Article

Nursing Ethics
17(4) 491–500
First- and third-year student ª The Author(s) 2010
Reprints and permission:
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nurses’ perceptions of caring 10.1177/0969733010364903
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behaviours

Suzana Mlinar
University of Ljubljana, Slovenia

The aim of this study was to investigate significant differences in the mean scores for the Caring Behaviors
Inventory between first-year and third-year nursing students. There were two sample groups: group A
comprised 117 first-year nursing students and group B included 49 third-year nursing students (n ¼
166). All participants were from one Slovenian university. Data were collected by questionnaire and ana-
lysed using SPSS v. 17.0. Independent sample t-tests were used for the comparison of means for each item
in both groups. The results showed that the students in group B (third year) often agreed more significantly
with Caring Behaviors Inventory items than the students in group A (first year). Principles of right action
indicate how nurses must behave in order to provide good nursing care. Nursing educators can prepare
students through demonstrations of their own behaviour in practice.

Keywords
caring behaviours, clinical work experience, nursing, nursing students

Introduction
Only individuals who have the knowledge, skills and commitment to practise nursing in a clinically, cultu-
rally and ethically competent manner should be admitted into the profession.1 Nurse educators have a pri-
mary responsibility to ensure the quality of nursing education and to share their own knowledge and
experience with nursing students. Caring is a core value in nursing practice and thus the capacity to care
is a desired attribute in nursing students. Clinical nurses should nourish, support and inculcate expressive
values and prepare students through demonstration of their own behaviour in practice. Nursing students need
to develop occupational socialization in clinical settings.2 However, they also need knowledge and beliefs
about how nurses should behave and act. Every nurse makes countless decisions about patient care, including
which care to give, when to give it, where it should be given, how it should be given and by whom. Each
decision requires nurses to consider information about patients in the context of values (personal, patient,
individual, communal, cultural and professional) to determine how best to care for patients or assist them
in self-care.1 Nurses who work with nursing students become more professional in their own work when they
take nursing and nursing education seriously.3 They therefore need to create working conditions in the pro-
fession and in their practice of nursing by their good example and ability to fulfil their duties effectively. In
Memarian et al.’s study,3 nurses reported that effective care requires the skilful application of knowledge and
that ethical conduct is important.3 Nurse educators need to share previous useful work experience to build

Corresponding author: Suzana Mlinar, Faculty of Health Sciences, University of Ljubljana, Poljanska Street 26a, 1000 Ljubljana,
Slovenia
Email: suzana.mlinar@zf.uni-lj.si
492 Nursing Ethics 17(4)

effective relationships and professional commitment in their students. Nursing students require a high level
of theoretical knowledge about nursing as well as clinical practice and constructive work experience, which
give them the ability to apply their knowledge in practice and ascertain patients’ needs.
Nursing also entails an important social and psychological aspect of emotional labour. This is a key com-
ponent of interpersonal nurse–patient relationships and integral to support structures in health services in
general and student nurse education in particular.4 Smith and Gray4 identified emotional labour as a social
factor insofar as it relates to ‘making patients feel at home’. It involves talking about how staff and patients
feel. Emotional labour also touches upon psychological aspects of care such as ‘friendship’, ‘being more inti-
mate and building up trust with the patient’ and ‘showing the patient a little bit of love’. This could involve
‘just making a gesture to the patient and holding their hand to make them feel better’. Thus, emotional labour
was reported as facilitating nurse–patient contact and ‘moving things along’ in terms of organizing the ward
and the nature of care. In the study by Smith and Gray, the nurses described their emotional work with
patients as a ‘gift’, which they regarded as an integral part of nursing work.4 It may not be possible for nurses
to develop personal relationships with all patients. Watson et al.5 suggest that nurses working in different
clinical areas perceive caring differently. For example, surgical nurses perceive caring in more technical and
professional terms than nurses working in medical wards.5 Thus, nursing students need experience in differ-
ent wards so that they become familiar with the range of hospital climates. Nurse educators can help nursing
students to understand that the perception of caring differs from the perception of nursing, in addition to
teaching them which behaviours make patients feel cared for. Caring behaviour should include social, com-
municative, organizational and medical–technical competence, and also how to manage contact with rela-
tives. For this reason, nursing students need to be guided by clear rules and principles of conduct. They
need to develop fully their academic knowledge and also appropriate caring behaviours. However, although
their nursing education will affect their caring behaviours, the direction of the change is not always positive.6
Smith and Gray’s study4 revealed that students who began the nursing course idealistically and eager to care
for patients were disillusioned, cynical and preoccupied with getting through the work by the time they were
in the third year of their studies. As a possible consequence of this, there are reports of nurses who stop caring
in some situations.7
Although many studies have linked nurse–patient interactions with the relational dimension pertaining to
the concept of caring,8 nurses tend towards psychosocial aspects of caring and the relational dimension.9 The
aim of this study was to investigate significant differences in the mean scores for the Caring Behaviors Inven-
tory (42 items) between first-year and third-year nursing students in order to determine whether nursing stu-
dents’ perceptions of caring behaviours in their nursing practice are likely to change between the first and
third years of their studies.

Methods
Participants
The study sample was derived from nursing students who were undertaking a three-year undergraduate study
programme for a professional degree in nursing in Slovenia. The participants were 166 nursing students from
one Slovenian university. The sample included two groups: group A comprised 117 first-year students; group
B included 49 third-year students, who had more theoretical knowledge as well as more practical experience
than group A. The students were given a full explanation of the purpose of the study by the investigator. Ver-
bal informed consent to collect the data was obtained from the student nurses. They were also informed that
their participation was voluntary and the data would be kept confidential.
All the students gained their practical experience at the University Medical Centre in Ljubljana, which is a
public health care institution providing medical services at secondary and tertiary levels. It is the leading
Mlinar 493

medical institution in Slovenia and aims to provide quality care to patients from Slovenia and other European
countries. The Centre’s organization and activities are geared towards the continuous improvement of ser-
vices, the development and introduction of new methods of treatment, and the transfer of knowledge to
younger generations of health professionals. The University Medical Centre emphasizes knowledge and
skills in professional nursing (technical skills, interpersonal communication etc.), and promotes ethical com-
petence. Nurse educators teach students to develop professional competence, and instruct them concerning
the professional code of ethics and decision making in nursing practice. Clinical nurses lead students in their
clinical practice, and in their implementation of standards of professional competence and professional codes
of nursing ethics. However, clinical nurses can be technically competent but morally or ethically incompe-
tent. Ethical competence is a fundamental part of and is inextricably linked with general professional com-
petence. When nursing students are caring for patients, they carry out all types of health care work,
developing and using moral dimensions and professional values as well as learning to respect the Health Ser-
vices Law and other executive regulations (Registration, and Licensing of Nurses Regulations) in their clin-
ical practice. The students draw up a report of their clinical practice for the nurse educator. Thus, nurse
educators play a major role in enhancing professionals’ ability to understand what a particular situation
involves, as well as in promoting positive views in the clinical learning environment by improving clinical
practice such as by building rapport between students and clinical nurses, fostering mutual respect, and hon-
ouring unit procedures.

Instrument
The Caring Behaviors Inventory, developed in 1994 by Wolf et al.,10 was used in this study. This is the most
frequently used empirical tool for measuring caring in nursing research and, for this reason, its reliability and
validity is the best established. The content of such tools tend to vary with the frameworks underpinning their
construction. The conceptual-theoretical basis of the Inventory was derived from caring literature in general,
and Watson’s Transpersonal Caring Theory in particular.11 Caring is directed towards the welfare of patients
and takes place when nurses respond to patients in a caring manner. This instrument defines five dimensions
of caring: respectful deference to others; assurance of human presence; positive connectedness; professional
knowledge and skills; and attentiveness to the experiences of others (i.e. this description of caring includes
skills and personal relationships).10,11
The Caring Behaviors Inventory has 42 items (Appendix 1) measured by a 4-point Likert scale (1 ¼
strongly disagree, 2 ¼ disagree, 3 ¼ agree, 4 ¼ strongly agree). Caring is defined as an ‘interactive and inter-
subjective process that occurs during moments of shared vulnerability between nurse and patient, and that is
both and other directed’.10,11 Participants indicate if they agree or disagree with each phrase is a sign of nurse
caring. Standardization of the Inventory was carried out on 278 participants. It is an established instrument,
with Beck12 citing an alpha coefficient of 0.83, and a test-retest internal consistency reliability of r ¼ 0.96
reported by Murphy et al.2

Data collection
Permission to perform this research was obtained from Nursing Department management.
In November 2008, of all third-year nursing students (n ¼ 64) invited to participate in this study, 15 did
not return the questionnaire (response rate 76.6%). The remaining 49 third-year students completed the ques-
tionnaire anonymously during week 9 of the first semester in 2008. Before they did so, they had to undergo
clinical practice for six hours a day, five days a week for eight weeks. In April 2009, all 117 first-year nursing
students were also invited and agreed to participate in the study. These students completed the questionnaire
anonymously during week 9 of the second semester in 2009. They had already received theoretical tuition
494 Nursing Ethics 17(4)

about caring as well as about ethical awareness and sensitivity and were in the initial phase of gaining
practical experience in basic nursing. The length of their initial clinical practice was six hours a day, five
days a week for four weeks. Thus, the questionnaire, which had been translated into Slovene by a translation
service, was completed by a total of 166 nursing students who all agreed to take part. This took place in the
classroom and completed questionnaires were placed in a box in the presence of an investigator.
The students were given a full explanation of the purpose of the study by the investigator. Verbal informed
consent to collect the data was obtained from the student nurses. They were also informed that their partic-
ipation was voluntary and the data would be kept confidential.

Data analysis
The data were analysed using SPSS v. 17.0 using descriptive statistics. Independent sample t-tests were used
as a comparison of means for each Caring Behaviors Inventory item for both groups A and B. P < 0.05 was
considered to be statistically significant.

Results
Of the 166 participants who completed the questionnaire, 89.8% (n ¼ 149) were women, and 10.2% (n ¼ 17)
were men; their age ranged from 18 to 42 years (mean 21.0, SD + 3.98). The sample group A (first-year
students) included 117 participants aged 18 to 37 years (mean 20.04, SD + 2.35); 89.7% (n ¼ 105) were
women, 10.3% (n ¼ 12) were men. Group B (third-year students) included 49 participants aged 20 to 42 years
(mean 23.30, SD + 5.79); 89.8% (n ¼ 44) were women, 10.2% (n ¼ 5) were men. There were significant
differences in the mean scores according to participants’ age (t ¼ –3.829, P ¼ 0.000); the 95% confidence
interval was –4.984 to –1.559.
The study (Table 1) showed that students of both groups strongly agreed with items such as 18, 19, 35 and
38. The students of group A also strongly agreed with items such as 1 and 8, and those in group B also
strongly agreed, for example, with item 2. For all these items the mean scores were equal to or higher than
3.88. The students in group A disagreed less with items such as 16 (mean 2.91). Both groups disagreed less
with items such as 9 (group A: mean 2.39; group B: mean 2.73) and 12 (group A: mean 2.50; group B: mean
2.88). Students in group A had a mean score range of 2.39–3.91; those in group B had a mean score range of
2.73–3.94.
Independent t-tests showed statistically significant differences between groups A and B for the Caring
Behaviors Inventory items (Table 2). For example, group B students agreed more than group A students with
items such as 2, 9, 11, 12, 16, 17, 21, 22, 24, 29, 33, 39 and 40.

Discussion
This study shows that many of the nursing students in both groups strongly agreed with Caring Behaviors
Inventory items that describe the caring behaviours of nurses, but caring behaviours were more important
to the students in group B. Important caring behaviours included being respectful to patients and helping
them as well as being appreciative of them and teaching them. For the nursing students, relationships with
patients, as well as having nursing skills and knowledge, were deemed important. Nurses need to be sensitive
and convey their sensitivity to patients and support them. Murphy et al.2 found that third-year nursing stu-
dents achieved lower scores than first-year students. This result was exaggerated for those aged under
26 years and increased even more for those under 26 with no previous experience in caring. In the present
study, third-year students aged 21 scored higher that first-year students. Education may develop general and
ethical competence, but ethical competence should be understood not just as a minimal set of standards but as
Mlinar 495

Table 1. Overall mean scores for Caring Behaviors Inventory items for groups A and B

Group A Group B

Item Min. Max. Mean Min. Max. Mean

1 1 4 3.91 1 4 3.82
2 3 4 3.68 3 4 3.88
3 3 4 3.72 1 4 3.71
4 3 4 3.65 2 4 3.69
5 2 4 3.23 2 4 3.33
6 1 4 3.13 1 4 3.37
7 1 4 3.44 2 4 3.61
8 1 4 3.91 2 4 3.82
9 1 4 2.39 1 4 2.73
10 1 4 3.02 2 4 3.41
11 1 4 3.51 3 4 3.78
12 1 4 2.50 2 4 2.88
13 2 4 3.28 1 4 3.37
14 1 4 3.32 2 4 3.43
15 2 4 3.68 3 4 3.80
16 1 4 2.91 2 4 3.37
17 2 4 3.22 3 4 3.57
18 3 4 3.88 3 4 3.88
19 1 4 3.90 3 4 3.94
20 1 4 3.19 1 4 3.37
21 1 4 3.28 2 4 3.59
22 2 4 3.41 2 4 3.73
23 2 4 3.62 2 4 3.73
24 2 4 3.69 3 4 3.84
25 1 4 3.24 2 4 3.35
26 2 4 3.66 3 4 3.76
27 1 4 3.58 2 4 3.63
28 3 4 3.85 3 4 3.86
29 1 4 3.38 3 4 3.67
30 2 4 3.38 2 4 3.49
31 3 4 3.76 2 4 3.71
32 1 4 3.38 2 4 3.55
33 2 4 3.40 2 4 3.63
34 1 4 3.61 2 4 3.63
35 3 4 3.91 3 4 3.92
36 3 4 3.79 3 4 3.86
37 2 4 3.62 3 4 3.67
38 3 4 3.90 3 4 3.94
39 2 4 3.24 2 4 3.59
40 3 4 3.61 3 4 3.78
41 2 4 3.54 1 4 3.61
42 2 4 3.56 3 4 3.71
496 Nursing Ethics 17(4)

Table 2. Comparison of statistically significant Caring Behaviors Inventory items between group A (first-year students)
and group B (third-year students)

Group statistics t-test for equality of means

CBI item no. Group n Mean SD t-value P < 0.05 Mean difference 95% CI

2 A 117 3.68 0.47

B 49 3.88 0.33 –3.025 0.003 –0.194 –0.321 to –0.067
9 A 117 2.39 0.82
B 49 2.73 0.86 –2.365 0.020 –0.342 –0.629 to –0.054
11 A 117 3.51 0.61
B 49 3.78 0.42 –3.183 0.002 –0.263 –0.426 to –0.099
12 A 117 2.50 0.70
B 49 2.88 0.60 –3.472 0.001 –0.373 –0.586 to –0.160
16 A 117 2.91 0.75
B 49 3.37 0.67 –3.906 0.000 –0.461 –0.696 to –0.227
17 A 117 3.22 0.66
B 49 3.57 0.50 –3.722 0.000 –0.349 –0.535 to –0.163
21 A 117 3.28 0.69
B 49 3.59 0.54 –3.100 0.002 –0.310 –0.508 to –0.112
22 A 117 3.41 0.65
B 49 3.73 0.49 –3.525 0.001 –0.324 –0.507 to –0.142
24 A 117 3.69 0.50
B 49 3.84 0.37 –2.047 0.043 –0.144 –0.284 to –0.005
29 A 117 3.38 0.60
B 49 3.67 0.47 –3.403 0.001 –0.297 –0.471 to –0.124
33 A 117 3.40 0.53
B 49 3.63 0.53 –2.573 0.012 –0.231 –0.409 to –0.053
39 A 117 3.24 0.71
B 49 3.59 0.61 –3.224 0.002 –0.353 –0.569 to –0.136
40 A 117 3.61 0.49
B 49 3.78 0.42 –2.237 0.027 –0.169 –0.318 to –0.019
t-test: independent samples t-test
CBI: Caring Behaviors Inventory, SD: standard deviation, CI: confidence interval

a continuum that indicates a developing process. The responsibility of nursing is to see human beings as
unique vulnerable persons, not what they have been, but what they are and could become; it is to bracket
their prejudices and meet human beings as people with their own potential.13 Nursing is seen not only as
walking in front of but also walking with. It is to inspire, motivate and acknowledge the importance of every
encounter with patients.14 Good nursing is defined by values. It is therefore important for nurses to under-
stand the values with which they practice, so that good nursing practices can be achieved. Understanding the
moral values in today’s nursing practice will help nurses to work together with a common comprehension of
their aims. Understanding and concordance of moral values are therefore vital for the entire health care envi-
ronment.15 As such, moral values have a great influence on the way nurses think and act and therefore play a
major role in patient care.16
All the Caring Behaviors Inventory items articulate some desirable attribute of caring in nursing. The stu-
dents were invited to express their level of agreement or disagreement. However, it is difficult to imagine any
students disagreeing with these items. It is therefore not surprising that the scores are so high overall.10 The
findings showed that the nursing students disagreed with items such as ‘calling patients by their preferred
name’ and ‘trusting the patient’. The key findings were, however, statistically significant differences in the
Mlinar 497

means of Inventory items between the two groups, with third-year nursing students scoring above first-year
students. The third-year students had developed caring behaviours such as essential standards of practice and
following a code of ethics. For them it was understood that both professionals and patients are fallible and
vulnerable, and therefore honesty is important. In Murphy et al.’s study,2 it was shown that the first-year stu-
dents, who were younger and had no previous experience in formal caring, typically expressed strong agree-
ment with the Caring Behaviors Inventory items, but it was these students who were the most vulnerable in
their practice.17 Younger students have been reported to hold beliefs and values about what caring in nursing
entails, and their expressed strong agreement with these may reflect their beliefs about how nurses should
behave and act18 and the expectations of patients. Principles of right action indicate how nurses must behave
in order to provide good nursing care. In Murphy et al.’s study,2 the position changed for third-year students:
some aspects of expressive caring, such as closely watching the patient, remaining cheerful and using a soft
voice scored lower, although the scoring remained very high overall. Entry into and acceptance by an occu-
pational group such as nurses will depend on learning the operating common values and adopting appropriate
behaviours to function within the group2 if the caring behaviours underpinned by expressed caring values are
seen as desirable in nursing students and nurses.2 Values are determinants of social behaviour because they
ordain a person’s beliefs and actions. Thus, it is important to understand how personal values influence job
satisfaction and motivation. In addition, values also affect the way people act in their personal and profes-
sional lives.15
However, emotional work and expressive care as a means of establishing a bond between patients and
nurses relates to meeting patients’ psychosocial and emotional needs, which is a central part of nurses’
role.8 Clinical work experience is an important part of the educational process for nursing students while
they are modifying their caring behaviours. Investing in workplace health schemes provides organiza-
tions with motivated workforces, higher morale, increased overall efficiency and improved organiza-
tional performance, competitiveness and public image.19 In addition, the workplace is an important
setting because it caters for the physical, mental, social and economic well-being of its employees. How-
ever, healthy workplaces promote the concept of positive lifestyle behaviours, which facilitate organiza-
tional development.20 Nurse educators do need to emphasize the psychosocial aspects of nursing2 in order
that nursing students will then recognize the values of caring behaviours as desirable. Nurses have a pri-
mary responsibility to people who require nursing care21 and care is at the heart of nursing practice and
synonymous with it. This perspective highlights expressive care as a means of establishing a bond
between patients and nurses.2 The nurse–patient relationship is a ‘special’ relationship because it is cre-
ated by the patient’s need for nursing care. Nurses are obligated to show caring behaviours in the face of
the need for health care because doing so promotes patient well-being.22 The ethical concept of caring has
long been regarded as foundational to the nurse–patient relationship, just as caring behaviours are con-
sidered fundamental to the nursing role.1 Caring consists of two key components: instrumental and
expressive.2 The instrumental component relates to the physical and technical aspects of care, while
expressive caring relates to meeting patients’ psychosocial and emotional needs. Nurses’ perspectives
on caring suggest that they see the latter as important, relating to patients on a human level and treating
them as individuals.23 Nurse educators need to give prominence to expressive caring, which ‘encom-
passes a humanitarian human science orientation’ with an ethical-moral stance.8 They must demonstrate
this to nursing students through their own behaviour in practice. The education of nursing students takes
place and is the responsibility of teachers in both academic and practical settings.

Study limitations
It is acknowledged that this study took place within a specific health care and nurse education setting and so
may not be generalized. The major limitation was recruitment from only one university. The instrument used
498 Nursing Ethics 17(4)

had been developed in another country and was not designed for testing Slovene nursing students. This was
not a longitudinal study and the two groups were from different student cohorts. It would be more appropriate
to compare matched groups rather than carry out a longitudinal study.

Conclusion
Nurses’ ideal caring behaviours were described as creating a culture in which patients regain their health and
will to live, and where nursing staff have the prerequisites for excellent nursing care. The basic attitude in
caring behaviour has always been to help patients and alleviate their pain and distress in a sympathetic cul-
tural atmosphere. Nursing educators convey their own knowledge of nursing and can modify nursing care
according to their ideals. They have the power to influence nursing philosophy and care, and to remind nur-
sing students often that they are there for the patients and not vice versa. Nurses minister to patients and must
create a culture that strives to provide excellent nursing care. When nursing students work within profes-
sional standards and ethical competence, they can engage with practice in an ethically knowing and reflective
way and demonstrate that they understand the ethical implications of their everyday practice.

Acknowledgements
I am grateful to Zane Robinson Wolf, PhD, RN, FAAN, for permission to use the Caring Behaviors Inven-
tory. I would also like to thank the students who participated in this investigation.

Conflict of interest statement

The author declares that there is no conflict of interest.

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Appendix 1
Caring Behaviours Inventory – 42 items

This inventory was used with permission of Zane Robinson Wolfe PhD, RN, FAAN.
1. Listening attentively 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 or 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 to 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
(continued)
500 Nursing Ethics 17(4)

Appendix (continued)

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 medications on time
39. Paying special attention to the patient during first hospitalization and treatments
40. Relieving the patient’s symptoms
41. Putting the patient first
42. Giving good physical care
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