Development of the research tools

The research tools for the project were used to collect the following data: demographic data, and knowledge levels related to self-efficacy and caring-efficacy. The research tools which also formed a component of the evaluation of the PD were qualitative and quantitative. Data were gathered from:

 A survey immediately prior to the MC (T1) to determine base line levels of knowledge, self-efficacy and caring-efficacy and immediately post MC (T2) and then after all RPJ was complete (T3).

 An online RPJ was an optional extra.

4.4.1.3.1 Survey

As caring is a difficult and elusive concept (Beck, 1999) the survey comprised of a comprehensive group of questions: participant’s background, knowledge, and skills; self-efficacy and a Caring Efficacy Scale (CES). The CES is an existing instrument which has been incorporated into this survey (Reid et al., 2015). The participant survey was designed to facilitate the determination of the extent to which a professional development program can support caring nursing practice in Western Australian hospitals.

The Master Class was based on five inter-related assumptions which inform the development of the survey:

1. “Caring is multi-dimensional

2. The potential to care is present in all individuals 3. Caring can be learnt

4. Caring is quantifiable” (Nkongho, 1990, p. 6)

5. Caring can be taught (Martin, 2015; Watson's Caring Science Institute, 2019).

97 Education in the form of a PD program on Caring Nursing Practice has its limitations because of the inter-related nature of the dimensions of caring nursing practice. There are factors, such as socio-demographic factors and organisational factors, which are beyond the bailiwick of professional development. These need to be considered when evaluating the extent to which a professional development program can support caring nursing practice in WA.

The survey aims to understand the educational impact on precursors or antecedents to caring which may pre-exist in participants. These include:

1. Motivation.

2. Educational gains in knowledge and skills related to caring nursing practice. (Such gains will be determined by measuring the difference in pre and post session assessment.)

3. Self-efficacy: “What I can do in this circumstance?” 4. Perceptions about the link between time and learning. 5. Caring efficacy: perception about ‘who I am’.

Antecedents have been cross referenced to survey questions and Watsons’ ten Carative Factors in Table 4.

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Table 4.1 Antecedents to caring by survey question and carative factors Information

required Description

Watson’s Carative Factors Antecedent and pre-requisites for caring – Demographic

Personal Maturity and life experience as indicated by

Age Q2

Marital status Q6

Self-awareness as indicated by

Motivation to work Q15

Motivation to continue nursing Q16

Motivation to care Q17

Sense of emotional drain-rejuvenation Q14

1, 2, 3, 4, 5, 8, 10

Professional Professional maturity

Insight into caring Q16

Educational preparation Q10, 11, 12 Q18-21

Number of years in profession Q7

6, 7, 8, 9

Cultural Predisposition may be affected by:

Gender Q3

Cultural heritage Q4

Languages spoken Q5

Religious or spiritual beliefs Q8-9

Experience with ‘alternative’ therapies Q21

1, 2, 3, 4, 5, 8, 9, 10

Antecedent and pre-requisites for caring – Organisational Organisational Capacity to care may be affected by:

Type of organisation Q29

Sense of autonomy Q30

Length of stay in an organisation. Q31

Approach to nursing care Q32

Nursing category and field of practice Q33 Colleagues demonstration of caring Q34 Responsibility for caring

HR issues

Selection criteria Q35

Appraisal including caring Q36

Caring at induction Q37

PD opportunities on caring Q38-40

7,

Antecedents and pre-requisites for caring Caring Efficacy

Scale

A care givers belief about their ability to

‘express a caring orientation and develop caring

relationships with … patients’ Q53-80

Self-Efficacy Comparison of self-efficacy related to

How good they are at their work Q18-22 How caring are they in their work

99 Information required Description Watson’s Carative Factors Antecedent and pre-requisites for caring – Education: Knowledge and skills

Data used to determine difference before- after surveys = Learning objectives

Has there been a difference in participants: Definition of nursing

Definition of heal Definition of cure

Difference between heal and cure Definition of caring

Ability to list 4 reasons caring is important

Understanding the link between caring and patient outcomes Understanding of knowledge, attitude/ behaviour required for caring nursing

Understanding the link between caring and organisational culture Understanding society plays a role

Understanding of change theory Ability to develop a change plan

Understanding of the nursing process Understanding of the role of the mind Understand and engage in praxis

1-10

The survey instrument was developed using acknowledged survey development practice (Seaman, 1982) and validity was guided by the literature review and interviews of expert nurses. Expert nurses were considered to be those with more then 10 years of experience, and who held a postgraduate qualifications relevant to the research, and were either at a senior or executive clinical or academic level. Surveys were used to gather qualitative and quantitative information from MC participants involved in the research to support understandings about caring nursing practice.

The survey examined personal, professional, organisational and cultural factors shown to have a direct impact on caring nursing practice. At the pre-MC survey (T1) it served to stimulate workshop participant engagement with questions related to caring such as: (i) understanding of key terms - health, healing, care, cure; (ii) an understanding of the theoretical underpinnings of caring and (iii) understanding of aspects affecting the ability to care such as: personal, professional, organisational and cultural factors. Some of these factors may be for example: personal history and motivation, participants’ perception of their own effectiveness as a nurse, understanding of patient needs, the impact of work and organisational culture, and the impact of society on a nurse’s ability to care. The survey provided the participants with an opportunity to think about their own caring inventory and personal, professional, organisational and cultural impacts on caring.

100 For the researcher, the background data was used to determine if the groups were reflective of the WA nursing population. Background data was also used to examine relationships between background data such as: knowledge and skills, self- efficacy and the CES.

Research by Reid (2018) was found on the relationship between background and caring efficacy in the Australian context. This research showed a relationship between caring efficacy and years of experience and marital status (Reid et al., 2018). The expert panel for this research found the question on marital status to be intrusive. The Master Classes also coincided with the marriage equality debate (same gender marriage) which generated enormous amounts of discussion and controversy in Australia. Due to these factors the question was removed

The Caring Efficacy Scale (CES) is used to determine participants caring efficacy, that is their perception of their ability to respond to “I can do this” in relation to caring nursing practice. The CES has been tested for reliability and validity in Australia (Coates, 1997). It was developed by Coates in 1997, and later modified by Reid et al. after testing of the psychometric properties of the scale (Coates, 1997; Reid et al., 2015). The CES was included as one component of the survey.

The CES (Coates, 1997) consisted of 30 items on a 6-point Likert scale. Higher numbers indicate higher levels of self-efficacy. The Coates’ (1997) sample consisted of two samples. The first had 144 nursing students: in their final semester (n=83), masters students (n=51) and doctorate students (n=10). The second had 850 graduates of different levels: baccalaureate (n=453), masters (n=387), doctorate (n=10).

Reliability was assessed for internal consistency using Cronbach’s alphas for the total CES on two forms. Form A (earlier version) and Form B had the same content; however, Form B had a balance of positive and negative items. Cronbach’s alphas were 0.85 and 0.88 respectively (Coates, 1997).

Construct validity was originally determined by use of an expert panel (known groups technique) comprising faculty associates at the University of Colorado’s Centre for Human Caring, checking for congruence with Watsons carative factors. At that point, no “tests of statistical significance were conducted due to different sample size” (Coates, 1997, p. 56). Validity was also determined using Pearson’s correlation between the CES and a recognised valid and reliable scale, the Clinical Evaluation Tool (CET). Concurrent validity was assessed by testing the relationship between the measures of ‘caring’ on the CES and the measures of ‘clinical competence’ as determined by the CET (Coates, 1997, p. 57).

The CES instrument had been assessed to be reliable and to have content and concurrent validity (Coates, 1997; Reid et al., 2015). Further testing of the psychometric properties of the CES was conducted by Reid et al. (2015) using Registered Nurses (RNs) in Australia who determined construct validity for the Australian setting.

101 Given expert analysis of the scale in the Australian setting the plan for this research was to use the 28 items of the CES determined to be valid in the Australian setting across two factors: (1) Confidence to care (CtC) – 14 items and (2) Doubts and concerns (DC) – 14 items with equal numbers of items weighted positively and negatively. After a review by the expert panel for this research (see 4.4.2 for details) the first two items were removed for the WA context as the panel felt the wording was confusing and the first question was unduly negative:

1. I do not feel confident in my ability to express a sense of caring to my clients / patients.

2. If I am not relating well to a client / patient, I will try to analyse what I can do to reach him / her.

The CES may indicate a nurse’s potential to have an impact on the quality of patient care as confidence in providing care is correlated with nurses practice behaviours (Manojlovich, 2005). Therefore, if caring efficacy is high it may in turn affect the quality of patient care provided.

The CES is based on the spirit of Jean Watson’s theory of Human Caring Science (Watson, 1979). The instrument provides educators with baseline data on their perception about their ability to care ‘I can do this in this situation’ (CES). The CES can provide a snapshot of the participants ‘mind-set’. There is, however, an appreciation between what participants are able to do and what they think they can do. Actual ability does not always match perceived ability. Some participants may feel ill prepared to care whilst at the same time demonstrating a relational ability to care. The difference between CES scores at the three time intervals is of interest to the research as T2 and T3 scores may be able to determine differences attributable to education.

Information from the participant survey was supplemented by data from reflective practice journaling.

4.4.1.3.2 Reflective practice journaling

RPJ did not have a tool; however, the practice of RPJ itself is considered a tool for reflection and learning (Mezirow, 1991; Silvia, Valerio, & Lorenza, 2013). Participants learned about and experienced different forms of reflection - about different aspects of nursing in the MC. Those who consented to participate in RPJ were sent an introductory e-mail (Appendix 1 Personal communications) outlining broad parameters and approaches to reflection.

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