17–25 age group and for older students, and
introduces a potential sampling bias (Tables 3 and
4).
However, when this group is excluded from the
comparison (Table 5 and Chart 3) the result is still
highly significant.
Overall the scoring is consistently high in both
intakes with almost 95% of returns as threes and
fours on the CBI scale.
 Author's personal copy

260 F. Murphy et al.

tween the intakes is also influenced by the fact

Table 3 (Intake A) Year 1: Students bv previous
that students with ‘‘lay care’’ experience, who as
experience
a group return a high mean response are only to
Experience Mean N Std. deviation be found in intake A (Tables 3 and 4) and are not
Null 3.4143 5 .46187 represented in intake B. This bias in the sampling
None 3.6023 37 .33830 contributes a sufficient amount to create the over-
Lay care 3.7143 7 .22629 all ‘whole group’ significant reduction, as without
Health care assistant 3.5346 31 .47927 it the overall reduction is not significant. However,
Total 3.5741 80 .39801 when other age groups are removed from the sam-
ple, and the change in the 17–25 age group mean
response analysed alone, this reduction remains
significant with or without the inclusion of the lay
care component.
Table 4 (Intake B) Year 3: Students by previous
experience
Experience Mean N Std. deviation
Discussion
Null 3.5444 15 .28385
None 3.5124 23 .23150 Study limitations
Health care assistant 3.4218 56 .32059
Total 3.4635 94 .29713
In addition to the identified potential sampling
bias, the findings are from within a particular sys-
tem of healthcare and nurse education and thus
Conclusion may not readily generalise. Additionally this was
a comparison of matched groups rather than a lon-
There was a consistent difference in mean scores gitudinal study. Watson et al. (1999b), however,
between students in year one (intake A) and year point to an important difficulty in longitudinal
three (intake B), with participants in intake B con- studies that of attrition. For that reason it was
sistently scoring lower than those in intake A. This decided to compare a first year group with a
is partly due to a high mean response from the 17– matched third year group who were not from the
25 to 26–35 age group in year one, where both same cohort.
groups score above the average for the year. In The response rate at 41% for year one and 56%
year three these groups score below average for for year three could have been improved and as
the year, with the scores for both falling by a sim- with other surveys, the responses may have been
ilar margin. The difference in the mean scores be- based on what individuals say they would do rather

Table 5 Comparison of age 17–25 for intakes A and B excluding ‘‘Lay Care’’ experience
Year N Mean Std. deviation Std. error mean
Group statistics
Mean 1 43 3.6351 .25239 .03849
3 42 3.4376 .29682 .04580

Levene’s t-test for equality of means

test for
equality of
variances
F Sig. t df Sig. Mean Std. Error 95% confidence
(2-tailed) difference difference interval of the
difference
lower upper
Independent samples test
Mean Equal variances .015 .904 3.307 83 .001 .19746 .05971 .07870 .31623
assumed
Equal variances 3.301 80.275 .001 .19746 .05983 .07841 .31651
not assumed
 Author's personal copy
The impact of nurse education on the caring behaviours of nursing students
Chart 3 Students aged under 26 years excluding those with lay care experience.
than what they actually do (Paley, 2005) and is vul-
nerable to response set and social desirability bias
(Coates, 2002).
The tempering of idealism
The CBI (Wolf et al., 1994) incorporates an assump-
tion that the behaviours making up the inventory
epitomise the more expressive aspects of caring.
There are no negatives in the scale; all the items
articulate some desirable attribute of caring in
nursing with which the subject is invited to express
a level of agreement between strongly agreeing
and strongly disagreeing. However, the structure
of the tool and the uniform direction of scoring
tend to mitigate in favour of high scoring returns.
For example, it is difficult to imagine any nursing
student disagreeing, let alone strongly disagreeing,
with statements such as; ‘‘spending time with the
patient’’ and ‘‘touching the patient to communi-
cate caring’’ (CBI items four and five). In this con-
text it is not surprising that scoring is so high
overall. It was clear that first year students in par-
ticular those who were younger and had no previ-
ous experience of formal caring, typically
expressed strong agreement with these behaviours.
In the third year the position had modified, with
some aspects of expressive caring such as closely
watching the patient, remaining cheerful and using
a soft voice scoring less highly, but the scoring
overall remains very high. Thus, there is a little
in these findings to support the existence of the
261
caring trajectory that Smith (1992) identified. The
change in this study is a movement from lay ideas
of caring to a more tempered idealism as part of
a model of professional caring (Wilkes and Wallis,
1998; Watson et al., 1999a,b; Kapborg and Berterö,
2003). Nevertheless, within this very positive re-
sponse set there is the slight, but statistically sig-
nificant fall in third year scores among younger
students that needs to be explained.
There are several possible explanations, an obvi-
ous one being that these students are in general
caring individuals whose outlook changes a little
after exposure to the realities of professional nurs-
ing. A further possibility relates to the items on the
tool. Potentially the behaviours listed and values
inherent in the CBI may no longer be regarded as
relevant to contemporary nursing practice. This
irrelevance becomes more apparent with longer
periods of clinical exposure hence the fall in the
third year scores. Dingwall and Allen (2001) argue
that emotion work and expressive care as espoused
by writers such as Watson (1988) are not tenable in
the current climate were never that highly valued
and indeed were not a central part of the nurse’s
role. Tracing a historical perspective, they exam-
ine nursing’s myths, of which caring, as being cen-
tral to nursing practice is one. This is compounded
by nurse educators who emphasise the psycho-so-
cial aspects of nursing (Patistea, 1999; Swanson,
1999) with the result ‘that nurses are trained to
do a job that did not exist in the past, does not ex-
ist in the present and may never exist in the future’
 Author's personal copy
262
(Dingwall and Allen, 2001, p. 72). It could be ar-
gued that these values operate as an espoused the-
ory (Argyris and Schön, 1974), which is perpetuated
through nurse education and may not be applicable
to the realities of practice (Pearcey, 2007) and the
theory in use in practice (Argyris and Schön, 1974).
Thus students may recognise these as desirable but
not always achievable.
Another explanation is recognising the effects of
occupational socialisation on students (Davis, 1975;
Melia, 1987; Smith, 1992). Entry into and accep-
tance by an occupational group such as nursing will
depend on learning the common values and adopt-
ing appropriate behaviours to function within the
group. This is achieved partly through occupational
socialisation a process, which is complex, proactive
and dynamic and influenced to some extent by the
student’s past experience (Howkins and Ewens,
1999). Younger students appeared to have come
to the course having internalised beliefs and values
from the wider culture about what caring in nursing
entails, and the strong agreement expressed may
reflect lay beliefs about how nurses should behave
and act (Holland, 1999; Karaöz, 2005; Mackintosh,
2006; Takase et al., 2006) and the expectations of
patients (Wolf et al., 1998; Attree, 2001; Rush and
Cook, 2006). However, on this particular course,
50% of the student’s time was spent in practice
where the student gets exposed to the world of
practical care delivery. This is shaped by political
and economic factors where demand will always
outstrip the resources available and where expres-
sive caring might give way to instrumental consider-
ations (Holmström and Larsson, 2005). Typically the
focus is on tangible outputs as exemplified by rapid
and efficient throughput of patients and not on less
tangible attributes such as spending time talking to
patients. Resource issues such as an inappropriate
skill mix may compound this. Practitioners in such
a system may focus then on getting through the
work in which work consists of the more instrumen-
tal and physical aspects of caring rather than the
expressive aspects (James, 1992; Pearcey, 2007).
Thus professional and managerial values operate
and dominate in some practice settings (Wright,
2004). These values are incompatible with lay be-
liefs about caring and students who hold such be-
liefs will be forced to modify them or leave.
Arguably the younger first year students with no
experience of formal care are most vulnerable to
this exposure to practice. Their idealistic views
are tempered resulting in a model of nurse caring,
where students still ‘care’ but some of the behav-
iours most associated with expressive caring are less
apparent (Wilkes and Wallis, 1998; Day et al.,
2005).
F. Murphy et al.
Implications for nurse education
These findings identify some positive implications
for nurse education in that the change found in stu-
dents’ caring behaviours is small, and moves from a
high base-line of expressive caring to an only
slightly lower one. However, the direction of
change is downward and these findings are consis-
tent with other similar studies. This means that in
terms of expressive caring value is lost rather than
added over the period of nurse education. If the
caring behaviours underpinned by these values
are seen as desirable in nursing students and
nurses, then this process should be halted. A chal-
lenge for nurse education is to effectively prepare
and support students to cope with possible disso-
nance between these different sets of values.
Where pressures threaten to squeeze out expres-
sive care, either because of resource constraints
in clinical settings or because the structure of cur-
ricula and forms of assessment favour the technical
and instrumental, nurse education should
unashamedly confront this, nourish, support and
further inculcate expressive values and equip stu-
dents to demonstrate them through their behaviour
in practice (Vanhanen and Janhoven, 2000). This
would involve recognition that the education of
students takes place in both educational and prac-
tice settings and is the responsibility of both
(Chambers, 2007). Clearly, younger students with
no previous formal caring experience showed the
steepest decline. This has implications both in
the selection of candidates and the pastoral, clini-
cal and academic support during the course. As
Smith (1992) and Smith and Gray (2001) identified,
it is important to support students in practice to
create a space where they can provide care. This
will necessarily involve supporting mentors in prac-
tice who can in turn provide support for the stu-
dents. Further research could include second year
students to identify at which point in the course
this effect may begin and following up students
after they have qualified would also be of interest.
Conclusion
Caring is a core value in nursing practice and thus
the capacity to care is a desired attribute in nursing
students. New students, particularly those in the
younger age groups, seem to have this attribute
in abundance. However exposure to the process
of nurse education seems to reduce the capacity
for expressive care. This has been partly explained
by considering occupational socialisation and
suggests a reassessment of whether these caring
 Author's personal copy
The impact of nurse education on the caring behaviours of nursing students
values as epitomised through caring behaviours are
still of relevance. If they are, the process of nurse
education should promote and support the student
to at least preserve the positive perspectives they
arrive with.
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