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Undergraduate nursing students’ perceptions of caring Best, Mary Veronica 1995

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UNDERGRADUATE NURSING STUDENTS' PERCEPTIONS OF CARING by MARY VERONICA BEST B.N., The University of New Brunswick, 1980 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES (Department of Educational Studies) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA March, 1995 © Mary Veronica Best, 1995 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia Vancouver, Canada DE-6 (2/88) Abstract What does caring mean to nursing students? How and from whom do they learn about caring? In order to better understand the meaning of caring in nursing and in nursing education, as well as how people demonstrate caring, nursing students' perceptions and experiences of caring were investigated in this study. Other researchers have investigated caring in nursing and nursing education, however, references related to students' experiences of caring in nursing education are sparse. Sixteen in-depth interviews were carried out with research participants from a large Western Canadian university school of nursing. Three major areas were explored: students' descriptions of caring, the effect of context on students' perceptions of caring, and faculty members from whom students learned about caring. Students identified five descriptors that represented caring: empathy, helping others by doing things for and with them, compassion, professional caring, and holism. Contextual influences on caring identified by students were also explored. Data describing caring faculty members were summarized with the acronym, C.A.R.I.N.G.: Capabilities; Attitudes towards students; Responses to students; Intuition; Nature of the instructor; and Generosity towards students. Students' descriptions of uncaring faculty members were placed into the acronym as well. In addition, participants described ideal faculty members and role models of caring. Conclusions were developed from this investigation. Implications were identified for nursing educators, nursing education administrators and nursing students. The first conclusion was that empathy is critical to caring. Implications for promoting empathy were addressed through the concept of reciprocity. The second conclusion was that caring requires effective communication. Implications for enhancing communication were explored through the term dialogue between educational administrators, educators and students. A third conclusion was that an emphasis on caring has to be developed and maintained throughout nursing education. Implications for achieving this emphasis were explored through collective commitment to encourage caring by faculty and administrators. Finally, the expectations for faculty members by students, administrators and themselves were examined. Implications were addressed through balancing the tension between these expectations which at present do not create balance between academic, professional and personal demands. iv Table of Contents Page Abstract . . . . . . . . . . ii Table of Contents . . . . . . . . iv Acknowledgments . . . . . . . . v i i Chapter One: Introduction . . . . . .1 The Research Questions . . . . 2 Describing What Caring Means . . . . . .3 Assumptions about Caring . . . . . .4 Defining Caring for this Research . . . . .5 Explicating Terms in the Research Questions . . .6 Chapter Overviews . . . . . . . .9 Chapter Two: Reviewing the Literature on Caring . . . .12 Caring as a Human Condition . . . . . .13 A Brief History of Caring in Nursing . . . . .16 Caring as a Way of Being in Nursing . . . .18 Caring in Nursing Education . . . . . .22 Conclusion . . . . . . . .39 Chapter Three: The Research Method . . . . . .40 The Use of a Qualitative Method . . . . .40 Ethical Concerns . . . . . . . .42 Sample Selection . . . . . . . .43 Student Profiles . . . . . . .44 V The Interviewing Process . . . . . .51 Reliability and Validity . . . . . . 54 Limitations of the Research . . . . . .56 Chapter Four: Students' Descriptions of Caring . . . .58 Descriptors of Caring . . . . . . . 59 Students' Beliefs about Caring . . . . 71 Attitudes and Actions of Caring . . . . . 73 The Effects of Context on Students' Perceptions of Caring . . 74 Conclusion . . . . . . . . 83 Chapter Five: Faculty Members who Teach Caring . . . .85 Descriptions of Caring Faculty Members . . . .87 Descriptions of Uncaring Faculty Members . . . .108 Role Models of Caring and Ideal Instructors . . . .117 Caring Instructors: A Prototype of Possibility . . . . 122 Uncaring Instructors: A Prototype of Negativity . . . 122 Conclusion . . . . . . . . 123 Chapter Six: Conclusions and Implications . . . . . 124 The First Conclusion: The Importance of Empathy . . 125 The Second Conclusion: Caring Requires Effective Communication . . . . . . . 128 The Third Conclusion: Emphasizing Caring in Nursing Programs . . . . . . . . 131 The Fourth Conclusion: Unrealistic Expectations of Faculty Members . . . . . . . . 135 Areas for Further Research . . . . . . 138 Conclusion . . . . . . . . . 139 vi References . . . . . . . . . . 140 Appendices . . . . . . . . . 148 Appendix A: Interview Themes and Questions . . . 148 Appendix B: Written Consent Form . . . . . 150 Appendix C: Information Flyer . . . . . . . 151 Appendix D: Terms and Phrases of Caring Identified by Frequency per Student . . . . . . . 152 Appendix E: Terms and Phrases of Caring Identified by Frequency per Year . . . . . . . 153 Appendix F: Terms Describing Caring Faculty Members . . 154 Appendix G: Terms Describing Uncaring Faculty Members. . 156 Acknowledgments I would like to take this opportunity to thank each of the 16 participants in this study. After all these months, I remain excited by the enthusiasm and insight these nursing students brought to the interviews and hence to this study. My greatest hope is that this paper has done justice to the data they shared with me. I would like to acknowledge the work and support from my research committee. I am grateful to Dr. Judith Ottoson who carefully offered gems from the text on which to reflect. These often resulted in minor alterations that had major impact. Wendy Hall offered editorial critique and nursing insight which strengthened this thesis. I am most indebted to my research supervisor, Dr. Allison Tom, who offered unending encouragement, flexibility, understanding, and caring towards me over the course of this research project. It was a pleasure working with an educator who was exemplary as a caring faculty member. I would also like to acknowledge the friends and family who supported me over the past several years. Thanks to Charlotte Sakaki, Connie Mcllwrick, Mavis Friesen, and Laurel Sheppard who provided support and encouragement throughout my victories and setbacks. I would like to thank all the friends who cared for my young child so that I could work uninterrupted. I also thank Lawrence, my husband, who supported me through his endless encouragement and understanding of the importance of what I was doing. Last, and certainly not least, thanks to my small son, Andrew, who took three hour naps because he knew I needed to work, and upon waking would always help me remember why if is important to be caring. Chapter One: Introduction I remember the first bedbath I ever gave as a beginning nursing student. My mouth was dry, my hands were cold and they shook. I stared at the floor until my client asked me what I was looking at. I remember struggling for words to start a conversation and that my instructor came in and began to talk about the weather. That was all my client and I needed to get started on a dialogue about playing in the snow and him remembering his youth. I recall my instructor at the door smiling and the whole thing made me feel warm inside. I also will never forget my first injection in second year. This time my hands shook so badly I dropped the medication ampoule and had to start all over again. My instructor had to place her hand over mine to direct the needle through the client's skin because mine was shaking so badly, I could have injected the client in the next bed. And I'll never forget how she told me that in time my hands would stop shaking and I'd do just fine with my skills. By the time I reached tiurd year, my hands were still shaking but I was beginning to feel a spark of confidence about my career choice. This confidence was tempering all the inadequacies experienced as a neophyte until one instructor told me that if she had anything to do with it I would never graduate. That is when I started to see that instructors could be what I had thought was impossible for a nurse - someone who was uncaring. Before that, I respected instructors for their intelligence, expertise and compassion. Instructors had been the epitome of nursing to me. Until that one instructor, who in the scope of a fifteen minute evaluation, tore my confidence to shreds. I learned that professionals committed to helping people could be cruel. I felt ashamed and belittled. All I wanted to do was to leave and find something else that I could do because I could not be a nurse. In a few short minutes one individual had made that clear. But somehow, I persevered. I finished that year and went into the next. One particular instructor was so patient, gentle and fair that my faith in nursing faculty was renewed. She understood how I felt, how I had been hurt and how to restore me with kindness, with caring. She brought out my confidence and ability. She made me feel that I could be a nurse and do it well. I will always remember her for that. She taught me that instructors do care about students, through caring about me. After graduating, I called her and told her how much I appreciated that. I told her that if I ever became an instructor, I hoped I would be like her. I have remembered her. I am now a nurse educator. Like many educators, I strive to understand students' positions and to promote intellectual and personal growth for each student. I struggle to help students clearly see that they can, and will, do just fine. I struggle to show them that I believe their thoughts are worthwhile and worthy of a response. In this thesis I will describe how students experience caring during their baccalaureate nursing education. An important purpose of the research was to consider what faculty members can learn about caring from students' perceptions of what caring is and how they experience it. Educators may be better equipped to help students learn and hence, practice caring through understanding what students perceive as caring. The Research Questions In order to accomplish this, I investigated how nursing students perceive caring, how they experience caring through interactions with faculty members and how the context in which caring is learned affects students' perceptions of caring. The research questions were: 1. How do baccalaureate nursing students perceive caring in nursing? 2. How does the context wherein caring occurs affect students' perceptions of caring? 3. How do baccalaureate nursing students experience caring as it is expressed through interactions with faculty members? The questions require explication, however, before I proceed with how I use the key terms in the research questions, it is important to introduce what caring means, to present several assumptions I have made about caring, and to offer a definition of caring for this research. Once I have done this, I will explicate the terms in the research questions. I will then conclude with an overview of the remaining chapters. Describing What Caring Means Philosophers and scholars have ruminated upon the meaning of the word caring throughout time. In the New Testament of the Bible, for example, Unger (1957) described the term as a derivation of the Greek word merimna which referred to being drawn in different directions or being anxious about something or someone. Being anxious about another person implies having an attitude of concern towards the other person. Caring affects many aspects of life because in addition to attitudes about caring, people are pulled in various directions by the things about which they care. Because people are drawn in different directions, they must make conscious and unconscious choices about what to care about in their lives. Then, they must find ways of balancing these things with everything else. They must consider that if they care too much, over an extended amount of time, without getting anything in return, they run the risk of emotionally wearing down. They have to balance caring about themselves with caring for others. People also have to balance how much they care about possessions and ideas, in addition to the people for whom they care. Between biblical times and the present, caring has been described in many ways. Gaut (1983) defined caring as "attention to or concern for; responsibility for or providing for; and regard, fondness, or attachment" (p. 315). Gaut concluded that when care is used in the verb form of caring, it implies action suggesting that caring involves doing caring deeds. Being caring is represented by doing caring things. Mayeroff (1971) outlined the major components of caring as patience, honesty, trust, humility, hope and courage. He implied that caring is ongoing and involves growth. "Caring as helping another grow and actualize himself [herself], is a process, a way of relating to someone that involves development" (p. 1). Bevis (1981) agreed with Mayeroff about the growth that results from caring, adding her perception that growth is positive and constructive. Key issues Bevis introduced are the dedication that occurs when people are caring and that the energy expended results in change. She defined caring as "a feeling of dedication to another to the extent that it motivates and energizes action to influence life constructively and positively by increasing intimacy and mutual self-actualization" (p. 50). Assumptions about Caring After reading about and contemplating caring, I made a number of assumptions about the concept before I developed my own definition. As much as possible, I maintain these assumptions throughout the research. These general assumptions about caring, specifically caring in nursing education include: 1. Caring is best described as a universal and necessary characteristic of existence, that is, as an ontology or way of being. 2. Caring consists of innate and learned attributes. People may be born with a predisposition to caring. They also learn attributes through socialization, modeling, positive reinforcement and maturation. 3. Caring consists of personality traits and actions. Caring combines particular characteristics of an individual's personality with actions that reflect these characteristics. Actions can be physical, psychological, social, or spiritual. 4. There are personal and interpersonal components of caring. Personal care, also known as self care, refers to caring for oneself and incorporates the physical, psychological, social, or spiritual actions. Interpersonal caring is the caring that occurs through interactions with others. It too, incorporates the above actions. 5. Caring is not static because it is influenced by life experience, gender, social context and culture. 6. Long term effects of caring are positive, however, short term outcomes may be viewed as negative by the one receiving care. 7. Caring is an essential component of the discipline of nursing and an imperative for nursing education. Defining Caring for this Research My definition of caring integrates these assumptions. For the purposes of this research, I define caring as "a combination of personality traits and actions that helps others feel understood, and may help them to grow". Although this definition does not specifically address caring in nursing education, it applies directly to caring in nursing education for a number of reasons. First, this definition relates to nursing education because it includes the personality as well as behaviors of an individual who is caring. In the educational setting, both must be taken into consideration. It is unfair to make assumptions about how caring a student is by looking at personality or behavior alone because although personality is demonstrated through behavior, there are times when one's personality or behavior is altered by circumstances. An example of this would be when a student is experiencing a high level of anxiety. Second, caring towards students is demonstrated when students feel understood on a consistent basis. There are potential problems with this because if students lack insight when receiving negative feedback, they may feel misunderstood or victimized. However, if faculty members consistently attempt to understand students and act upon this understanding, these faculty members are demonstrating caring towards their students. The final way this definition relates to nursing education is that caring facilitates students' growth. Growth, in this context, refers to development in a positive direction. It implies change and it implies action. In nursing education, helping students feel understood informs them about caring which in turn may help them under stand and express caring towards others. The growth that occurs through faculty members caring for students may promote the acquisition of wisdom in students which allows them to demonstrate caring towards others. Explicating Terms in the Research Questions A number of terms require explication in order to answer the questions: 1. How do baccalaureate nursing students perceive caring in nursing? 2. How does the context wherein caring occurs affect students' perceptions of caring? 3. How do baccalaureate nursing students experience caring as it is expressed through interactions with faculty members? The term baccalaureate nursing students refers to students enrolled in an undergraduate program in nursing at the same university. I did not include registered nurses returning to the university to obtain their nursing degree in my sample because their experiences are different. I interviewed students in the first, second, third, and fourth years of the nursing program on one occasion. By collecting data from students in each year of the program, experiences of caring throughout the students' education were accessed. I did not distinguish between students on the basis of age or previous experiences. All generic students were considered because most nursing programs have a combination of younger and older learners. Students who enter nursing programs have responsibilities outside of the academic arena. I acknowledge family responsibilities, social commitments, religious convictions, job-related obligations and personal health and fitness resolutions. Both faculty members and students are viewed holistically when these obligations are taken into consideration. Although commitments outside of the academic arena are accounted for in the research, they are not the focus. The term perceives is explained through the noun perceptions. Perceptions have been chosen for this investigation because they represent individual views of reality. In this case, perceptions are the participants' feelings and ideas about how they experience caring in nursing education. Random House (1991) defines a perception as "immediate or intuitive recognition or appreciation, as of moral, psychological or aesthetic qualities; insight; discernment" (p. 1001). In other words, perceptions are the insights and appreciation of ideas that help determine who a person is. An individual's perceptions about reality make him or her unique because these perceptions have been tempered by genetics as well as social learning. Perceptions are also reflected through actions. They order what we do because our being is expressed through our doing. In this research, perceptions were articulated through students' descriptions of what they thought caring meant in nursing and how they experienced it. Students had to share their perceptions with a stranger which may have influenced the way they expressed themselves. There are problems with perceptions as well. Individuals are not always consistent. People do not always behave as they intend to behave. Distractions and circumstances alter the way people interact. For example, if a personal crisis occurs in a faculty member's life, he or she may be coping but seems disinterested. This may leave students feeling uncomfortable, misunderstood, or convinced the instructor is dissatisfied with their work. What people say they do and what they actually do are not always congruent. People often say what they think others want to hear. During the interviews, students may have had notions about what my questions really meant or what I wanted to hear in a response. I have made the assumption that people have been truthful. The term experiences of caring refers to encounters students had, primarily in the educational process, which they perceived as caring or uncaring. This research is focused on students' comprehensions about caring within their nursing education. Although it would be easier to look at only one component of caring, I chose to investigate it through a variety of students' experiences. In using this term, I attempt to examine caring as a gestalt, and not look at only one perspective. Instead, I consider caring from the various ways that students experience it. Students' experiences include interactions with faculty members, fellow students and clients. These experiences consider observations of caring and uncaring treatment towards themselves or others. Experiences of caring include treatment within a school of nursing as students progress through a program. Past experiences with friends and family also strongly affect how students view caring, especially how they describe what it means to be caring. The term interactions is defined by Random House (1991) as "reciprocal action, effect or influence" (p. 701). Interactions occur throughout childhood, adolescence and into adult life because of the need for each of us to communicate. Through interactions, people try to understand and be understood by each other. Interactions provide a model of behavior. Skills are developed through interactions. These skills can equip people for effective or ineffective relationships. For example, sensitivity, curiosity, inquisitiveness, intuition, humor and patience are learned through interactions which foster effective relationships, whereas victimization, intimidation, and insensitivity inhibit relating effectively with other people. The term faculty members refers to educators within a Western Canadian university department of nursing. In this setting, a large number of educators, particularly clinical instructors, are employed on a sessional basis, therefore, I have not differentiated between sessional and tenure-track faculty. The term context refers to circumstances surrounding the educational process which affect how students perceive and experience caring. In this research, contextual influences refer to students' progress through and impressions of the program and interactions that affected their views of caring. Now that I have introduced each component of the questions to be investigated in this research, I briefly outline remaining chapters. Chapter Overviews The literature review follows this introductory chapter. The literature has been reviewed primarily from the discipline of nursing but some references from education and philosophy have been included as well. Three areas of caring are examined in this chapter. The first of these, caring as a human trait, explores whether caring is innate or learned. I ultimately conclude that caring is an ontology, a way of being which includes both innate and acquired 10 characteristics. The second area surveyed in the literature is the importance of caring in the profession of nursing. Terminology, such as caring personality traits, caring actions, caring for, and caring about, is clarified. The final area of caring that is addressed in the literature is caring in nursing education. I review the history of behaviorism and empiricism in health care, and the impact of this on nursing education. Research pertaining to learning caring in classroom and clinical settings is discussed. I critique the literature about how students and faculty members experience caring. I conclude that more research is required before educators will understand how to better implement caring in nursing curricula. Finally, from analysis of the literature, I offer support for addressing the research questions in this study. Once the necessity for research about nursing students' perceptions of caring in their education has been addressed, I clarify the method for this study. I begin this chapter with a justification of the use of a qualitative methodology for this inquiry. I review the sample selection and introduce each of the participants in the study. I outline the process of carrying out the interviews including the identification of the questions used and a description of data analysis. The next two chapters present the findings. The first chapter deals with student descriptions of caring. I extracted the themes of empathy, helping others by doing things for and with others, compassion, professional caring and holism from this data. I also address the contextual influences on how students perceived caring. Several of the important components of context were students' perceptions of the nursing program, interactions with client, and interactions with fellow students. The second chapter analyzing the findings addresses students' descriptions of caring and uncaring faculty members. I develop an acronym C.A.R.I.N.G. to describe characteristics of caring in faculty members. I also spend time investigating what uncaring treatment means to students, mostly through their descriptions of interactions wherein they felt a lack of care. I briefly discuss role models of caring and the ideal instructor. I draw conclusions from the research in the final chapter of this thesis. I discuss the importance of empathy and communication in caring. I confirm the demands of becoming and remaining a caring member of a nursing faculty. If only one conclusion were to be drawn from this research, it is that educators can exemplify caring through taking a holistic approach not only towards their students, but also with themselves. I offer implications for nursing educators, nursing students and nursing education administrators. I make suggestions of areas for future research. 12 Chapter Two: Reviewing the Literature on Caring The previous chapter provided an introduction to this research. Before going any further, it is important to review and critique existing research about caring. The literature devoted to caring is extensive and characterized by the work of many disciplines. I have limited the scope of the literature in this chapter primarily to sources within the domain of nursing, however, sources in the disciplines of education and philosophy augment my understanding of the concept. I did not spend a great deal of time contemplating the philosophical musings of contributors such as Buber and Plato or the literature on nurse-client interactions of caring because the context for this study is caring in nursing education. The caring literature has been categorized into three sections for investigation. I have explored literature about the meaning of caring in general terms, in the nursing profession and in nursing education. In the first section, I consider caring as a basic human trait. Caring as a human trait means that caring is something necessary to the human condition. When we understand caring, we understand each other and ourselves. Researchers have studied how caring may be innate or learned through social interaction. The evolution of what makes caring people has been explored by researchers. I summarize what some researchers have concluded about the origins of caring. It is important to understand caring as a human trait because, in order to understand what caring means in nursing education and how to engender caring, we have to know what it means to be caring in the first place. Once the meaning of caring has been clarified, I then specify the type of caring to be examined in this thesis. In the second part of the chapter, I briefly address the history of caring in nursing and caring as a way of being in nursing. Nursing theorists and 13 researchers have been committed to developing the concept of caring within nursing, especially over the past fifteen years. By explicating the concept through examining the philosophical components of its meaning, researchers have delved into what caring means and how it is demonstrated in the profession of nursing. Much of the research on caring in nursing, particularly philosophical findings, is transferable to nursing education. This is because caring in nursing education is one avenue of exploration of caring in nursing. This work informs my research because perspectives about caring in nursing are a starting point for gaining perspectives related to nursing education. The third section receives major emphasis in this literature review. In it, I address research on caring in nursing education. This provides a context for understanding and justifying the current study. Research on caring in nursing education is limited. Investigators are just beginning to explore possible differences between caring in nursing and caring in nursing education. Qualitative research methods are becoming more accepted as they are more frequently employed. The lived experience of caring as it relates to the educational process is being studied from both students' and faculty members' perspectives. Both types of studies will be discussed in this section. Researchers have also begun to probe caring in classrooms and clinical settings. These studies will also be examined. This research base contributes to a greater understanding of caring in nursing education. Following the literature review, I discuss the gaps in the current literature that describes caring in nursing education. I will also identify questions arising from these gaps. I conclude the chapter by demonstrating how the research questions in this paper address some of these gaps. Caring as a Human Condition Some individuals come across as more caring than others. They devote 14 themselves to their friends in good and bad times. They listen, empathize, console and admonish in order make others feel significant, understood and validated. What does caring mean and what makes these individuals caring? Perhaps an appropriate place to start is by looking at what theorists believe are the roots of caring. Noddings (1984) postulated that caring comes from two basic origins. One origin lies within the hereditary sympathy of relating to the pain and happiness of fellow human beings. She concluded that people sympathize with the joy and suffering of others because they are genetically coded to relate to each other. The second origin of why people care, according to Noddings, lies in their desire to recapture the tenderness and caring that occurred throughout infancy and childhood. Somewhere deep inside, people remember how they were lovingly treated as children and desire to share this. Dunlop (1986) critiqued Noddings argument and concluded that, if it is accepted, caring falls into the philosophical debate between innate characteristics (nature) and learned behaviors (nurture). This debate is problematic because both innate and learned characteristics are reflected in behavior. Most of the literature I surveyed concluded that caring is a combination of innate and learned characteristics. This supports the impossibility of determining whether caring is entirely inherited or entirely learned. Discovering whether caring is learned or innate is not as important as exploring what kinds of traits and behaviors define caring people. Historically, women have more often been associated with caring activities than men (Benner & Wrubel, 1990; Gilligan, 1982; Leininger, 1984a; Ray, 1981). Being caring and performing caring deeds may be part of how women construct their world. Gilligan (1982) articulated women's views of reality as being connected and interdependent in contrast to men's views of being separate and independent. Women appear to place greater importance 15 on relating to and understanding others and connecting with them, whereas men are geared more towards autonomy. Chodorow (1974) supported the notion of gender differences between men and women and suggested that the way they are parented creates those differences. She thus introduced the possibility of social learning as the foundation for gender differences. Chodorow's research concluded that men are socially prepared for a role which is absolute and separate, women for a role where attachment to and care for others is vital. This is not to say that men are uncaring or lack the capability to care, but that women may be predisposed to caring attitudes and behaviors not only through their genetic makeup, but also through their early socialization. Another perspective on what constitutes caring deals with the moral obligation people have to be caring. This means that an individual is caring towards another because, for them, it is ethically correct. It is the right thing to do because people deserve to be treated with respect and compassion. Scholars have paid much attention to this moral basis for caring (Gilligan, 1982; Gustafson, 1988; Morse, Solberg, Neander, Bottorff, & Johnson, 1990; Noddings, 1986; Watson, 1985). Watson (1985) believed that "caring calls for a philosophy of moral commitment toward protecting human dignity and preserving humanity" (p. 31). Whether or not caring is viewed as a natural predisposition, or a learned phenomenon, it is a way people live their lives. It is a way of being, or what scholars may refer to as an ontology. Theorists have been describing caring in this way for the past twenty years (Boykin, 1990; Mayerhoff, 1971; Morse, et. al. 1990; Roach, 1984). In conceptualizing caring as an ontology, I have concluded that it is important to recognize that ways of being include ways of acting. Regardless of a caring personality, caring is demonstrated through behavior 16 which is reflected in the way people live their lives. Many caring people cannot conceive of being in this world and not encouraging the growth of people around them by interacting in a caring manner. Caring for, and about, other people are primary objectives for these individuals who see opportunity and potential in all people and promote it through caring attitudes and actions towards others. In order to live out meaning in life, people choose career paths which allow them to remain true to their personal belief systems. People who are caring are no exception. Some individuals enter nursing to satisfy the need to live out their caring. Kersten, Bakewell and Meyer (1991) concluded that the primary reason students chose nursing was because of caring. "It is clear from the data collected that the largest percentage of individuals going into nursing do so because they believe that caring is a major component of the profession" (p. 32). A Brief History of Caring in Nursing Being caring has often been a challenge for nurses, and the concept of caring has historically received varying levels of emphasis. Recently, theorists have become more attentive to exarmning the concept of caring in nursing. Unfortunately, the nursing profession has not always overtly studied the caring, humanistic approach to health care (Bevis & Watson, 1989). In the following section, I address several reasons why the study of caring in nursing has been less emphasized than it is today. I will also outline the recent history of research on caring in nursing. The devaluation of caring by society (Watson, 1985) reached health care through an emphasis on medical diagnoses and technical skills (Bevis & Watson, 1989; Smith, 1991). The focus was on the cure and not on the care of the client. This, of course, influenced the education of health care 17 professionals, including nurses. "Although students, like patients, recognized caring as an integral part of nursing, they did not associate it with any underlying theoretical framework that needed to be learnt. A gap appeared between the professional rhetoric of caring and the empirical reality" (Smith, 1991, p. 75 ). This gap needs to be addressed. Students who enter a nursing program and want to help others may find the program emphasizes the medical side of illness and competence at skills, instead of caring. The nursing community is beginning to incorporate studies and theoretical papers that examine the meaning of caring into nursing practice and education. Progress has been slow, but steady. Some of the developments in the literature about caring in nursing are now discussed. Madeleine Leininger organized a conference in the late 1970s which pioneered investigations of caring in nursing. At this conference, the mandate to study caring in nursing was emphasized. Since that time, research about caring in nursing has included historical investigations (Dunlop, 1986; Gaut, 1981), philosophical explorations, (Gaut, 1984a; Gaut, 1984b; Greene, 1990; Ray, 1981); construct explication (Bevis 1981; Boykin & Schoenhofer, 1990; Leininger, 1981; Leininger, 1984a; Morse et. al., 1990); research into the antithesis of caring (Gardner & Wheeler, 1984); patients' and nurses' perceptions of caring (Cronin & Harrison, 1988; Forrest, 1989; Larson, 1987; Morrison, 1989; Pugh, 1986); descriptions of caring exemplified in nursing education (Bevis, 1993; Cohen, 1993; Diekelmann, 1993; MacDonald, 1988; Malek, 1988; Metcalfe, 1990; Nelms, 1993; Paterson & Crawford, 1993; Tanner, 1990; Watson, 1985); and nursing students' perceptions of caring (Beck, 1991; Chipman, 1991; Deska Pagana, 1988; Mangold, 1991; Postlethwaite, 1990; Wilson, 1994). One benefit from this research is a richer understanding of the meaning of the concept. Definitions have been formulated and 18 revised. Components of caring have been reviewed and clarified. Caring has been explored from philosophical and practical perspectives. Caring as a Way of Being in Nursing Exploring caring as a way of being in nursing provides further insight into the understanding of caring. A nurse's personality is reflected in what he or she does. I address researchers' perspectives on the personality traits of caring in nursing as well as actions which depict caring. I then discuss how researchers have effectively articulated how caring occurs in nursing through the blending of caring personality traits with caring actions. Personality traits of caring have been philosophically described in the nursing literature. Ray (1981) reviewed Nightingale's work and described caring as a dedication and responsibility to "giving, helping, compassion, loyalty, constancy and freedom of material gain" (p. 32). She also described caring as empathy and a willingness to give time, energy and love. Nurses are viewed as caring when they are committed to understanding others and trying to help them. In the familiar language of beginning nursing students, caring nurses were described as "cheerful, friendly, a good listener, happy, good-natured, empathetic, compassionate, patient, thorough and safe" (Kelly, 1992, p. 123). Personality traits affect the types of nurses people become because personality is reflected through the approach to, and execution of, work performed. Caring obviously involves more than personality traits such as those mentioned above. It is demonstrated through competence at skills and the application of various types of knowledge. Caring is clearly demonstrated through the nurse's actions. Nursing theorists have carefully refined the definitions of what caring actions are. Gaut (1981) differentiated between the acts and actions of caring. A set of acts (behavioral description) entails biophysical operations, 19 movements, or events. A set of actions are the acts in the perspective of the actors, expressing certain attitudes and expectations and thereby having social and psychological significance or "act meaning" (p. 23). Acts can be performed tedtnically, with little, if any, interaction occurring between the nurse and the client. An example would be taking a blood pressure without talking to the client, or making a bed while talking to a helper instead of the client. These acts do not demonstrate caring. Rather, caring is demonstrated through purposeful actions. A purposeful action includes an act but places it into context. When nurses perform caring actions, they consider the individuals acted upon and the effect of the act upon them. Measuring blood pressure differs when the nurse deliberately sets out to perform a caring action. In this instance, he or she not only measures the blood pressure but ascertains how the client is feeling about the procedure, and explains the procedure and findings. When making a bed, the nurse uses the opportunity to listen, to touch and interact with his or her client. Integration of caring in nursing comes when caring personality traits are blended with caring actions. For instance, Leininger (1984b) described caring in terms of actions which embody caring attitudes. "Caring refers to the direct or indirect nurturant and skillful activities, processes, and decisions related to assisting people in such a manner that reflects behavioral attributes which are empathetic, supportive, compassionate, protective, succorant, and educational" (p. 4). Koldjeski (1990) described caring as qualities or essences and actions or entities of caring. For him, essences of caring included valuing and involvement, instilling hope, and being present for the other. Essences represent the creative, implicit and humanistic side of reality. Actions or entities of caring included professional nursing relationships, health 20 promotion and maintenance, and technological monitoring. Entities represent specific actions which are often technical and scientific. Koldjeski viewed nursing as a combination of humanism and science: "the humanistic ideals and scientific goals of nursing can be unified into a whole and expressed through a special kind of relation involving being, relating, and doing" (p. 54). Morse et. al. (1990) developed five conceptions of caring that described caring in nursing as a blend of personality traits and actions. These conceptions included: a human trait, a moral imperative, an affect, an interpersonal relationship, and a therapeutic intervention. The first conception, that caring is a personality trait, proposes one aspect of caring as an essential component of human nature, although early experiences can affect the expression of caring. Caring is also a moral ideal in nursing, which means that nurses are committed to maintaining the dignity of their clients. The third conception of caring developed by Morse et. al. is that caring is an affect. An affect reflects being understanding of the client's experience and becoming emotionally involved to the point of selflessly acting on behalf of the client. Caring as an interpersonal relationship, encompasses the belief that the discourse between nurse and client expresses and defines caring. The fifth conception is that caring is a therapeutic intervention. Caring is defined by all of the actions a nurse does with and for the client. These concepts imply that caring occurs in nursing when a caring personality is reflected in caring actions. Roach (1984) outlined five C's of caring: compassion, competence, confidence, conscience, and commitment. She linked attributes or personality traits with behaviors and suggested that one does not occur without the other. "These five C's are referred to as attributes of caring and, 21 while not mutually exclusive, they are a helpful basis for the identification of specific caring behaviors" (p. 19). These categories confirm that caring is effectively viewed through a holistic blending of personality and behavior. In addition, this caring paradigm recognizes the need for nurses to positively reinforce caring qualities. A final means of addressing the integration of personality and behavior occurs when investigating the distinction between dependent and authentic care (Scudder, 1990). This is also referred to as caring for an individual versus caring about them (Gaut, 1981). This distinction hinges on the sensitivity of the nurse's approach to the client and the interventions to be performed. Based on the work of Heidegger, Scudder (1990) described dependent care as meeting physical needs when these cannot be met by the one receiving care. Dependent care implies the care-giver is doing things for the other because they cannot do it for themselves (Gaut, 1981). The potential difficulty is that caring for may foster domination by the care-giver resulting in a lack of respect and caring towards the individual. This directly opposes an attitude of caring towards the client. In contrast, authentic care helps the recipient of the care to care for himself or herself (Scudder, 1990). Authentic care implies caring with or about the other (Gaut, 1981). In order to provide authentic care the nurse must be aware of and sensitive to the client's feelings about the management of their illness. This is simply expressed as showing respect for others and leaving the locus of control in the hands of the client. The nurse consults with the one receiving the care and capitalizes on the capabilities present within the individual. Interventions, in this case, are based on understanding and preserving dignity. They depict caring. When addressing the importance of caring in nursing, describing it as an ontology is useful. Many nurses embody caring by their way of being and the way they behave. 22 Advances in the concept of caring have resulted from the research efforts of numerous scholars. Despite this wealth of knowledge, clarity about the concept of caring in nursing has yet to be achieved. According to Morse, Bottoroff, Neander and Solberg (1991) "there is a need for theoretical preciseness, clarity and parsimony especially when describing such complex concepts as care and caring" (p. 126). Due to contradictions and conflicts between theorists and researchers there is still much to be done to clarify the meaning of caring in nursing. This is especially true in nursing education. Caring in Nursing Education Caring in nursing education is an area where further research is warranted. As theory describing caring developed, some researchers assumed that caring in nursing extended to all avenues of nursing, including education. "The definitions of caring in nursing education are rarely articulated in the literature; the assumption seems to be that caring in nursing practice is merely transferred as an analogous concept to the arena of nursing education" (Paterson & Crawford, 1993, p. 165). The assumption that caring in nursing has been transferred to nursing education has been strongly questioned. These scholars combined an extensive literature review and doctoral research to address this issue. Caring in nursing education has been described primarily from faculty members' perspectives because faculty members have constituted the sample for research in nursing education. Although parallels exist between caring in nursing and caring in nursing education, caring in nursing education is distinct from caring in nursing practice. Paterson and Crawford distinguished caring in nursing from caring in nursing education. First, they defined caring in nursing education in two ways. The definitions include shared meaning, lived experience, and 23 reciprocity as intrinsic to ontological definitions as well as caring subsuming the way faculty members think about and inform their practices as educators (Paterson & Crawford, 1993). Second, caring in nursing is distinct from caring in nursing education because the purposes for each differ. One purpose of caring in nursing education is for students to experience caring in order to implement it in their practice. The other purpose is to empower students. The authors establish the need for greater emphasis on reciprocity as an additional purpose of caring in nursing education by implying that faculty members and students alike deserve to be treated in a caring manner by each other. In addition, there are mutual benefits when caring is practiced. Third, the authors identify attributes of caring faculty members which they view as unique from attributes of caring nurses. These attributes include: knowing the student as an individual, listening to the student, maintaining confidentiality regarding information disclosed by the student, acting as the student's advocate, instilling in students the vision of hope and success, being fair, being competent as a teacher and clinician, and being nurturing, (p. 167) A final distinction between caring in nursing and caring in nursing education is that caring in nursing education has a number of unique constraints. Caring is suppressed by time limitations with students due to the variety of faculty responsibilities, the impact of the evaluatory role of the instructor, lack of preparation of clinical teachers, student anxiety, and student perceptions of uncaring treatment. One could critique this research by replacing the instructor/ student relationship with the nurse/client relationship in a number of the above arguments. They could then conclude that caring in nursing is the same as caring in nursing education. However, making such deductions may not be 24 that simple. For example, the nature of the relationship may be quite different. Clients often have little choice about their hospitalization. They are placed into the client role, often a role of dependency, out of necessity. Their interactions with nurses are affected by their perceptions of the power discrepancies between the client and the health care team as well as the client's perceived control over the outcome of their illness. Students, on the other hand, have chosen the career path of nursing and may interact with those influencing them differently than a client interacts with his or her nurse. The nature of the instructor/student relationship contains elements of control and outcome just as the nurse/client relationship does, however, students chose to be in that situation. The consequences of choice in this context could result in interesting conclusions about similarities and differences in nurse/client and instructor/student relationships. Paterson and Crawford have identified possible distinctions between caring in nursing and caring in nursing education which merit further exploration and debate. In this section of the chapter, I discuss the literature on caring in nursing education. I address the history of behaviorism which led to a mandate for change towards a more caring curriculum in nursing education. Furthermore, issues surrounding caring in classroom and clinical settings, faculty members' experiences of caring, and students' experiences of caring and uncaring will be discussed. The exodus from behaviorism in nursing education. The history of behaviorism in nursing and, consequently, it's place in nursing education have been well documented (Bevis, 1993; Bevis & Watson, 1989; Cohen, 1993; Demerath Learn, 1990; Diekelmann, 1990; Diekelmann, 1993a). Behaviorism "emphasizes such concepts as control, behavior modification, learning through reinforcement, and management by 25 objectives" (Elias & Merriam, 1980, p. 10). Behaviorism has served nursing education well and continues to be relevant in acquiring certain knowledge and skills. However, directing content through behavioral objectives adversely affects nursing education by limiting the content offered as well as the way students learn. This is especially significant in the affective domain of learning wherein caring falls. Measurement of student progress in affective learning is simply incongruent. Watson and Bevis (1989) criticize behaviorism because some educators have become bound to it. "Its [behaviorism's] misuse has come in trying to make it uniformly applicable to all nursing curriculum matters and in limiting curriculum exploration to behaviorist theory" (p. 3). Behaviorism has affected how students learn caring if an action cannot be observed or measured, then it is deemed irrelevant. "Concepts of presence, support, comfort, and other care measures are ... discussed [in limited ways] in most nursing classes. Clinical experiences remain focused on medical activities rather than caring ones" (Leininger, 1984c, p. 91). Some theorists believe that because the emphasis on caring has not been overt, caring in nursing education has not been promoted and taught. The value of behaviorism for some components of the nursing curriculum has been recognized but greater emphasis is now being placed on incorporating caring as an essential, unifying thread. What we must find is a balance, a truce, a truly liberated climate of teaching, of inquiry, so that we fuse the "scientific" with the metaphysical, and infuse a new respect for those things uniquely human: morality, judgment, intuition, reflection, imagination, creativity, values, meaning, and spiritual sensitivity (Bevis & Watson 1989, p. 64). Scientific empiricism has also dominated the discipline of nursing (Bevis 26 & Watson, 1989; Leininger, 1981). The history of empiricism in health care, particularly medicine, emphasized diagnosing and treating illness using interventions that could be measured quantitatively and objectively. Personal, psychological or sociological issues in health care that could not easily be reduced to numbers were neglected or ignored altogether. This has had an impact on nursing and, in some cases, on how caring was demonstrated in a number of practice areas. The more human side, the caring side of treating ill people, was almost completely abandoned because scientific credibility associated with caring was lacking. "Nursing education and the medical care system parallel each other with their common emphasis on objectionist interventions. ... Thus nursing education has been handicapped by an oppressive model in both worlds of learning and practice" (Bevis & Watson, 1989, p. 38). Caring was one of many concepts that was not amenable to scientific empiricism. Caring was not investigated thoroughly because the methods necessary to do so were viewed as invalid. According to Leininger (1984c), "care has not been systematically studied until recently because qualitative research methods have only been minimally valued in nursing, and care research generally necessitates knowledge and skills related to qualitative methods" (p. 88). Humanistic approaches in theory development appear to be incorporated in nursing philosophy and nursing research with increasing frequency, possibly due to increased acceptance of these methods. Nursing scholars, however, have been open to conversation between the scientific and the humanistic approaches for some time (Bevis & Watson, 1989; Koldjeski, 1990). As Watson (1985) points out, "nursing scholars must seek out alternative methodologies that lead to increased understanding and contribute new human care knowledge that is internally relevant for 27 humans" (p. 22). Humanism in nursing education. Caring is highly visible in nursing education. It falls under the umbrella of humanistic education. Humanistic education strives towards "the development of persons - persons who are open to change and continued learning, persons who strive for self actualization, and persons who can live together as fully-functioning individuals" (Elias & Merriam, 1980, p. 122). Humanistic education has been criticized for promoting individualism or egocentrism because it promotes self actualization. However, proponents of humanistic philosophy would argue that self actualization assumes a responsibility to the overall good of humanity (Elias & Merriam, 1980). When caring is placed into a humanistic paradigm, it emphasizes this type of self actualization. It balances caring for self with caring for others by recognizing that in order to care for others, a person has to first care for him or herself. When discussing the new direction of nursing education, caring within the humanistic paradigm promotes ideals such as respect, dignity and personal development. Humanism and caring are reshaping nursing education as they co-exist with behaviorism. As humanism takes hold in nursing education, some scholars are broadening the objectives of educational reform in nursing. Tanner (1993) outlined four basic goals for reform in nursing education developed by the American National League for Nursing. These are: to promote egalitarian, cooperative faculty-student and faculty-faculty relationships; to recognize racial and cultural diversity in individuals and families; to provide learning experiences for students which critique health care systems; and to increase contact with people at health risk. Tanner indicates that institutions have subverted caring by making it invisible through dehumanizing language and 28 a detached approached to patient care. In spite of this, there are ways of ensuring that students do not lose sight of caring in nursing. One method she identified for accomplishing this was through faculty developing strategies for helping students to care. Other investigators continue to identify alternative educational approaches which promote the philosophical shift towards humanistic caring. One approach is a move towards learning through experience (Bevis, 1993). This is accomplished through the implementation of praxis throughout nursing education. Praxis, in this context, implies that experience informs and guides practice. Praxis means reflecting on activities and interactions that occur on a daily basis, and altering approaches towards activities based on these reflections. It fosters sensitivity to individuals as integrated, whole beings. Caring about the student is accomplished by the instructor when she or he is in tune with the student's thoughts and feelings about experiences, makes decisions based on how the student is feeling and then has the confidence to act on these perceptions and decisions. Caring towards the client occurs because each client is viewed and treated compassionately as an individual. Praxis allows the student to learn to be intuitive and it helps them treat themselves and others with respect and dignity. It promotes caring. Another educational approach which encourages a departure from behaviorism is the emphasis on critical thinking skills. Diekelmann (1993a), for example, sees this as a shift from learning nursing content through memorization or rules to learning through thinking about or understanding content. An emphasis solely on cognitive gain promotes step-by-step approaches to many situations. These approaches can be seen as cold and uncaring as well as unsafe. 29 But what is really important about nursing is not noting changes but rather the thinking about what the changes mean. ... Thus, one danger of behavioral pedagogy is that it emphasizes learning content and the acontextual application of content; thinking is de-emphasized and/or defined as merely applying content to specific situations (Diekelmann, 1993a, p. 247). A final shift occurs when nursing education takes on a caring and humanistic paradigm. That shift is towards empowerment for students and, subsequently, their clients. After assessing educational, feminist and nursing literature, Cohen (1993) concluded that caring perspectives in nursing education result in liberation, transformation and shared meaning. These three themes "are concerned with respect for human dignity, fulfillment, knowledge through understanding and a sense of responsibility to the future" (Cohen, 1993, p. 624). Liberation, transformation and shared meaning promote understanding and validation of a person's experiences and they make change more realistic and attainable. These concepts are not new to education, feminism or nursing, (Bevis & Watson, 1989; Freire, 1974; Gilligan, 1982; Giroux & McLaren, 1986) but they are relatively new to nursing education. Theorists have called for major revisions in the educational process. Revisions such as faculty development, the promotion of praxis, development of critical thinking skills, and the empowerment of students will alter the environments where day to day interactions in nursing education occur. The implementation of these revisions requires creativity in devising teaching/learning strategies as well as research to identify their effectiveness. I now turn to research that addresses how caring is being implemented in classroom and clinical teaching. 30 Caring in classroom and clinical settings. A survey of over 250 accredited American schools of nursing revealed that although 97 percent of the schools surveyed addressed caring in their curricula, only eight percent had caring as the major or an organizing concept. "Caring, as the focus of classroom theory presentation, was reported most frequently in the senior year (39.9%), followed by the junior year (39.8%). There was minimal focus on caring in the sophomore year (16.7%) and freshman year (3.9%)" (Slevin & O'Dell Harter, 1987, p. 24). If caring content is only emphasized in the later years of nursing education, how can students develop and refine skills of caring throughout their educational experiences? Will they develop resistance to caring theory if these concepts are introduced late in the program, after they have formed many of their concepts of nursing practice? More recently, the need to introduce theoretical concepts about caring early in the nursing educational process has been asserted. Symanski (1990) proposed a first year course on the philosophy and science of human care. This would reinforce caring as a crucial element of nursing education. Introducing students to the humanities as part of their nursing education may also assist learning about caring (Bartol, 1986; Bishop, 1990; Darby shire, 1994; Gelazis, 1990; Symanski, 1990). According to the work of Reed, "the thesis behind this approach is that students who are exposed to subjects such as art, literature, history, music, and anthropology will have a deeper appreciation of humanity in general and greater respect for humans on a one-to-one level" (Symanski, 1990, p. 138-139). There may even be further evidence to support use of the humanities in learning about caring. Gelazis (1990) suggested that "nursing education has focused on left brain types of learning - that is, logical processes in thought and expression. ... Today, nurse educators must include a variety of approaches to teaching to educate the full 31 person" (p. 156). In conjunction with appreciating the wholeness of the individual, a final way to help students learn about caring may be by teaching communication skills. Being able to communicate with others facilitates caring about them. Communication is commonly taught in nursing programs, however, some approaches may imply a right and wrong way of communicating. Bishop (1990) addressed the need to use creativity and variety in communication theory. She argued that there are many ways to communicate effectively and that effective communication skills are needed in faculty-student interactions as much as they are needed in student-client interactions. Ways to improve communication skills in faculty members and students require further exploration. In nursing, the application of theory is typically associated with learning in the clinical setting. Application of theory is often a challenge for students, especially for beginning students (Hayes-Christiansen, 1988). Integration of content presented in classrooms typically occurs in the clinical settings because that is where students believe they learn about caring. They acquire skills of caring through interactions with clients as they are caring for and about them. Clinical placements include a variety of nursing specializations: medical and surgical nursing, psychiatric nursing, maternity nursing, children's nursing, and community health nursing. Research on how students perceive caring in specific settings is scarce. Additional research may identify whether certain clinical placements foster caring more than others, or if faculty members teaching in distinct areas model caring differently. Recent research in nursing education has directly and indirectly addressed caring. Studies have examined what is emphasized in clinical teaching and learning (Metcalfe, 1990; Smith, 1991); anxiety in clinical performance (Bell 32 Meisenhelder, 1987; Deska Pagana, 1988; Kushnir, 1986); clinical evaluation (Gallagher, 1992; Malek, 1988); and the effectiveness of clinical teachers (Fong & McCauley, 1993; Mogan & Knox, 1987; Zimmerman & Waltman, 1986). Each area affects how caring is implemented in clinical instruction. One major goal of nursing education is the ability to provide competent patient care in a variety of settings. Striving towards this competence has sometimes resulted in an over-emphasis on science and the acquisition of psychomotor skills by both students and faculty members. The affective aspect of nursing wherein caring resides can be neglected. Research by Smith (1991) outlined how students' views towards caring changed throughout their education. In her study, students described their initially high levels of awareness of caring which, as they progressed through their education, became less important as students became more preoccupied with the technical aspects of nursing. Metcalfe (1990) identified that, although caring is exhibited through an integrated approach to skills, these skills are not always approached in such a way. "Nursing and nurse educators too frequently ignore the fact that nursing skills include a motor component, a cognitive component, an affective component, and a cultural component" (p.148). By placing so much emphasis on the technical side of nursing, students and faculty members potentially minimize the importance of demonstrating caring towards their patients. Stress or anxiety, particularly among students, may also decrease the ability of students to demonstrate that they care about their clients. Research has confirmed that the clinical setting is stressful for students, especially if students are entering it for the first time (Deska Pagana, 1988; Kushnir, 1986). Deska Pagana (1988) suggested stress in clinical performance can be broken down into threats related to feelings of inadequacy, fear of 33 making errors, uncertainty, lack of information about the instructor, being generally afraid, and fear of failure. She concluded that students need to verbalize some of these negative feelings and that nurse educators provide a caring environment when fears are acknowledged and addressed. Bell Meisenhelder (1987) specified strategies to decrease student anxiety. These include helping students to verbalize the anxiety, draw on past experiences, and set realistic expectations. Faculty members who use these approaches with students demonstrate caring towards them. Kushnir (1986) attributed student anxiety to the presence of the instructor who is seen primarily as an evaluator. "One of the possible solutions to this problem is that instructors should emphasize less their evaluative role and help create a more supportive learning atmosphere in which errors are treated as opportunities for learning rather than as occasions for criticism and punishment" (p. 19). Other studies have also investigated evaluation (Gallagher, 1992; Malek, 1988; Wilson, 1994). Caring and evaluation are not often linked in the literature. Evaluations of clinical performance have traditionally been based on Tylerian objectives with an emphasis on skill acquisition. Too often, positive performance is determined by the student's technical ability to do the skill correctly. Although this is important, there are other components of clinical competence. "Student evaluations need to consider the affective as well as the cognitive and psychomotor aspects of learning" (Malek, 1988, p. 34). Using positive reinforcement and giving specific, detailed feedback have been identified as caring strategies when evaluating students (Gallagher, 1992). These two studies were designed to reflect educators' perspectives. Wilson's (1994) research explored evaluation from students' perspectives. Her examination of students' perceptions about learning in the clinical setting included evaluation. "Evaluation was the most frequently mentioned 34 aspect of the instructor's role. ... Evaluation was rarely viewed as a formative process that helped the students to improve their nursing practice" (p. 85). With this type of perception, "students approached or avoided instructors based on how confident and competent they felt" (p. 84). Until students perceive evaluation as only one aspect of their interactions with faculty members, the shift towards a more caring paradigm in nursing education will be problematic. As I have indicated, evaluation by faculty members has been viewed as an aspect of clinical experiences which students did not view as beneficial to their practice. Three studies have addressed the roles and behaviors that make nursing educators effective (Fong & JVfcCauley, 1993; Mogan & Knox 1987; Zimmerman & Waltman, 1986). The effectiveness of educators is not equated with caring, although they may be related. In a review of the research on effective teaching behaviors, Zimmerman and Waltman (1986) identified six broad categories of effective teaching behaviors. These categories are: availability to students, professional competence, interpersonal skills, teaching practices, personal characteristics and evaluative practices. Detail about each category was not provided although concepts such as availability, empathy, positive regard, and respect are included in the categorizations. Mogan and Knox (1987) examined how faculty members and students distinguished the best and worst clinical instructors. Students and faculty members agreed on what constituted the best instructors. These instructors were described as "good role models who enjoyed nursing and teaching. They were well prepared for teaching, and seen as self confident, skilled clinicians who took responsibility for their own actions. They were also approachable and fostered mutual respect" (p. 333). There was less agreement on characteristics of the worst clinical instructors. Faculty members saw them 35 as people who did not enjoy nursing, and as individuals who lacked both communication skills and the ability to help students. Students viewed them slightly differently. They identified characteristics such as being unapproachable, lacking empathy, and being belittling. Both faculty members and students agreed that the worst instructors were poor role models, closed minded and judgmental. Fong and IVF-Cauley (1993) developed a quantitative research tool to evaluate clinical teaching by reviewing the literature on teacher effectiveness, reviewing other evaluation tools and consulting with faculty members. Although no item specifically addressed caring, several items incorporate caring characteristics. These items were recognizing student individuality, respecting confidentiality, demonstrating confidence in the student, and being objective and fair in the evaluation of the student. Paterson's qualitative research concluded that in order to be effective in clinical instruction, faculty members must know their students. "It is significant that the participants in Paterson's (1991) study stated that it is essential to know students in a personal, connected way in order to maximize the positive student outcomes associated with clinical learning" (Paterson & Crawford, 1993, p. 168). In addition to nursing and teaching competence, effective clinical instructors must take a humanistic approach to their students. The ways faculty members incorporate caring into nursing education. Researchers are investigating educational strategies that address humanism and caring in nursing education. Diekelmann (1993b) wrote about the benefits of spending time with students. She emphasized that students are not the only ones to benefit when instructors spend time with them. Spending time with students helps educators learn how to teach by 36 helping them recognize that not all teaching and learning is strictly curriculum based. There are times when the best teaching has nothing to do with content. Bauer (1990) conducted phenomenological research which looked into the way five nursing programs used caring as the central curricular theme. Specific ways faculty in these programs taught caring included: instilling feelings of self-worth; being available, willing to become involved with students and spending time with them; stating performance expectations and setting limits; sensitivity to student needs; providing both positive and negative feedback; providing encouragement and support; and demonstrating a prevailing belief that one cannot teach caring if one really doesn't display it (p. 262). This study also discussed the impact of role modeling. Role modeling not only occurred through faculty interactions with students but also when faculty members interacted with each other and clients. Nelms, Jones, and Gray's (1993) research supported Bauer's findings that role modeling is a powerful means of teaching caring. These researchers added that if faculty members are committed to teaching caring through role modeling, they need to be consciously aware of their attitudes of caring and ensure their behavior is congruent. Miller, Haber and Byrne (1990) interviewed six faculty members. In analyzing the data, they also found that role modeling is a means of promoting caring. Facilitation and effective communication skills also promote caring. "The caring teacher reaches out to students with empathy, sensitivity, openness, warmth and respect" (p. 130). These researchers also concurred with the need to be available to students mentioned earlier by Diekelmann (1993b). "By providing unbounded availability, follow-up and 37 acceptance, they protect students from pitfalls while empowering them through encouragement of self-exploration, self-discovery, and expansion of perceptual boundaries" (p. 130). Three important questions can be asked after reflecting on this literature. Can educators be all these things to students? Do these qualities of caring faculty members accurately convey students' experiences of caring? How do these expectations relate to personal perceptions of balance and reciprocity? Students' experiences of caring. Some research has explored students' viewpoints on caring, but offerings remain scarce. Studies have addressed student perceptions of caring in registered nurses, in students' educational experiences and in interactions with faculty members (Chipman, 1991; Mangold, 1991; Nelms, 1990; Tantano Beck, 1991; Wilson, 1994). Chipman (1991) described students' observations of caring behaviors in practicing nurses. She identified three categories of caring: giving of self, meeting patient needs and providing comfort. Giving of self generally referred to taking extra time with a patient or their family. Meeting patient needs included "pain relief, attention, self esteem, and religion" (p. 173). Providing comfort was associated with easing psychological not physical distress. Mangold (1991) asked students to sort terms related to caring into bipolar dimensions and concluded that no significant differences in the sorting of dimensions existed between students and registered nurses. Students and practicing nurses have similar perceptions of caring. The most important caring behavior identified by participants in the study was listening to the patient while the least important was appearing professional. There is limited research addressing how students perceive caring throughout their education. Nelms (1990) asked students to discuss their experience of caring in nursing education. Students identified time spent in 38 the clinical setting as the most positive aspect of their nursing education because of their interactions with and positive feedback from patients. Students also indicated that their lives outside nursing school were not acknowledged by faculty members. Participants described ideal instructors as competent, caring, supportive, and able to value students as unique individuals. Miller, Haber and Byrne (1990) studied caring interactions between faculty members and students. These authors asked students to reflect upon and then discuss a caring interaction they had with a faculty member. From the student data, the researchers concluded that caring interactions involve four themes: holistic concern, teacher ways of being, mutual dimensions, and student ways of being. Students identified that caring interactions resulted in improved self-worth, esteem and confidence. Students also discussed the types of faculty members they viewed as caring. Caring faculty members were "non-judgmental, respectful, patient, available, dependable, flexible, supportive, open, warm, and genuine" (p. 129). Tatano Beck (1991) asked 47 nursing students to describe a situation with a faculty member whom they saw as caring. Analysis of this data revealed three themes: attentive presence, sharing of self, and consequences of the situation. Attentive presence involves listening to and understanding what the student is saying as well as sensing when something is bothering the student. Sharing of self means sharing student time and emotional support with the student and being non-judgmental. Consequences of situations refers to student outcomes after a caring interaction. These outcomes are feeling respected, wanting to reach out to someone else in a caring manner, and feeling energized after such an encounter. These themes parallel findings about faculty perceptions of caring. As future research is carried out, 39 designs must address distinctions and similarities related to the meaning of caring to nursing students and their educators. Conclusion Students' perceptions about caring require additional investigation. Appleton (1990) identified this need as did Paterson and Crawford (1993). "Limited research is available which examined caring in nursing education from the perspective of the student. If nurse educators are to understand how to enact caring in their interactions with students, such research would be invaluable" (p. 170). An area necessitating study includes an examination of students' experiences of caring throughout their education. This may reveal areas of the curriculum wherein caring is expressed with varying degrees of clarity. Examining students' definitions of caring will help educators appreciate both the unique perspectives of students and the common perspectives of students, faculty members, and practicing nurses. Exploring uncaring interactions as the antithesis of caring interactions will help educators better understand both concepts as they relate to nursing and to nursing education. In this chapter I have addressed literature on caring. I have explored caring as a human condition, as a way of being in nursing, and as it occurs in nursing education. It is obvious that there is much more to do. The research project described herein addresses the gap in research describing students' perceptions and experiences of caring throughout their education. It will illuminate a number of these areas to provide greater understanding about caring in nursing education. This research will broaden the understanding of caring in one avenue of nursing education: that area of students' perceptions about the meaning of caring and how it is taught or learned. The method for this research will be explained in the following chapter. Chapter Three: The Research Method In this chapter, I address the method used to answer the research questions. I begin by discussing the use of a qualitative method in this study. After reviewing this qualitative method, I briefly discuss ethical concerns related to the research. This is followed by an explanation of how I selected the sample. I then introduce the student participants from whom I collected all of the data for this research. I briefly outline the types of questions and themes employed in the interviews. Data handling and the methods for extracting meaning from each transcript are described as well as a brief discussion of the reliability and validity of this study. I conclude the chapter with a discussion of the limitations of the study. The Use of a Qualitative Method To answer the research question posed in this investigation, I required a method of inquiry which would permit understanding of students' perceptions of caring during their nursing education. Because caring is highly subjective and interpreted by each individual and because perceptions come from experiences, a method was necessary that addressed participants' subjective experiences. A qualitative method is suitable when studying caring in nursing because this method emphasizes understanding through rich descriptions of phenomena. The focus is not on objectivity and statistical relevance unlike quantitative methods. Human phenomena (such as caring and events of being, that is illness, health) are not object like; they cannot be inspected or studied in the manner of objects. ... They are not neutral items that call for a neutral and detached independent description. They have to do with modes of existing and the meaning of being (Watson, 1985, p. 80). The qualitative approach is based on an assumption that reality and the knowledge created from reality are subjective rather than objective. Reality is interpreted by both the person who lives the experience and by the researcher. Thus, the biases, intuitions and feelings of inquirers and their subjects must be considered. Qualitative inquiries also seek holism by fitting data into a context. "The strengths of qualitative studies should be demonstrated for research that is exploratory or descriptive and stresses the importance of context, setting and subject's frame of reference" (Marshall & Rossman, 1989, p. 46). The qualitative paradigm seeks to understand the whole, the gestalt, by considering the phenomenon being studied in context and through the process of investigation. How the data is collected is as important as the nature of the data collected because these two aspects must be congruent. Although a holistic view is being sought in this research, I acknowledge the data collected during interviews may provide only a small sampling of the experiences of caring for the participants in the study. In-depth interviews were appropriate to answer the research questions. In the interviews, I used an unstructured interview schedule that consisted of open-ended questions. The questions addressed participants' views of caring in nursing and nursing education. This approach allowed the participant's perspective on the social phenomenon of interest to unfold from their perspective, not from the researcher perspective (Marshall & Rossman, 1989). Interviewing in this manner made it possible to listen to students' perceptions of caring in their education. Students described caring in nursing, the impact of the context wherein caring was learned, and their perceptions of caring and uncaring instructors. This process assisted in placing control of the process in the hands of the participants, rather than in the investigator. Interviews where students could direct what they wanted to say about caring best answered the questions. Although questions existed so that certain areas could be addressed, these areas were not necessarily covered in all interviews. I referred to the interview schedule in an attempt to cover as many of the experiences of caring as possible and to give students a variety of topics for discussion (refer to Appendix A). Participants were encouraged to provide detailed answers to questions. They were reassured that important issues identified by them were also important to me. Qualitative research is often evolutionary. Participants were directed to talk about caring and they provided a wealth of information. Themes revealed in students' descriptions of experiences of caring evolved because they were clarified and refined as part of the analysis and synthesis of the data. Although unanticipated or uncontrollable methodological issues may alter the course and results of any research, the outcome of this research has been decided by myself and by the data provided by the study's participants. Ethical Concerns Interviews and observations require time and energy from participants. "Where people adjust their priorities and routines to help the researcher, or even just tolerate the researcher's presence, they are giving of themselves" (Marshall & Rossman, 1989, p. 69). Formal written consents were obtained for the interviews (see Appendix B). I expressed my appreciation to each participant following the interview and after they reviewed the transcripts. Each participant was informed that all interview transcriptions would be anonymous and confidential. Methods of coding transcripts were developed that were consistent with this. I must acknowledge the possible threat I presented to students because I am a nursing educator and have been, in the past, affiliated with the nursing school wherein this data was collected. Because I know a number of the nursing faculty in the program being investigated, I acknowledge personal biases towards these individuals. When students referred to caring or uncaring faculty members, I asked them to avoid stating the names of individuals. I assured participants that the aim of the study was to better understand how students describe and experience caring in their education. Their interactions with faculty members would be an integral part of caring. By acknowledging the relationship, I attempted to reassure students that it was appropriate and desirable for them to discuss both caring and uncaring treatment by faculty members. As well, I identified myself as an impartial, if not unbiased, listener. Participants were also informed at the time of the interview that data analysis could result in emphases different from what was discussed in the interviews, depending on how themes emerged from the pooled data. Another related ethical consideration was the length of time between the interviews and the completion of the written report. Students were sent information about the status of the research and their transcripts for validation. They were encouraged to contact me if they had any questions or wanted to discuss the progress of the investigation. No transcripts were unacknowledged , however, several letters updating the research were returned because the participants had moved. Unfortunately, only one participant contacted me and discussed the research. I had intended to validate findings in group or individual interviews but because of students' frequent and long distance moves as well as busy schedules, this proved to be an impossibility. Sample Selection The sample selection for this research resulted from the cooperation of faculty members in each year of the program. Interview participants were solicited from a short presentation I did at the end of class in a required course in each year. At this time, I also circulated a handout outlining the research and offered my phone number so that interested individuals could contact me (see Appendix C). The first time I attended classes, I received a poor response. I returned again and was able to get four volunteers from each of the four years in the undergraduate program. It was important to talk to students in all four years of the program to determine if there were any trends or special experiences that set one year apart from another. Criteria for participants included enrollment in one of the four years of the nursing program, being a generic student (i.e. a student who was receiving basic nursing education as opposed to a registered nurse returning to school to obtain a degree in nursing), and being a resident in the greater metropolitan region over the summer of 1993. I planned that the first several interviews would act as pilot interviews. I wanted to clarify the themes and questions for the interviews and to develop my interviewing techniques. Due to the richness of the responses in these initial interviews, the data was pooled with the remaining interviews, resulting in 16 interview transcripts for data analysis. Student Profiles Prior to discussing the content of the transcripts, it is important to gain an understanding of the participants. I do not pretend to know the participants intimately, although a large number of them shared personal experiences and information in the interviews. The impressions I received from the participants were limited to a particular point in time. Gross generalizations cannot be deduced from brief descriptions of aspects of people's lives. The criteria for choosing the participants did not include conventional information such as age and previous experience because the sample size was limited. I could not select the sample to ensure diversity because I had so few volunteers. I hoped to interview three to four students in each year of the program to provide diversity among the participant group. The first time I attended class to ask for participants, no one came forward or called me. The second time I attended class, I was pleased to receive exactly the number for which I had hoped. I was not about to screen the group, knowing I did not have a reserve of participants from which to choose. In the end, I interviewed 16 students ranging in age from late teenagers to individuals in their late thirties. Two students were male. Three participants were visibly identifiable or identified themselves as having an ethnic heritage different from the other 13 participants, whom I have designated, with great discomfort, as members of the dominant culture. The interviewees are introduced according to the year they were in at the time of the interview. Their names have been changed to provide anonymity. Beth was a first year student who came into the program directly out of high school. She saw caring as a genuine concern for someone. Beth saw nursing faculty as mother figures who care about students by taking an interest in their overall well-being. She described caring faculty members as willing to talk and use touch to convey understanding and encouragement. They also were viewed as highly knowledgeable about the content they were teaching. Beth did not see any faculty member as being uncaring. She emphasized the presence of mutual respect between faculty members and students. Sharon was in first year nursing after volunteering in a hospital for a year while awaiting entry into the program. To Sharon, caring was intricately tied to family relationships. Caring depended on the experiences of caring outside the practice setting and included how people were brought up. Caring was described as helping other people by determining what was needed. Sharon talked about the lack of caring she witnessed in the hospital setting and how people were treated without respect. She defined the caring instructor as one who could empathize with the student and saw the student as an equal in all areas of life except school where the instructor was more powerful because of specific knowledge. Dianna entered nursing out of high school and was in first year: Dianna was trying get over a negative situation in which she felt victimized by a nursing faculty member. Dianna was still reeling from encounters which made her feel threatened and insecure. Having experienced these encounters, Dianna's views about caring were based on negative examples rather than on positive ones. She contrasted the only two instructors she had as two sides of one coin. One had been empathetic, patient, and thorough; the other she saw as harsh, rushed, and insincere. Anthony was one of two male students interviewed in the research. He was a first year student who had attended a community college prior to entering the school of nursing. Anthony said that caring was reflected in whatever it took to respect another person. Anthony was able to see parallels between caring in his personal life and caring professionally. He sought connections between these to help him grow. He described the caring instructor as one who respected him by Ustening to and empathizing with what he was saying. The caring instructor also invested time in the life of the student, both in and out of the clinical setting. Sandra was a second year student, and my first interviewee. Sandra had struggled with a faculty member who she viewed as critical and belittling. However, Sandra was able to look beyond this unpleasant situation and also talk about the caring instructors who had influenced her education. She explained that caring instructors were empathetic and available for students. They were able to show students a personal side in contrast to the uncaring instructor who was purely professional and didn't trust students. Martha had one degree prior to entering the nursing program and was in the second year. She described caring as maintaining a person's dignity. One striking thing in her interview was that she was unable to describe any faculty member as caring. The majority of her interview focused on uncaring instructors although she did not indicate that negative interactions had been personally directed towards her. Martha outlined uncaring actions towards students that included grilling in clinical settings as well as a lack of positive reinforcement. Martha also discussed the distance between faculty members and clients, and wondered if this was due to power inequities. Charlotte was a second year student who came from a large family. She went to nursing school directly out of high school. One interesting emphasis in her interview was the concern she had that instructors be cared about and respected. She was the only student to overtly discuss the concept of reciprocity as a component of caring in nursing education. Charlotte described caring instructors as those who chose to focus on positive things rather than negative ones. The caring instructor also attempted to maintain students' dignity by not embarrassing them in front of other people. Communication, especially listening, was important in caring instructors. Kelly said she went to nursing school because of her compassion for and desire to help others. Kelly had been through a negative situation with an uncaring faculty member who was unapproachable, grilled her, made her do everything the instructor's way, and even made her cry. In contrast, she thought the caring instructor was one who worked cooperatively with each student and was there to help students learn. Flexibility and gentleness were admired and opposed the harshness and intimidation she experienced in an uncaring faculty member. Page was a mature student in the third year of the nursing program. Caring was described as having basic respect for another human being. Professional caring was advocating for another person's needs. Caring was viewed by Page as holistic, or incorporating the entire person in any illness. The caring instructor was one who could use humor and self-disclosure to help students learn. Caring faculty members had perspective and were able to use perspective so that errors were not seen as the end of the world. Page described a caring instructor as supportive and someone who trusted the student's judgment. Caring instructors treated students like people instead of like students. In contrast, uncaring faculty members were condescending and brought their own agenda to their teaching. They allowed little creative thought in their students. Kathleen was another mature student in third year. She could not identify any uncaring faculty member but did relate several stories about uncaring actions she had witnessed. Kathleen stated that the stress of being a student often clouded students' abilities to care. As anxiety increased, caring decreased. She pointed out that students take mistakes too seriously and need someone to put them into perspective. Kathleen indicated that caring instructors conveyed respect, approval and trust in students, and gave them responsibility. They also listened and guided students by letting students work things out on their own. Tess was a third year student who felt caring was seeing the client holisticaliy, in addition to anticipating, and then meeting, client needs. How the client was treated strongly influenced Tess' views on caring. She felt that caring instructors treated clients with understanding and respect. Caring instructors were seen as guides who allowed errors and showed an interest in students' lives outside of school. Uncaring instructors made students feel like they could do nothing right. They drilled students and yet implied students either knew too much or not enough. Tess spoke often in her interview about the power relationships that occurred between uncaring faculty members and students, particularly the power held over students through grades. Sheila was a mature student in the third year of the program. She had previously been in education and had also worked in a hospital. Caring meant loving on different levels. It also meant trusting, respecting, and making a difference in another person's life. Her perception was that caring instructors were able to appreciate the idealism in students and maintain some of it. They were seen as accepting, positive and willing to make a conscious effort to see the things students did correctly. When caring faculty members listened, they heard what students were saying and acted appropriately. Uncaring faculty members, on the other hand, did not relinquish the control of learning to the student. They were waiting for errors. Uncaring faculty members didn't acknowledge what students knew. Sheila felt third year students were treated with more respect than students in the first two years of the program. Zelda was a fourth year student pleased to be at the end of a program where learning about caring had been a challenge. Caring instructors, according to her, were calm, relaxed, gentle, and accepting. Students were made to feel competent and confident by a person who was sincere and encouraging. Being a real person was also seen as an important trait in a caring instructor. She related the ability to discuss normal things like family life and activities as one way instructors were real. Overall, she did not feel that faculty members cared about students in the program. Peter, a mature senior student, had been involved in the lumber industry-prior to entering the program. Caring was seen by Peter as being there for another person as well as seeing people as holistic beings. Caring in the nursing program didn't begin until third year when students were treated as adults with respect and equality. What Peter learned about caring in the nursing program he learned in the clinical setting. Peter also commented that caring was conveyed to students through a personal interest in their lives. Faculty who cared were there to get students through the program. Paula was in the final year of the program and actively involved in school politics. She had not encountered any uncaring instructors although she indicated that the first two years of the program were difficult because students had to prove themselves to each instructor. In these years, students were dealing with so much anxiety that it impeded their performance. Caring faculty members were seen as instructors who could acknowledge anxiety and help students overcome it. Paula also described caring faculty members as those who were able to bring out competence and confidence in students and did this through being approachable, fun, positive, interested, truthful and honest. These instructors made people feel comfortable. Paula did relate that the school environment was not caring and supported this by explaining that there was little or no flexibility with grades. She also described how certain leaders in the school reflected apathy towards students through a lack of interest in student affairs. Wenda , a senior student, saw caring as a holistic concern for a person's well-being. Caring involved not imposing her beliefs on others and accepting people as they were. Caring instructors she had encountered were viewed as understanding, warm, and knowledgeable. They had insight and perspective. Wenda described caring instructors as willing to open up and talk. They were relaxed and flexible which resulted in equality between students and instructors. She saw uncaring instructors as being there to make sure students did not make mistakes. They made students feel insecure and inferior. Each of the 16 participants has been introduced in this section of the chapter. These short introductions fail to do justice to how insightful, honest and sincere each participant was, however, the data reveals this depth. I am grateful to them for their unique, special contributions about their experiences of caring in nursing education. The data provided by the participants permitted me to render numerous meaningful lessons for myself as an educator and for others who read the research. I now address the interviewing process in greater detail. The Interviewing Process The interviews occurred towards the end of the school term. Participants were sought in February and interviews went on until early May. I was pleased that students took time for interviews when they were also preparing for final examinations. I expected students to come to the interviews feeling tired, but instead found them alive and vibrant with enthusiasm for the topic. Each of the 16 students gave over an hour and a half of their time to describe caring in nursing education and for this I am grateful. I arranged to meet with students at a mutually agreeable location, away from the school of nursing. I felt it was necessary to avoid the school, because students might have felt inhibited by the physical environment. All but three interviews took place in a theological school on campus, the remaining interviews occurred in individuals' homes. Interviews transpired at all times of the day, lasting from one and a half to three hours. Before we began our interview, I tried to make sure participants were as comfortable as possible, and had something to drink if they wanted it. I started out by briefly explaining the research in terms similar to those used on the information sheet provided in their classes. I took time to explain the intent of the interview prior to beginning it. I described the need for written consent, obtained it and then reviewed the use of the tape recorder. I also outlined the use of non-structured questions and indicated the discussion was not limited to the interview format. Interview questions. The interview format or schedule I developed was broad. It consisted of questions that could be explored during the interview but were not mandatory. Most of these questions were in fact covered in the interviews and, as well, several lines of inquiry were added after the first several interviews. As students talked, I listened without interrupting unless I needed to clarify a point. In the first interviews I sometimes felt that students were off topic and wondered how to redirect them, but on reflection, I realized they needed to verbalize anger or frustration before addressing caring. Students talked about their experiences of caring in their interviews. The participants included interactions with faculty members in their discussions but were far broader in their descriptions of the concept of caring. Students defined caring and articulated the ways caring was shown, discussed classroom and clinical experiences of caring, and described caring and uncaring treatment throughout their education. It is worth noting that the content from the interviews focused primarily on caring in the clinical setting. I did not specifically ask for information related to clinical teaching, but when students talked about their experiences of caring they often placed them in the context of clinical learning. One reason for this may be that students associate the clinical setting as the primary environment where caring takes place. This is where the participants felt they learned the most about caring. Data analysis. Once the interviews were completed, I listened to them individually and then began the arduous task of transcribing them. Anonymity for each participant was provided by coding the transcripts according to the year and juggling the participants' initials, so that they were recognizable only to the participant and myself. I used pseudonyms in all references to participants. The transcription process extended for longer than I had planned, and I did not return transcripts to the participants until late August. Transcripts were returned to ensure congruence between participants' perceptions of their experiences and their expression of these ideas through their use of language. No participant contacted me about the content of their transcript; only one called to discuss the progress of the research. After the transcripts were completed, I read them, jotted notes on the transcripts and made detailed notes about each interview. It was necessary to read transcripts repeatedly until themes began to emerge from the data. I searched for words, phrases and themes that occurred in one specific transcript and then looked for these components in other transcripts. This process of going back and forth between parts of an individual transcript, that entire transcript and all transcripts is known as the iterative process used in hermeneutics. Approaching the data in this manner gave me insight into what was important about caring to participants. I also wrote in a daily journal about my reactions to the data and how I was interpreting the data. The next step in the process of data analysis was to break the transcripts down into excerpts of meaning. This was done by first reading each transcript, then marking, cutting out, and pasting each excerpt onto a white 5X8 card. This resulted in stacks of cards from each transcript, which were coded on the bottom right and left hand corners. They were coded according to year, participant, and page on the left lower corner, (i.e. 2:3:7) and according to the order in which they were taken out of the transcript on the right lower corner. Over 550 cards ensued from this process. Once this was completed, I began re-reading the excerpts, and wrote descriptors in the upper right corner. The descriptors were single words or phrases used in or deduced from an excerpt. These descriptors summarized or clarified key points in an excerpt. Most excerpts had several descriptors. In the upper left corner, I categorized the excerpts by content. For example if an excerpt was about an ideal instructor, those words were placed on the upper left corner and descriptors went on the upper right corner i.e. understanding, individualized teaching, desired student learning. From this coding of the excerpts, categories began to materialize. The three main categories to evolve were: the meaning of caring, the context of caring, and educators of caring. The three categories became the source of organization for the analysis of the data. Within each of the categories, there was further breakdown of the excerpts into subdivisions that changed with further analysis, but not significantly. Reliability and Validity Having addressed how the data from the interviews was handled, I will turn my attention to issues of reliability and validity. This research sought to richly describe how caring is experienced by students in the educational process. The credibility of this research depends on the reliability and validity of the study. How reliable, or replicable the study is, may not be as important as understanding the phenomenon as it occurred in this one setting at this one time. It none the less requires discussion. Reliability addresses whether independent researchers would obtain the same data and results obtained in this study. I now address several problems associated with reliability as outlined by Geotz and LeCompte (1984) that were applicable to this research. Researcher status position asks the question "to what extent are researchers members of the groups being studied and what positions do they hold?" (p. 214) Because I was conducting the research as part of an advanced degree, participants may have seen me as more of a colleague than a faculty member or an independent researcher. This may have affected what they told me. An additional factor affecting how students interacted with me may have been the fact that I had previously worked in their school of nursing. This may have led them to disclose information differently to me than they would or would not have if they were discussing caring with another researcher. Disclosure of information also relates to social situations and conditions which addresses the appropriateness of sharing certain information with the researcher. When trying to replicate the study, this would have to be considered as would the fact that volunteers may be motivated to share information differently than participants selected through other means. In dealing with analytic constructs and premises or the delineation of research constructs and categories, I explicated all terms in the research questions and sought consistency with them throughout the study. Methods of data collection and analysis means that the researcher "strive[s] to present their methods so clearly that other researchers can use the original report as an operating manual by which to replicate the study" (p. 216). Prior to collecting any data, I was required to present a proposal of the research to the research committee and the ethics committee of the university. Both assessed and accepted the research plan. In addition, I explained the research at the class presentations and at the outset of each interview using the same information sheet and cue cards to cover salient points. To maintain consistency, I also performed all of the interviews myself and scheduled only one interview per day with one exception. Immediately after the interview, I wrote field notes which I used prior to listening to the interview. After kstening to it once, each interview was transcribed verbatim, by myself. I tried to remain as close as possible to the data while analyzing it by reading, making notes, and reflecting on transcript content. By using examples and cross references from interview transcripts, I attempted to ensure that the concepts, categories and conclusions were rooted strongly in the data. Validity refers to the accuracy of the research findings and how comparable the results are to other populations (Geotz & LeCompte, 1984). An important threat to the validity of this study is referred to as "observer effects" by Geotz and LeCompte. Reviewing findings with participants ensures that the categories derived from the data and findings are meaningful to participants and, in fact, reflect participants' views of the phenomenon being investigated. Transcripts were returned to participants to allow validation of what they said during the interview. I planned and attempted to meet with students to validate the findings of my study, but because participants could not be contacted, this was not possible. The transferability of the research to other populations depends on how well the concepts and findings are described. I have attempted to sufficiently describe the research process to guarantee that other researchers can compare this study to related studies about caring in nursing education. Also, because rich descriptions of caring in nursing from students' perspectives are the focus of the research, the themes identified should be meaningful to other nursing students in other educational settings. Therefore, the results should also have some transferability. Limitations of the Research After reviewing the research process, it is not difficult to see things that could have been done differently. To maintain the philosophy of qualitative research, the investigation of students' experiences of caring in nursing education could have included participant observation in clinical settings, classrooms and within the social aspects of the school environment. I could have performed faculty interviews in addition to those conducted with students. The sample size could have been significantly larger and could have been purposefully selected. These are not factors easily incorporated into one research study. Investigating caring in nursing education as I have is none the less valuable and important. I have addressed the qualitative research method used for the study. I have reviewed how the sample was selected and have introduced the participants in this study. I have outlined how the interviews were conducted and how the data was analyzed. Validity and reliability have been discussed. The next two chapters deal with the findings from this research study. ^ Chapter Four: Student Descriptions of Caring Thus far, I have taken a look at what caring means from the viewpoint of philosophers, theorists and researchers. I have also outlined how the research was conducted. The next two chapters address what participants shared in their interviews about their perceptions and their experiences of caring in nursing education. This chapter communicates students' descriptions of caring. It includes a section describing how the context in which education occurs affects students' perceptions of caring. The following chapter describes the types of instructors from whom students learn about being caring and uncaring. This chapter addresses participants' descriptions about caring in nursing and in their nursing education. The definitions of caring are not neat and tidy definitions because participants did not provide dictionary definitions of the term. Throughout their interviews, students grappled with the meaning of caring in nursing. Students described caring using statements about how they thought caring was demonstrated in the nursing profession. This chapter presents the terminology used most frequently by students to describe caring in nursing. The descriptors chosen for this discussion are: empathy, helping others by doing things for and with them, compassion, professional caring, and holism. Each descriptor is explored in an attempt to elucidate nursing students' thoughts about the meaning of caring. Although the terms and phrases used to describe caring are the primary focus of this chapter, I also discuss student beliefs about caring, as well as students' descriptions of relevant contextual influences which affected caring. The descriptions of caring provided by the students are explored as a blending of attitudes and actions. I conclude by summarizing students' comments and briefly relating them to nursing education. Descriptors of Caring The content for this chapter comes from words or phrases which have been condensed into what I refer to as descriptors. In total, 13 descriptors emerged from the data. A number of the descriptors included other terms. The descriptors that best captured students' definitions of caring are included in this discussion. I classified descriptors according to the students who said them and according to the year in which they occurred. Lists of descriptors and the number of times they were mentioned were compiled (see Appendices D and E). Empathy. Empathy was the most commonly used term to describe or define caring in nursing. It was mentioned by 13 participants and was recognized by students in all four years of the program. The term empathy encompassed statements about a variety of ideas and actions. Words and phrases included in the empathy descriptor included understanding, putting yourself in the client's position, seeing another person's point of view, being emotionally or physically present and listening. Dianna said "it [caring] means to be understanding; to see their point of view. ... You have to put yourself in their position more and you know, look at it from their point of view instead of your point of view." Paula described caring as "being able to, whatever situation you are in, to be able to think about what it is like for the other person." According to the research participants, being present and available for another person helped them have empathy for that person. They sometimes referred to this as being there. Being present included a physical component such as simply being in the patient's room and talking about current affairs or life outside the hospital. When students referred to being there however, they emphasized emotional, not physical presence. Being emotionally present and available for clients was seen as critical to empathy and deserves attention here. For Charlotte caring "is showing that someone is there. It is a real aspect of caring, to show that you are there and to show that you are concerned." To Anthony, being present for a client meant helping them adjust to changes resulting from their illness. He indicated that "caring means that you sit there and not get in the way of them going through whatever they are going through. I think sometimes that that's what it comes down to, not so much being there but not getting in the way of the other person resolving a lot of things." Reassuring people was also involved in being there. Sandra commented "I think it's the psychological part of making sure that the patient is comfortable and relaxed and looking after them psychologically like talking with them and being there. ... It's like making sure that they are at ease mentally." According to participants, when attempting to understand another's point of view and emotionally support him or her, the caregiver must also use effective communication skills. Listening was identified as the most important communication skill necessary to being empathetic and caring. Students identified that individuals are caring towards others when they take time to listen. Charlotte said "caring involves an awful lot of listening. ... Listening is so important. Not many patients get listened to. And validated, 'yes you have pain. Okay we can deal with that.' Listening and saying 'yeah, this is happening.' " Martha indicated that nurses show caring by "being able to listen to someone instead of telling them what to do, or how to do something or telling them how they should feel." Paula said that "empathy in caring [is] taking some time to really listen to a person." Anthony portrayed caring as listening to his clients. "One of the nicest parts was learning how to put the brakes on for a second and stop and listen to the little important things. There were a couple of clients I had who really just needed someone to listen to them." Being empathetic towards another person demonstrated that students cared about them. Caring was also described by participants as acting upon the empathy one has for another person. Often, this action was related to helping a person by doing something for them or with them. Helping others by doing things for and with them. The phrases doing things for or helping others were mentioned by 11 participants. What do they mean? For a number of students, the descriptor, helping others by doing things for and with them was tied intrinsically to empathy. According to students' comments, to do things for or to help others implied that the caregiver was acting upon their empathy for the client. For these participants, caring meant understanding each client's position and then acting upon that understanding. As caring nurses, they used their empathy towards their clients to inform their nursing practice. Kelly indicated that caring meant "to be empathetic and to feel for people. [It means] to try to put yourself in their shoes. I think it really helps you to deal with the care you are giving them ... [by] just doing little things that will help them understand what you are doing with them and just feeling for their whole situation." Peter said "it's just how much you can feel for what they [the client] are going through and what you can do to help them out." Martha discussed how caring meant understanding and then anticipating the needs of others. I think [caring is] just being able to appreciate what someone is going through and knowing what they are going to need or what they want before they ask for it. [It involves] being able to listen to someone instead of just telling them what to do or how to do something. Students also said that the nurse must appreciate and act upon the client's perception of what they want or require, rather than purely impose what the nurse thinks is in the client's best interest. Caring nurses work with clients by respecting their individual concerns and demands. They do not impose a treatment without considering their client. Page indicated that when doing things for others the nurse is "making sure that the needs they [the clients] perceive are met." Sharon put it this way. It [caring] is doing things for others. It's your ability to look at a patient in nursing and to try to interpret, to figure out if they need anything. To sort of interpret their needs, without always asking if they are struggling with something, if they need help. Instead of asking "do you need help?", maybe just going ahead and helping them. To help others meant that a need for help existed. Participants discussed how, in the context of caring in nursing, people are typically going through a crisis or challenge that may inhibit them from coping independently. Thus, an individual becomes more receptive to external help, in this case, from a nurse. Participants discussed that although helping another is the nurse's job, they are privileged to influence another's life in such a special way. Anthony said "it is a sense of walking beside someone when they are going through something difficult." Zelda concurred that "it's a real privilege to be with a person in a critical moment in their life and to care for them." Sheila said "you just care about meeting their needs in their moment of need." Helping others by doing things for and with them doesn't just happen. There are skills involved in helping other people. These encompass some of the skills of caring. Anthony identified these skills as "doing the footwork, [such as] listening and being supportive and non-judgmental and being accepting." Appropriately responding to clients in a caring manner was another skill which allowed students to help and subsequently to care for and about their clients. The way words and actions are communicated to the client determines whether or not the nurse and his or her actions are interpreted as caring. Communicating caring is another skill associated with helping others and thus caring about them. Dianna expressed that communicating caring is "feeling for that person and showing [that feeling] through your speech and non verbal ... communication." For Beth, caring was demonstrated through the sincerity of her emotions. "I think [caring is] being sincere with my feelings. I guess [it is] in your facial expressions too. You can tell if someone is caring for you. There is definitely a feeling that's brought across when you actually care for someone and when you don't." Kathleen discussed how caring means making sure that the client interprets any action towards them as a caring action. This was important to her because "caring without being able to communicate that you care isn't worth a lot. ... In order for a person to feel cared for or about, they have to perceive it as being caring. And that is how caring is manifested." Finally, helping others by doing things for and with them enhances the meaning of caring when whatever is done is done well. It implies respect for a person by choosing to care for them the best a person can. Tess depicted this respect for clients when nurses perform tasks to the best of their ability. As I reflected on this, Tess appeared to be committed to a personal ethic of excellence in carrying out her professional responsibilities. If she was going to do something, she felt that the client deserved her best efforts. Caring is acting on the patient's behalf for the best of the patient whether it be doing your skills well or whether it's communicating with them well or going out of your way to do something that will mean a lot to the patient. Doing that something is really important. Not just going in and doing your job and leaving. Doing it to the best of your ability. In summary, helping others by doing things for and with them describes caring in nursing because when the nurse acts upon his or her empathy for the client, caring is demonstrated. There is an expression of caring as the nurse sensitively anticipates and then meets needs to the best of the nurse's ability. When a nurse does things for the client, he or she may not be acting out of empathy for the client. The nurse may be carrying out a physician's order or acting upon her dinical judgment. Regardless, the client deserves consideration and involvement in these actions whenever possible. Compassion. Compassion was another descriptor participants used to describe caring. In this research, compassion subsumed the terms love, concern and kindness. It was mentioned repeatedly by students in three of the four years. For Sheila, caring was a form of love. People let you into their lives differently because I think there is an opportunity and if you are willing, the opportunity presents itself [and] you can have a very special relationship and I guess ... what we are talking about is caring and it boils down to love and you can love on many different levels. Anthony, Beth and Charlotte alluded to caring as being genuinely concerned for another human being and linked this concern to compassion. For example, Beth said "I think caring is showing a genuine concern for someone. It does follow along the same lines as caring for a friend but with a friend ... it changes things, you know who they are." For Anthony, caring "comes from an area, a genuine area of being helpful and concerned ... It's compassion really, like it is a sense of walking beside someone when they are going through something difficult." Kathleen linked kindness and compassion with caring in the profession of nursing. Nursing is important when there are so many times a small amount of nurturing, of human kindness, can take people miles. People can go a long way in a world where there isn't a lot of it. People are starved for a moment of real human kindness. Nurses are really privileged because often they are in positions where they are able to give it. Upon reflection about comments relating caring to compassion, it occurs to me that being in a position to show compassion towards others and actually showing it are not the same thing. Nurses must sometimes avoid intense personal connections with clients for a number of reasons. For one thing, it is not appropriate for nurses to get too involved in their clients' problems. In addition, they must maintain a professional perspective in order to remain effective health care providers. Nurses must be selective about caring on a more personal basis because, otherwise, the emotional demands could diminish professional performance and result in negative personal consequences. Professional caring. Distinguishing between personal caring, or caring for family and loved ones, and professional caring, or the caring associated with nursing, was another important way in which students described caring. Making these distinctions helped clarify what professional caring meant and why it was important to participants. Students viewed professional caring as having less depth than personal caring because relationships with clients are not as deep as those with loved ones. Time and intimacy were often limited in professional relationships between students and their clients. Kelly stated "you've grown up with your family, there is more than just caring, there is love. With a patient, I would never say that I love my patient. I wouldn't say that." One reason the depth of the relationship is limited may be the time restrictions placed on nurse/client interactions. Martha indicated that "the only real difference is that I wouldn't get too involved with someone who is a patient whereas if I had friends and family, the caring thing is something that goes much deeper than for just a few days." Tess talked about the flexibility with time when dealing with loved ones. "With friends and family you can work around [time] whether you expand it over an hour, a day, a week ... you have a lot more time that way." In contrast, "with your patients you only get five minutes with one patient and that is only five minutes of whatever and four minutes and fifteen seconds is doing [something] practical and the other forty five seconds is something [else] so it [time] is very limited." Anthony summarized that professional caring differed from personal caring by saying I think professionally that's different from personally because personally you have more time to know the nuances of how people like to be cared about. As a professional, sometimes people [clients] won't share the little discomforts with you and all of a sudden they have this huge discomfort that they lay on you and they need help to cope with. Then as a professional, you feel sort of lost in there. ... On a personal level, you have a chance to feel the situation out over time. Another reason for limitations on the depth of professional relationships of caring results from the focus of the relationship. In the nurse/client relationship, the client is the obvious centerpiece. Dianna said it's not like when you are interacting with your family ... because in the hospital as a nurse it is not appropriate to tell them your feelings. It's them who is the prime focus. It's their feelings you are listening to. ... In the hospital, you don't really offer as much [about yourself] as you take in [about them]. Another reason why professional caring between the client and nurse is different from personal caring is that choices must be constantly made about becoming personally involved or professionally detached. These choices do not always exist when dealing with family or friends. Kathleen indicated that when she became involved on a personal level, she lost her ability to be effective in her professional caring for the client. "I guess that's what helps me guard against getting too personally involved, I get too emotional and then I can't function to help the person. I become a commiserator instead of a facilitator." By becoming too involved with a client, Kathleen ran the risk of becoming ineffective as a health care provider. Kathleen described becoming entangled in her client's problems instead of finding solutions to those problems. When she was aware of this and pulled herself away from it, she was able to help the client. One striking example of caring occurred when a participant chose to ignore the professional detachment of the nurses around him. Peter told a compelling story about the caring he showed to a family with a dying child. He prefaced it by saying he didn't know how grave the situation was. He just jumped in and cared for a family in need. [I] remember when I was in pediatrics in third year and I don't know if it is a good example or not because I did it almost by accident and what happened was that there was a young baby that was really ill with a heart defect and would not live more than a couple of weeks and I hadn't been on the ward very long and I didn't, I wasn't up enough on, on the condition that I [would] know how badly the baby was doing. And the parents came in and apparently all the nurses had been really standoffish with the parents because they knew how ill the baby was. And the parents came in and I talked with them and the dad was really dirty because he had just come off work and I went and got him a gown and showed him how to wash his hands and got him a pair of gloves so he could sit and hold his son. And the nurse came up after and said "we haven't done that, we, none of us have done that, that's the first time he's gotten to hold his son." And it was because they had all been so stand-offish and didn't know exactly how to go about it. And the dad was really happy that he could do that. Although participants realized that becoming personally involved with their clients could not go on all the time, they discussed how they wanted and needed to make a difference once in a while by making a personal commitment to a client. Sandra said it well. "My goal was to, if I could make a difference to a patient, mentally, once in a while, not all the time, but once in a while, then that would be my ultimate goal in nursing." A final aspect of professional caring identified by students was being caring with clients when clients did not seem to care for themselves. What students learned was that all clients, even the taxing ones, require sensitivity, respect, and acceptance. As Wenda put it "I mean you are in there and you have to care for this individual but it seems to you that they are not caring for themselves. ... You have to ultimately leave the decisions with the patient and just sort of accept them and work with them when you can." Page added the need to look beyond the anger or denial in the client. "You go in and sometimes people are real angry about being there and they just want you to leave them alone. But you respect that and somehow gradually help them to bring back some of their self-control." The responses regarding challenging clients revealed a mature approach for dealing professionally with people in pain. Understanding and caring for people who seem reckless about their health may be facilitated by taking a holistic view towards them. Holism. Most students described caring in nursing according to physical, psychological and social aspects. They united these components through the concept of holism. Participants felt that caring occurred through treating the person as an integrated being with physical, emotional and social aspects. Students saw their clients as complicated, intricate beings who juggled a number of priorities, illness being only one of them. Seeing a client as a whole person demonstrates respect. Page said It's showing an interest in their family or their job or something that they do or it's just letting them know that the reason that I'm interested in them is not just because I have to come in here. ... Looking at them as a whole person is respecting them, and that to me is really a basis for where my caring starts. For Wenda, caring began when she was able to relate to the client as a normal person experiencing everyday occurrences. By just talking with them about any, any sort of, talking with them on an everyday basis. Asking how they are doing, how their family is if they have been in to visit. Talking about situations in their home environment, things outside of the hospital aside from "do you have any pain, how are you coping in the hospital." Like dealing with their hospital situation or experience but also expanding for other parts of their lives that might be affected. Tess concluded that "it's not specific to one area of nursing, I think it's more than just emotional or social. It's a combination of all those things and if you don't look at all those things, I don't think it's really caring for the patient. I take a very holistic view." Why is it important for nursing students to take this holistic view of their clients? By viewing clients in this way students express their caring because they are trying to appreciate and accommodate complexity in people's lives. In this section I have addressed words and phrases the participants used to describe caring. According to the students interviewed, this complicated concept involves having empathy and helping others by doing things for and with them. Communication skills such as listening also helped participants define what it means to be caring. Caring consists of compassion, professional aspects, and holistically envisioning another person. I would now like to discuss the descriptors according to their locations in the program. It is interesting because this distribution helps illuminate the timing associated with learning about certain aspects of caring in their education. In addition, it reveals possible gaps in participants' learning about caring. Terms absent from one year. When all of the descriptors were collated according to year, as shown in Appendix E, at least one was absent from every year in the program. The phrase missing from the interviews of first year students was holism in caring. Although this term included physical and psycho-social aspects of caring, students in the first year of the program did not mention it. Perhaps refined views on caring emerge as students progress through the curriculum. In second year, honesty and respect were descriptors curiously absent from transcript excerpts. Students interviewed from second year repeatedly talked about feeling inadequate and misunderstood by their instructors. Each of the four participants in second year discussed experiences in their education which they had equated with a lack of respect and understanding. There may be an association between what the students experienced and the fact that they didn't mention respect and honesty in their descriptions of caring. The third year transcripts mentioned all descriptors except acceptance. In fourth year interviews, compassion was not mentioned. Perhaps participants in the latter years of the program assumed that acceptance, compassion and talking were a part of caring and did not articulate it. Further research could explore these terms in greater depth to determine whether their absence actually indicates gaps in participants' learning about caring. Terms mentioned in two years of the program. Terms present in two of the four years also provoked thinking about findings. Acceptance was used to describe caring by participants in the first and final years of the program. Nurturing was referred to in the second and third years whereas advocacy showed up only in the latter two years of the nursing program. It may be that advocacy is a more advanced concept that is not taught until later in the nursing program or that students are not confident enough to act in the role of advocate until later in the program. Empowerment was mentioned in first and third years. Perhaps content on empowerment is most clearly presented to students in these two years. Students' Beliefs about Caring Before leaving this discussion about students' descriptions of caring, it is helpful to explore additional comments made. Participants in the study provided data about their perceptions of caring through discussions about what caring meant to them before they entered nursing school and through discussions about whether caring is learned or innate. Student perceptions of nursing as a career choice. The students were asked: "Tell me about your ideas about caring when you first started the program. How does it compare to how you feel now? If it has changed, why do you think it has changed?" The answers to these questions resulted in a discussion about why participants wanted to be nurses and what motivated them to choose nursing as a career. The most common descriptor used by participants to describe why they chose nursing was helping others by doing things for and with them. Nurturing was also mentioned. Recall that the former descriptor involves acting on one's empathy with the client, communicating caring to the client, helping someone who needs help, and being committed to doing the job well. Peter saw nursing as an opportunity to help others. "I've always been interested in it because to me, it is something that is important, like you are actually working to help somebody and make their life better in some way." Dianna chose nursing because she "really wanted to do something for other people rather than for myself and that's the reason I went into nursing, just to help others." Zelda chose nursing because of the "satisfaction you can get... from doing a good job with a patient and relating to them and helping them out." Students sought nursing as a career because they thought they could help people. The students neglected to indicate if they contemplated the impact of helping individuals help themselves, rather than a more dependent mode of helping. Also, their thoughts about the consequences of constantly giving or offering help if they can often receive little in return from clients might have been interesting. It was also interesting to explore students' views about caring as they ruminated on whether it is learned or genetic. Nature versus nurture. Participants were asked whether they thought caring is something you are born with or something that is learned. Respondents from each year said that caring is either innate or a combination of innate and learned characteristics. No respondent indicated that caring is solely learned. Of eight students who addressed this issue, five felt caring was innate. Beth announced "I don't think caring is, I don't think it is something that can be taught exactly, do you know what I mean? I think you either have the ability to care or you don't, no matter what amount of teaching, you can't change that." If caring is described as being completely innate, why would educators attempt to teach it? Wenda stated You know, I think it's a combination. I think a significant part is probably innate and you learn to develop that sense within you through learning about caring,... role modeling. But I think it absolutely has to be a part of you innately. I think that's how come some nurses are better nurses maybe. They have that sense of being able to really care about somebody. And you can't always learn that. Attitudes and Actions of Caring Caring was described as a blending of attitudes and actions which can be learned or innate. When students depicted caring in this way, they supported conclusions drawn by a number of theorists in nursing (Gaut, 1981; Koldjeski, 1990; Leininger, 1984b; Morse et. al., 1990; Roach, 1984). Educators can learn from students' views about caring being innate and learned. Faculty members can affect students' perceptions of caring by role modeling caring attitudes and demonstrating caring behaviors towards their students, clients and colleagues. Educators must work from the premise that through caring interactions, the attitudes and actions of caring can be positively affected. A number of the descriptors can be classified as being more attitudinal than action based. Empathy, compassion, and respect were brought up numerous times by the participants. Another descriptor, helping others by doing things for and with them, is best classified as action oriented. Two descriptors, professional caring and holism consisted of components of both attitudes and actions. Professional caring involves learning acceptance and respect for clients in addition to providing physical and emotional care. It also involves making choices about the level of involvement a nurse has with his or her clients. Holism seeks to appreciate the individual as an integrated whole and acts by taking this into consideration. Having described students' descriptions of caring, and their beliefs about caring, I would now like to address how various influences throughout the educational process affected students' perceptions of caring. These influences are included as a part of the context in which caring is learned and played an important role in students' learning of caring. The Effects of Context on Students' Perceptions of Caring Before nursing educators can facilitate learning about caring in nursing, they will benefit by knowing as much as possible about students' thoughts about caring. If faculty members do not know what students think about caring in nursing, what affects their thoughts about caring, or it how it is demonstrated, then developing effective interactions where caring behavior is modeled may be severely impeded. As faculty members learn more about students' views about caring in nursing and about caring as part of the educational process, instructors are better equipped to positively influence students' development of caring. Thus far, I have explored what caring means to students. I would like to now turn to what affects perceptions of caring. Students addressed a number of contextual influences on caring. Context was defined earlier as the circumstances surrounding the educational process which affect students' experiences and perceptions of caring. The contexts affecting students' perceptions of caring to be discussed are: students' perceptions of their progress through the program, the emphasis on specific content, the transfer of theory to practice, interactions with clients, interactions with fellow students, the role of leadership, and an environment where caring occurs in the educational setting. Students' perceptions of their progress through the program. Every student must complete the required and elective courses outlined in the university calendar in order to graduate. Students talked extensively about what they experienced in the various years of the program. Discussion in this section explores the students' progress through the nursing program. One second year, two third year and all fourth year participants expressed concern about the treatment of students in the first two years of the program. Paula reflected "I remember coming to first year and I didn't have a great start. I don't remember why in particular, but I remember thinking to myself 'am I in the wrong place?' I thought these people were nurses and I don't feel like they are caring at all. And that has changed I guess for me. But I remember feeling that at first." Peter and Paula talked about the emphasis placed on skills in the first two years of the program and the difficulty of applying them in the clinical setting. Peter related that "with almost all of the instructors I had in the first two years it was so focused on the skills we were doing. There was no focus on any personal trait... that we could bring to nursing." Paula added "the first couple of years are hard to get comfortable and you have to build that up in the clinical setting ... but I think it could have been made easier. How? More encouragement, more let's see, confidence in the level I'm at." Becoming more comfortable with the skills associated with clinical competence takes time and by third and fourth year, participants felt more confident. As Wenda explained "I found that maybe third and fourth year students are more comfortable or maybe more oriented because ... they have had a bit more interaction, they are feeling more comfortable with themselves and with the nursing process and everything." Paula felt competence was anticipated by the faculty members in the last two years of the program. "Maybe it's an expectation that in third and fourth year you are able to do that so it's easier to be confident as a student because it's expected. But in first and second year it should be acknowledged that 'of course this person doesn't know exactly how to do this.' " Although research participants expressed greater self-confidence towards the end of the program, the price was high. Sheila relayed "I did a really good job in my clinical experiences in second year and even my evaluations were good but I didn't feel good ... I left in tears." Students explained how their passage through the nursing program got easier after the first two years were completed. Why this was so, invites further research. Emphasis on specific content. In first year, the lecture content associated with caring was described in terms of nurturance and empathy. Beth characterized it this way. "Empathy. I think that is basically what the whole course is about. Like they were teaching us to ... give unconditional care to people and in doing that you have to be caring to every sort of person no matter what cultural background they have." Although content on caring was presented in first year, opportunities to apply the content were described as limited. Second year student Charlotte, expressed it this way. You are given this great big concept of caring in first year and you think "oh how boring." I think they could do a better job of it... because yes, it is important in first year, but you are so limited with your skills to grasp the concept of caring ... and you don't really get that many opportunities. I think they could intersperse it more throughout the first and second year. Sandra amplified Charlotte's sentiments. "I think they could include that aspect [the caring] of it in the lectures and whenever we talk about factors or whatever. In anything that we learn, that component really should be encouraged." Other content taught throughout the curriculum positively affected students' learning about caring. For example, Wenda recounted how communication theory promoted her assimilation of caring. "I think the communication development is part of the program all the way through and has helped express the caring." Peter described how the emphasis from specific to whole aided his learning about caring. "What has changed is that the focus has gone away from zeroing in on a specific aspect of a person ... [to] looking at the whole person, the whole family, and sometimes the whole community. We can't care for anything unless there is a more holistic approach taken to it." Page detailed how an emphasis on holism also promotes caring by helping understand or empathize with another human being. This is one thing I really appreciate about... this program, that they really push looking at what's beyond this person in the hospital bed. ... It's always looking at this person and where they've come from and the environment and the resources that they have or don't have. ... Looking at them as a whole person is respecting them and that to me is really the basis for where my caring starts. 78 Transfer of theory to practice. Although caring is introduced directly or indirectly in course content, learning about caring, and actually providing care, are not the same thing. Students' ability to apply the theory they learn is essential to practicing caring. This transfer of theory proved to be challenging for a number of participants. Students in each year of the program addressed the difficulty of shifting classroom theory to something that was practical and relevant. Students' experiences in the clinical setting help them apply theory because they provide opportunities to use it. As Sheila put it "I think I have learned to be more caring ... and have learned it on a theory level,... intellectually ... and on an emotional level because of my experiences with students, patients, clients and ... with instructors." The integration of theory and practice was often not smooth. Martha and Kathleen talked about the frustration associated with the incongruity between classroom learning and clinical application. Martha asked "why are we learning this here in lecture when the hospital is completely different and it seems like two different worlds?" Kathleen too, said "it [caring] is presented in theory and yet it doesn't get translated, the import of it doesn't get translated." She concluded "sometimes you are almost penalized as a student when you take time to do something the patient needed that you felt you had to do at the time. The instructor doesn't realize it and they are like 'get it organized.' " When students have opportunities to use theory, they learn more thoroughly. Peter said "you can talk about it all you want in class but the theory doesn't sink in 'til I actually put my hands on it and use it. They give you a bunch of concepts but they are only words until you start in the hospital." Interactions with clients. Martha and Charlotte discussed how they learned to be caring by being aware of and acting on client needs. Charlotte talked specifically about how school generally and the clinical setting specifically "[have] helped me to be more aware of what their [the client's] needs are and when you are more aware of what their needs are, it's easier to communicate with them, it's easier to empathize with them." Martha suggested that learning to show caring involved maintaining a person's dignity and showing respect for them. "Just things like, if a patient is in a four bed room, not talking to them about personal things in front of the other people in the room, and closing the curtain when maybe other people wouldn't think of that ... you know, because you put yourself in their position and know how they feel." In addition, working in the clinical setting allowed students to deal with the harsh realities of clients' defeats and victories when coping with life-altering events. Students learned a great deal about caring by observing interactions of members of the healthcare team in the hospital. Unfortunately, most comments about professionals in the hospital were negative. In one way or another, students were upset by the impersonal treatment of clients. They witnessed this in a variety of behaviors. For Martha, it was how health care professionals talked about the treatment of clients as if they were not there. "I think one of the major things is, and this comes from being a teaching hospital, is talking about people as if they aren't there. Right? While the patient is lying in bed, talking about what you should be doing with this person." Sheila was distressed by health care professionals who did not talk to clients at all. "People go in and they don't talk to the patients ever. They go in and they pull them up and they do this and that and the other thing." First year student Sharon related how clients are referred to as numbers. "They didn't call patients by their names or whatever, it was numbers or letters you know, 958C. ... It says to me they are not taking the time to get to know that person. They really don't care." Peter recounted this incident that depicted a lack of sensitivity and concern for his client. And he was really feeling a loss and he'd been crying all night long and I was sitting there talking to him and the doctor comes in and says "how's so and so?" And I said "he's not very good, he's had a rough night and this, this, and that." The doctor looked at him, and said "yup, that would be cause for a rough night." And he left. The guy's vital signs were fine so the doctor was gone. And just there was no caring for the human being at all. Students working in the clinical setting learned a great deal about caring and shared this in their interviews. The manner in which they treated each other also affected students' views on caring. Interactions with fellow students. Students learned about caring through interactions with fellow students. When students discussed competition during the interviews, they discussed their interactions with each other. I had expected competition to be a major issue for students. When talking with students about it, however, I found it to be of minor importance. Ten students indicated that competition did not exist between them. Instead of finding their fellow classmates competitive, participants described their colleagues as supportive and cooperative. Sandra expressed it this way. "I'm really enjoying the camaraderie. We all talk about our experiences in clinical and how we feel openly, and we give each other a lot of support." Martha compared her undergraduate years in zoology to nursing. "Everyone was out to get an A' at the expense of everyone else. In nursing, I think everyone helps out everyone else. ... The students are sticking together." Tess described how cooperation replaces competition in first year and carries on throughout the program. "I don't think it's competitive with your fellow students, I think it is more cooperative with your fellow students. It starts in first year when you have your friend come in and help you make your first occupied bed." Although cooperation was not identified as a descriptor of caring by research participants, one can see how caring is demonstrated through cooperation. By working with fellow students instead of in opposition to them, there is an atmosphere of openness, sharing, understanding, supportiveness, respect and nurturance. Many of these were descriptors used by students to describe caring. The close interactions and cohesiveness between students helped them learn the meaning of caring. The role of leadership. One contextual influence actually resulted from an absence in the data. I wondered how and if the Director of the school affected students' perceptions of caring. When exploring the role of leadership and the administration in the school of nursing and their effects on students' learning of caring, references to the impact of the Director were limited. Most comments associated with the Director came from students in the final years of the program. Questions arose about whether the Director cared about undergraduate students when she made an appearance to the fourth year class and the majority of students did not know who she was. Paula explained "I think that says something about the visibility and the caring that is portrayed from the top and where our instructors get their feedback, pressure and support." Wenda added I think sometimes the faculty want to be more caring or get that across but it's sometimes very difficult because I don't know whether or not it's a sense of loyalty, or just that there's a tone set at the top and they don't have any room for movement. You're the instructor, you are there to teach. They are just students. Don't interact with them too much. Sheila and Zelda talked about the hierarchy between faculty members which they concluded resulted in competition. Sheila put it this way. "I think there is a lot of, this competition. And power that is shared in courses. Some people do all of the teaching and they don't let the others in. Tenure." Although tenure was only mentioned once, one questions the power associated with it, and how caring is or is not demonstrated as a result of tenure pressures. A caring environment in the educational setting. The laboratory setting is designed to help students acquire skills in an environment where students learn through practice, personal feedback, and diminished anxiety. Several students felt that carrying out a skill effectively and safely embodied caring. As Beth said "they weren't actually teaching us caring. But I guess they were, in the sense that they were showing concern that we would execute the skill okay." Charlotte felt the emphasis on caring in labs is beneficial. "It is so important for the lab instructor to get across how important it is to care for the clients. So I think as students, it is hard to feel the caring coming towards you, but it is so important that it is shown how we can care in that situation." The laboratories in the school of nursing are part of the learning resource center (L.R.C.) which also includes a multimedia resource room. It is relevant to discuss the L.R.C. because students identified it as a place within the school of nursing where they felt caring occurred. Five students commented about the caring in the L.R.C. Beth talked about the availability of the staff specifically affiliated with this setting, all of whom are non-tenured. "They cared about me as a learner too. There were lots of times to go in and practice. And they seemed to be really approachable and really laid-back." Zelda appreciated the staff's sensitivity. I think some of the lab people can be the most caring staff people because they are just sensitive that you are feeling awkward about a skill and want to learn it. She was just really helpful and she said "you are doing great" and she made suggestions, but the way she made them, made me feel like I was competent. Paula concluded "they are in their role to be there for students and they do that very well. Paper after paper there are always things and they ... come and help you and, have gone out of their way, for me at least." As these students proceeded through their education, this area within the school of nursing provided support and encouragement. They felt they had learned about caring there. Each of the above subheadings identifies a circumstance which affected students' views on caring in positive and negative ways. A number of these will be further discussed in the final chapter of this thesis. Conclusion The emphasis of this chapter has been to explore participants' descriptions of caring. This chapter has examined and summarized the words and phrases participants used to characterize caring. Students described caring in nursing as having empathy for their clients, helping them by doing things for and with them, and being compassionate. They identified a professional side of caring and the need to see others as whole, integrated beings. Each of these descriptors influenced how caring in nursing was perceived by participants. Students' thoughts about caring were articulated in their quotes. Peter summarized caring as "how much you can actually feel, ... empathize with the person you are dealing with. And it doesn't matter if it is one of your classmates or a client. It is just how much you can feel for what they are going through and what you can do to help them." Students also learn about caring through interactions with faculty members. It is my belief that faculty members help students learn caring by modeling caring in a variety of settings. The manner in which faculty members relate to clients in the clinical setting is one way caring is demonstrated to students. Faculty members provide physical and emotional support for clients as they supervise students in the clinical setting. This requires being able to listen; empathize; and effectively, compassionately communicate with a person who is in need. It requires respect for clients. Each of the aforementioned characteristics of caring can also be transferred to the relationships that faculty members have with students. These will be further addressed in the next chapter. 85 Chapter Five: Faculty Members who Teach Caring In the previous chapter, I described the ways students expressed caring. Caring was described as a combination of the way people are and the way they act. It is important for educators to know how students view caring because this knowledge can guide teaching. It is essential that student voices on caring be heard and that modifications to content and teaching style be considered. Students believed that educators had a significant effect on students' development of caring. Participants were specifically asked to describe qualities and actions of caring faculty members, encounters wherein students felt caring or did not feel caring, the effects of role modeling on learning about caring and their views of an ideal instructor. In this chapter, I discuss actions and attitudes of caring instructors as identified by the research participants. I explore students' perceptions about uncaring instructors. Students identified characteristics of instructors who were caring and uncaring which are described in depth. Students also described ideal instructors and instructors who role model caring. Before proceeding with the chapter, two biases affecting the analysis of the data need to be addressed. The first bias is that I maintain that caring can be learned by nursing students. I have come to this conclusion through examination of students' comments about the nature/nurture debate in the previous chapter and from synthesizing caring literature, particularly that written by Bevis and Noddings. Caring is not purely innate, it is acquired through social learning. Thus, I believe that educators facilitate the learning about caring by attempting to teach with a philosophy that espouses it. An educator teaches caring by having attitudes that students see as caring and by acting in ways which demonstrate caring. 86 The second bias I hold is that students learn about caring from both caring and uncaring experiences. Much attention is paid to what and how students learned about caring through their interactions with faculty members. For example, some students learned about caring through faculty members acting in a caring way towards them. This may have been expected or unanticipated. Caring expressed towards students clarified their definitions of caring and their perceptions of caring actions. Students also learned about caring by witnessing or experiencing uncaring attitudes or actions. Some students viewed caring as the antithesis of uncaring. These participants remembered negative interactions with faculty members vividly and quickly identified them as uncaring. In such interactions, students learned about caring because they experienced something they never wanted to encounter again and would strive to avoid in their interactions with others. Other participants discussed their feelings of aggression or hurt which developed in a relationship with a faculty member because of an uncaring encounter. They needed to relive the experience before they could look past it. Once this had occurred, they were able to reflect on what they had learned about caring from uncaring encounters. I feel that it is essential to identify the tension I felt as a nursing educator as I analyzed this data. When I read all of the characteristics of caring instructors and all of the criticism directed towards instructors who were not caring, I felt as if the expectations and demands required for an instructor to be considered caring were not attainable. There were times I concluded that caring was a superhuman feat. No one could achieve this. I wondered whether or not students recognized the complexity associated with the requirements of faculty members in an academic setting. And yet instructors were described as caring far more often than uncaring. I now see that striving to be super-instructor is not the goal I wish to achieve as an educator. Identifying the tension between all of the demands made on faculty members and balancing these demands has made me examine my educational practices. Being caring as an educator involves looking at all of the qualities students expect in a caring instructor. At the same time, the knowledge that these are not attainable or desirable with all students, and the struggle to balance students' needs with personal demands must be considered. This will remain an important process to develop. I now turn the discussion to caring and uncaring instructors. I developed the acronym C.A.R.I.N.G. to provide an organizer for the data on caring and uncaring faculty members. The C.A.R.I.N.G. acronym consolidates excerpts which included general comments about faculty members as well as the skills and attitudes instructors have that relate to being caring or uncaring. C stands for capabilities, A for attitudes towards students, R for responses to students, I for intuition, N for the nature of the instructor, and G for the generosity shown towards students. Each heading has a number of terms within it which require explication. After the discussion of the caring and uncaring faculty members, the key characteristics of role models of caring and ideal instructors are identified according to participants' views of them. Descriptions of Caring Faculty Members Research participants specifically described caring instructors in over 125 excerpts. Fifty-two terms or phrases were used to characterize caring instructors (see Appendix F). Terms or phrases used to describe uncaring faculty members were also explored (see Appendix G). Terms were consolidated into six headings outlined through the acronym C.A.R.I.N.G. As in any consolidation of data, not everything fits neatly into one of the headings. There is flux between several of the six headings in the acronym. Kathleen, for example, described the caring instructor as "competent, empathetic, a good communicator, kind, forgiving and understanding." This quote includes terms which fall across several of the acronym headings. The acronym does, however, sort important content into a workable organizational structure. It is important to note that the structure is not perfect but practical for the purposes of this discussion. Each heading in the acronym will now be discussed. C. is for capabilities of instructors. Capabilities of instructors refers to the skills and proficiencies associated with being a teacher of nursing. Caring instructors were viewed as good nursing instructors. In discussing the skills required of instructors, I will clarify a variety of the capabilities students identified in caring instructors. A major phrase used to describe caring instructors was helping students learn. Faculty members were viewed as caring by participants when they were committed to contributing as much as possible to enhance student learning. This was expressed in a number of ways such as developing confidence and competence, decreasing student anxiety, guiding students, using several approaches to material, offering effective evaluation, and being committed to their work. Each subheading will now be explored. Faculty members helped students learn by having the ability to sense, and then develop, confidence and competence in students. Page said "I did get a sense of feeling confident from her, and that she trusted that... if I said I was fine, then I was fine. She was really good at, I guess bringing out a sense of self-esteem." Zelda said "they [caring instructors] perceive that you are competent. They perceive that you are a worthwhile person who has gotten to this point because you have done your stuff and you know your stuff." 89 Kathleen talked about how her confidence was improved by an instructor. If I said "I really don't remember" or "I don't know", then there wasn't any "why don't you remember" or "you should know this by now." It was "oh, okay, well I'll come along and we can go through it first and then you can do it and if you still don't feel too good about it then I'll go in with you to do it." It was nurturing. Bolstering self-confidence is a teaching skill because when students feel good about themselves, they are better able to learn. I recognize that it is not possible in all situations, for example, when the student is acting in an unsafe manner. However, the overall desired goal, even in such circumstances, is that the student learns and has a self-concept that remains intact. Students described how instructors helped them learn by dealing with their anxiety. Students' anxiety was alleviated by positive feedback, encouragement, joint priority setting, instructors' anticipation of students' panic, suggestions for nursing interventions prior to entering the clinical setting, and appropriate interventions to relieve anxiety. Charlotte and Page summarized it through their comments. Charlotte said "that is caring, that is showing that you are concerned about what the student is feeling and about what the student is nervous about and that you are willing to take it and go a step further." Page agreed with Charlotte's comments. She really picked up on if people were starting to build up towards panicking if it was really busy. And she'd just say, you know, she'd take the time and just draw you back a little bit and say, "it looks like you're really busy, is there anything I can help you out with" or "do you need some help prioritizing what you need to do, and is there anything that you can leave off your list?" Another method to assist student learning was identified by Tess when she described caring instructors who acted as guides to students. "You know they ... allowed you to make a few mistakes and they were there to guide you along. It wasn't just 'if you don't know what you are doing then go back and read your text.' ... Guidance was a really big thing." Kathleen did not use the word guide, but described someone who exemplified this. "I guess she was supportive in ... what we would call a therapeutic manner in as much as she didn't necessarily come up with a solution. She would kind of feed things back and let you work it through yourself. But without undermining or making you second guess yourself." Sharon outlined the importance of understanding a concept or skill before applying it and how the instructor fostered that understanding. If we had any questions we didn't understand she would make sure that we understood. Like she would go over it and if we didn't understand then that was okay, like she didn't get mad "why don't you understand if I just showed it to you?" She would maybe explain it from another perspective. Obviously that perspective was not working so she would try another way. According to the participants in this study, one of the most important capabilities that caring nursing instructors possessed was the way in which they evaluated students. Students indicated that the approach taken towards evaluation of their performance influenced their perceptions of caring instructors. Overall, students found the process of evaluation a caring and positive one. Participants in the study specifically explored the kinds of evaluation from faculty members that were most productive. When faculty members offered evaluations that were ongoing, immediate and free of surprises, they were seen as caring by participants. Wenda spoke about the benefit of ongoing evaluation. "Ongoing evaluation can be very positive. I think it can show caring. We are there as students to learn, it's an integral part and, through evaluation, you can see that they are concerned about your development as a person." Sandra expressed her feelings about the method of evaluation she had experienced. I think the way it's done is really good. I like the way it's done. We are evaluated on an ongoing basis through every clinical experience and half way through they tell us, sit us down and tell us "these are the good points I've noticed and these are the things to work on." ... And at the end we are told again how we have improved from midterm and things to think about for next year. Kelly recognized the merit of being kept aware of progress throughout each term. "I think it is a lot easier when the instructor tells you throughout clinical and has helped you correct things along the way and not just thrown it on you at the evaluation." Kelly went on to describe how, in addition to ongoing feedback, she was grateful when instructors were specific. "Being specific too about what I had done wrong and not being really vague [was helpful]." Martha expressed how she felt that the more detail her instructor offered, the better "because you are never going to find out again. Because when we are done, we won't know unless something goes terribly wrong." In addition to being effective at evaluating students, instructors who encouraged self-evaluation were seen as helpful and caring. Charlotte articulated it this way. "An instructor who maybe takes a bit longer and finds some things and says 'why are you doing it this way?' ... That is caring because it is taking the time to find out what is behind it, why you are doing something." For Anthony, self-evaluation gave him perspective on his performance. "I like the idea of self-evaluation because I think my perception is important in that area. If only because I can see how someone else sees it with how I see it and the reality is somewhere in the middle." Students also identified several approaches faculty members used when evaluating them which promoted the development of caring. Effective communication skills were identified as essential in the evaluation process. Charlotte described how verbal and non-verbal skills were interpreted by the student. Examples of these skills were "whether or not they focus on the negatives or positives, how they talk to you, are they busy doing something else, are they concerned and are they really listening to what you are saying, and what you want to improve about yourself?" What is communicated to a student during an evaluation affects the student's view of the instructor and student's view of himself or herself. If an instructor does not show caring to the student through their actions, the student may be left feeling threatened and insecure. When evaluations were seen as helpful to students, they were perceived as caring, regardless of whether the evaluation itself was described as good or bad. Martha found the whole process of evaluation caring. "I think it's a caring thing to do because I think I should know if I am doing something extremely wrong or I'm doing something the wrong way or could improve on that." Page agreed. "I guess evaluation, in the sense when it's so individualized and they've taken the time to, not only let you know where you stand in terms of guidelines and the objectives, but how they think you are doing, ...when it's done like that, I think it's caring." The level of commitment of instructors was a final capability identified in caring faculty members Students associated capable instructors with being committed to their work. This commitment was particularly reflected through their enthusiasm and conduct in the clinical setting. Regardless of the number of years they had been in nursing or teaching, caring instructors remained idealistic and fresh. Paula said "she really showed an interest in the area too. She wanted to be there and she was clinically keen." Caring faculty members also demonstrated their commitment to people and to their work by their conduct in the clinical setting. Students learned how to be caring from faculty members who were able to make clients comfortable. Zelda explained "I had a good teacher who was very gentle and [asked] what the client wanted, what her wishes were and [the instructor] was very unassuming but got everything done." Kelly described how her instructor used touch to demonstrate caring. "The whole concept seems to be abstract, but it's touch. How much they touch the client and comfort them and talk about certain things [demonstrates how caring they are]." Students learned about caring through actions taken by faculty members to make clients comfortable and at ease with having students and instructors around them. Charlotte reported You watch so closely how they deal with the patients. Because they come in and introduce themselves to the patients and they are often there when you are doing your stuff and it is really important that you not only communicate with the patient, but also they do. I think when the instructor can openly communicate with the patient and "how are you doing today" or if the patient gets a little apprehensive about you doing a procedure, like maybe it's the first time you have given an injection, ... the instructor starts to praise the student. Page agreed "they go in and it seems like they really make an effort to make the patient comfortable with them being there in the first place." Tess described a caring instructor's conduct towards nursing and nursing education as highly professional. "They seemed to be interested in the patient and in what I was doing and they seemed interested in giving me constructive criticism and how to better organize or improve my skills or communication." Sheila indicated that a caring instructor was one who was not just intelligent. I think it was seeing that things that... [are] important to ideological [sic] nursing students ... [are] still important to her. You learn theory and you talk about stuff but actually doing the practical stuff, doing the extras whether it is clean sheets or a lot of eye contact and touch with patients. She works hard and she is a good nurse. You see her interacting with the patient and she goes the extra mile. Faculty members helped students learn through sensing and building self-confidence, dealing with anxiety, acting as guides, and seeking understanding through using various approaches to problems. Faculty members also helped students learn by offering evaluations that were specific, ongoing, employed self-evaluation and used effective communication skills. Instructors were seen as caring when they were committed to their work and conducted themselves accordingly. Faculty members who used these capabilities to help students learn were seen as caring. A. is for attitudes towards students. Students described effective and caring instructors as those who interacted with students in certain ways. Attitudes towards students refers to how faculty members approached students, most commonly in the clinical setting. It refers to the attitudes instructors held towards students as opposed to what instructors may or may not have done with students. The heading attitudes towards students will be discussed according to two terms reflecting it: equality and respect. When faculty members approached students as equals> they were 95 perceived by students as caring. This related specifically to the clinical setting, but extended beyond it into the personal lives of students. Zelda talked about how her instructor approached her as an equal in the clinical setting. "I think it is an attitude and feeling that they are not seeing themselves as higher than you, but just relating to you on an equal level. Although they are a nurse and you are not, they just sort of relate to you as an equal." Peter concurred by saying "I think all of those people I've had [who] looked on us almost as equals. You know 'we are here together, we are almost like a team, and this team will get through this.' " Sharon didn't see her instructor as an equal in terms of experience and knowledge, perhaps due to Sharon being in first year in the program, but she did see equality in the personal relationship between them. "I know I would feel equal with her if I had a problem outside of school. ... But the majority of our relationship was teacher/ student so I mean I wouldn't say it was equal. But I know if there was anything else, I would feel equal." Page described one way equality was communicated to students. For her instructor, it was all right to not have all of the answers all of the time. "She was the first one to say 'I haven't got a clue what that means' or 'I have no idea what he's talking about. Maybe we should go look in a book.' So, she ... was great that way. You know she never ... talked down to me." Students felt cared about when an instructor acknowledged that although students had specific deficits in information, in other ways they were equal with the instructor. Respect towards students is a second attitude which participants identified as characteristic of caring instructors. Respect in this context refers to the respect a faculty member has for students as opposed to respect students have for faculty members. Respect for students shows faculty members care about them and results in positive outcomes. For Kathleen, being shown respect by 96 her instructor boosted her confidence and proved enabling. Overall, she conveyed that she respected and trusted me as a student. She put a lot of responsibility in my hands but not too much. I never felt over or under monitored because she gave me an opportunity to tell her what was going on with me and then she respected that. That made me feel very respected and cared for.... Everything I brought to her she stopped and gave weight to. She showed students respect... by entmsting that what... [was] said was the truth. And that is the way it was. It was good enough for her. And it was an enormously empowering experience. Wenda discussed how respect for her ideas allowed her to work through problems and issues. This, in turn, promoted her academic growth. "I guess they respected me for my ideas. And they didn't try to change my ideas to fit what they thought something was." In a reference to a term paper she had written, Wenda continued, "in the end, my idea did evolve to be more similar to hers but... I didn't feel she had pressured me or said those things to me. She let me develop it. I guess the understanding, the warmth, friendliness [made me feel like she cared]." Being respected as individuals was important to the nursing students in this study. Caring instructors were those who were respectful towards student. They accomplished this through encouraging the evolution of students' ideas and knowledge. These faculty members provided support while allowing students to test their ideas and accept responsibility for them. R. is for responses to students. Responses to students refers to the actions of faculty members which fostered student success and positively reflected caring. Three kinds of responses to students accomplished this: anticipating academic and professional growth, communicating caring to students, and preserving 97 student dignity. Students saw these things as caring because they inspired personal, professional or academic growth. Faculty responses to students were seen as caring when they promoted academic and professional development. Sheila described caring instructors as those who "are interested in you as an individual reaching a different level." Paula indicated that caring instructors were "looking out for my learning needs too and wanting me to learn more and to get me thinking." Charlotte put it this way. "They were concerned that you felt you were doing enough and learning enough. They were concerned that you were making the most of your schooling time." Showing a commitment to professional growth in addition to academic growth was also important to students. Seeking professional growth in students was viewed as caring by Peter who said "the thing I got was that she really cared about her patients and the only way they could get cared for properly was if she cared for us too and made sure that we knew how to do that." Paula's professional growth was promoted by instructors who emphasized taking care of herself by taking time away from nursing care. One way this was accomplished was for Paula to take her coffee and lunch breaks. "Whether they say it sternly or not shows that they care that you get some time away from the ward. And I think that's very important not just for showing caring but for caring for yourself because you will carry that on in your practice because it is so important." Having students take time away from the actual care of clients is one way faculty members show that they care about students and that students are developing strategies for effective coping as professionals. Another way they do this is by communicating effectively with students. Communicating caring as it relates to responses to students refers to the unspoken messages, rather than spoken ones, conveyed by faculty members 98 when interacting with students. Students described the non-verbal communication in conversations they had with faculty members. This aspect of communication is included in this heading because it demonstrates how faculty members interacted with students. Students in the study appreciated being listened to and remembered the instructor's tone of voice. They associated these things with caring. Listening was one way faculty members responded to students in a caring fashion. One notable characteristic about listening is that it requires.time. It is easy for an instructor to get caught up with the numerous tasks to be performed in the clinical setting and not pay complete attention when being addressed by students. According to the participants, instructors who conveyed they had time to listen to what students had to say were seen as caring. Paula put it this way. "She would sit down and you know, she would make sure everything, everyone was looked after, but then spend time with you ... to listen to you and find out what it was. And it just made you feel better." Sheila summarized how she felt about an instructor who listened to her. "I think that is why she was such a good instructor too, because she listened lots, ... and she really listened well too, she heard as well as listened." Listening resulted in students feeling someone understood their position, demonstrated respect for them, and cared about them. Conveying patience and understanding through tone of voice is another response to students which participants perceived as caring . Three second year students made direct references to the tone of voice used by a caring instructor. Sandra described her instructor this way. "[It is ] just subtle things ... like her tone of voice. [It] was softer and more motherly. I think we all need to be mothered along a little bit." Charlotte added that "the way she talked with us was a soothing way and it was very non-judgmental." Kelly 99 associated tone of voice with other non verbal cues like the way people look at you. "The way people look can be harsh or it can be gentle." Caring was communicated to students through a faculty member listening to students and using a soothing tone of voice. These two communication skills reveal that respect and caring for students can be demonstrated through how instructors say things as well as through what they say. Caring instructors were seen by research participants as people who prevented them from being humiliated or embarrassed in front of other people. Students referred to this as preserving their dignity. When faculty members preserved the dignity of students, they were consciously seeking to affirm rather than diminish students. This preservation of dignity let students know that their instructor respected their position and cared about them. Charlotte said I think one of the main things is that they don't knock you down in front of the patient or other students. The main thing is to preserve your dignity. Yes, you are going to mess up, yes you are going to make mistakes, but you need to move on, you need to learn from them. You don't need to be made a fool of. Sandra discussed how her instructor preserved her dignity when performing a new skill. "She would watch quietly and not interfere too much and then afterwards, she would take me aside, away from the patient, and she would say 'that was good but, you could do this and this, but overall it was good.'" For Kelly, caring was demonstrated when she was in tears over failing a skill in the lab. "And she was really caring. She drew me aside so my peers couldn't see me and she talked to me about how I was feeling and stuff." These examples describe instructors committed to keeping the learning environment positive by preventing students from being 100 humiliated. Caring instructors respond to students in a way that helps students develop scholastically and professionally. As illustrated, this occurs through anticipating growth, communicating caring to students, and preserving their dignity. Another important way caring was accomplished towards students was through instructors being sensitive to students. This responsiveness to the feelings and potential problems of students was part of a broader concept, intuition, which described the caring instructor. I. is for intuition. The intuition provided by caring instructors refers to their sensitivity towards students, the perspective instructors bring to situations, and the instincts faculty members have about students. As mentioned earlier, faculty members being sensitive to student anxiety and then acting appropriately, helped students learn and was viewed as caring. Sensitivity involves looking beyond the obvious and overt. As Page put it "sensitivity is crucial to meeting individual needs in terms of caring. You really need to have a sensitivity to ... the way people think, ... the way people look at you or their body language or just things like that." Sensitivity also involves tempering reactions. Sheila said "they would take things into consideration, maybe the baby was up all night or your husband and you, I don't know. But there was a human being there." Being sensitive to another person corresponds to having empathy for them. When a faculty member demonstrated sensitivity towards a student, she or he felt that the faculty member recognized and acted appropriately on the complexity of the student's experience. Being sensitive to another person can also result in helping them put things into perspective. Perspective setting is the ability to step back from a situation and place it in the context of the overall picture. In the case of student learning, perspective 101 setting involves balancing one single experience with a student's overall general performance. It is helping the student see the landscape instead of one blade of grass. Participants valued and hoped for this in their instructors. Kathleen said "I think people are capable and [yet they] still make mistakes and have oversights. Instructors need to put things into perspective for students and say 'next time you can do things a little differently and this is wrong, but bear it in mind.' " Charlotte indicated that keeping things in perspective occurred when faculty members were open to discussing things with students. [Caring is] just always talking with them [students],... about all the exciting things going on and all the responsibilities [they] are going to have and even though they feel nervous now, that everything, as you step back and look at it, you realize that it is not that bad and that you can get through it if you take it one day at a time. Instructors who helped students break things down into manageable pieces by talking were seen as caring. These faculty members were sensitive to the students' position and took the time with students to address these concerns. They cared about the seriousness with which students approached their education and took actions to help students see beyond the moment. Seeing beyond the moment, or being able to put perspective on things also promotes learning. When students were devastated by what they saw as a failing, faculty members proved to be caring as they helped the student see the possibility in the situation instead of the impossibility in it. Kelly had been unsuccessful on a skill in the lab. "I thought 'oh this is the end of the world.' But she made me realize that it was something I could fix. It wasn't some inherent sort of quality in me. She helped me see that I could fix it." Zelda said "if we were having one of those days when we thought Tm really out of 102 it', she'd say 'well, you did really well at this' and she'd really make you realize 'oh, I have done quite well actually. I'm just seeing the bad stuff.' " Often students are their own worst critics. Self-criticism needs to be balanced with a larger perspective. Being able to tell when a student is being overly negative depends on using intuition to increase sensitivity towards a student and put things in a larger perspective. The way faculty members demonstrate sensitivity about situations plays an important role in how students view their instructors. In addition, instincts are important to being a caring instructor. Being intuitive helps faculty members anticipate the needs of students by helping identify emotions that may affect learning. Being receptive to anxiety, excitement, confidence and fear affected an instructor's approach and response to students in the study. Fourth year student Wenda relayed a story from her first year in the program. I think it is really important for clinical instructors to get to know each of their students a little bit before getting into the clinical setting; maybe in orientation. I guess I didn't mention it earlier but especially in first year, the clinical instructor went around the group setting and said "tell me a bit about yourself, what are you maybe anxious about?" And she was really good about keeping all those things in mind when we were up on the unit. And she would take that into consideration when she was approaching the student. Taking time to get to know students prior to going into the clinical setting is one strategy faculty members can use to develop these instincts about students. Sometimes however, being intuitive is inherent in an individual. There are certain personality traits which make some people more caring than others. Personality traits are described herein as the nature of the 103 instructor and are explored in the following section. N. is for the nature of the instructor. All of the headings in the acronym describe the nature of the caring faculty member to some degree. In this section I want to look briefly at characteristics identified by participants which were not bound to the teaching/learning situation but described the caring faculty member more genericaUy. These characteristics describe how caring individuals demonstrated the values they hold through their actions. Twenty-nine terms were used in the data to depict the nature of a caring instructor. I condensed them into three areas: being accepting of students, being real, and being empathetic. The first area I explore is the way instructors accept their students. Caring instructors were perceived as accepting by participants because they recognized that students are not consistent one hundred percent of the time, they fluctuate. A caring instructor's accepting nature identified this and allowed for individual variations. Words students used that described acceptance were relaxed, patient and gentle. Zelda declared "I didn't feel I had to be up to snuff all the time. I felt if I had a question it was okay to ask it. It was a relaxed atmosphere, very gentle and accepting. Those were the qualities in her, being relaxed and accepting." Being relaxed was identified as being accepting. Being genuine, friendly, positive and comfortable were all components of the next subheading: being real. The concept of being real was important to students who found these instructors were special people. These faculty members related to students and for Zelda, allowed her to relate back to the instructors. "If they can be relaxed around you and talk about normal things and not always be talking clinical. You feel like it's a real person, I can relate to them." Paula described one instructor in this way. "She was genuine. And I guess everyone can't be 104 like her. I trunk she's the type of person people are attracted to anyway because she makes people feel comfortable." Kathleen's story about how her instructor's presence made her feel cared for describes ah individual secure and comfortable in almost any situation. Kathleen had just lost her first patient. She could see that I was upset by it and she just walked beside me for a while and then she put her hand on my shoulder and just stood there really quietly and a couple of long seconds went by and she said "are you okay?" She didn't intrude. She wasn't trying to do the right thing and I felt very reassured by that. Being comfortable and being real, in a variety of situations, help people understand each other because they can relate on some level. This understanding of another person's situation has been referred to earlier as empathy. Nursing instructors who were empathetic were seen by students as caring. In the previous chapter, empathy was one of the prime descriptors used by students to define caring. Empathy once again became significant as research participants described caring instructors. This final attribute of a caring instructor's personality was the ability to understand what a student was experiencing and to put themselves in the student's position. Faculty members who were understanding of the student experience were viewed as having greater flexibility in their approaches to how students met academic requirements. Anthony appreciated how his instructor helped him to develop realistic expectations of himself as a result of her understanding his circumstances. He had been dealing with some emotional personal issues and felt drained. He was worried about the upcoming exams and the high standards he had set for himself. 105 She empathized quite a bit and she gave me some slack to work with. I appreciated it a lot because I was wondering if I had gotten a less warm response, I wonder how I would have felt about studying for my exams. ... It was a nice reality check because she would say "I imagine it is very difficult to focus mentally right now because of all the things you have going on." ... And it was important for me to hear that. Empathetic instructors also thought about assisting students' learning. Wenda related that caring instructors understand students by "putting themselves in the position of a student saying 'if I was just learning this new, what are some of the questions I might have and how would I need it answered.' " Sharon was impressed by her instructor's understanding of Sharon's experiences as a student. "She sort of made you feel like she, that she understood what we were going through and that she understands us. Which I guess made me feel cared for, that someone understood me. Someone knew me." Faculty members are seen as caring when they have empathy for students, come across as being real, and accept students through being relaxed, gentle and patient. In order to accomplish these things, instructors must devote time and energy to student development. This commitment often requires giving time, effort, and energy which a number of professionals would refer to as going beyond the call of academic duty. This has been identified under the heading generosity shown to students. G. is for Generosity shown to students. Generosity towards students refers to faculty members sharing their time, energy and lives. For these research participants, generosity meant giving of oneself beyond normal working hours. Sharon articulated it this way. I felt that it wasn't really part of her job, it was a part of her life and she 106 sort of wanted to share it with us. I think for a lot of people their job is nine to five and they leave it there and that is it and they don't take it home with them. You know for them if you want help, you had to come between those working hours and couldn't invade their private life or their home life. Whereas for her, she didn't do that. From the participants' perspectives, generosity towards them was demonstrated most notably when faculty members were generous with their time. This generosity included giving time in the clinical setting as well as non-clinical settings. In the clinical setting, caring instructors took time out to help students reflect upon whatever issues they were encountering. Anthony discussed how his instructor provided time during each clinical day for students to process the things they were seeing in their clinical rotation. "She would make time to listen to the group and then question us about certain things so we would get an opportunity to think about what we had seen and grow from it." Outside of the clinical setting, the most significant action which demonstrated generosity was giving out a home phone number and making sure students knew they could call. This was mentioned as caring by a number of students. For Tess, caring instructors made themselves available beyond the school setting. And another thing they do is give their home phone number which in the university setting seems really strange. Why would anyone do that? They are saying that "even when I am not in the school setting and I'm in the home setting, you can call me up to nine o'clock if you have a problem or if you need an extension. If you are having a problem, come talk to me." You can almost always reach them. They make themselves very approachable. 107 Perhaps giving out a phone number was acknowledged because students' felt their roles extended beyond school boundaries and the instructors' roles should as well. Whatever the reason, students appreciated having the instructor's phone number and being able to call. Students also appreciated instructors taking an interest in their personal as well as their professional lives. Tess, having dealt with the deaths of two close friends in one term, ended up discussing her personal grief with her clinical teacher. And I ended up telling her and she was really, really good about it and very supportive. I thought it was really nice to have someone support me in my personal life because it reflects in my professional life and for someone to take concern for what was going on in my personal life meant a lot to me. Caring faculty members were portrayed as willing to take the time and effort to get to know their students as people, not just as students. Having a holistic concern for students' well-being included instructors' recognition that their educational preparation was only one aspect of their lives, one facet of a complex human being. Caring faculty members also realized that sometimes education wasn't the most important thing in students' lives. These instructors were willing to put in the time and effort to view students as unique, multifaceted people. Students identified caring faculty members as people who recognized the complexity in their lives. These instructors were special because their genuine concern for students was demonstrated by investing time and energy in them. This section has explored what participants had to say about instructors they perceived as caring. To summarize, students identified instructors as caring when they possessed certain skills or capabilities such as the ability to 108 help students learn, effective evaluation methods, and commitment to people and their profession. Caring attitudes towards students included seeing the student as an equal and respecting them. Responses to students involved promoting students' growth, the communication of caring and preserving their dignity. The concepts of sensitivity, perspective setting and being instinctive are encompassed by the heading of intuition. The nature of the caring instructor involved possessing the personality traits of being accepting, real, and empathetic. Finally, when instructors demonstrate generosity, they give freely of their time, energy and lives. Conclusions about caring faculty members or the desirability of being seen as a caring faculty member cannot be made before because the converse of caring: uncaring is examined. The following section of the chapter contrasts caring instructors with uncaring ones by using the headings of the C.A.R.I.N.G. acronym. Descriptions of Uncaring Faculty Members In an ideal world, students would view every faculty member as caring all the time. However, the world is not ideal and this is an unrealistic expectation. Participants in this study identified interactions and experiences with faculty members which left them feeling wounded and feeling a lack of care. Sixty-four excerpts address uncaring faculty members. I explore these uncaring excerpts which represented the antithesis of caring under each heading of the acronym. One or more characteristics which caused students to view an instructor as uncaring will be identified. Characteristics outlined may be in opposition to the examples cited earlier in the chapter or they may be entirely different. Regardless, all excerpts ended up in one of the six headings of the acronym. 109 Capabilities of uncaring faculty members. Capabilities of caring instructors referred to a number of teaching or nursing skills which helped students learn. According to the data, uncaring faculty members were contrasted with caring ones because they impeded learning. They employed skills which often made students uncomfortable such as intensely examining, or grilling students, making students anxious, and compelling students to get along with their instructors. A number of participants described instructors who chose to examine or grill students instead of working cooperatively with them. For Peter "there was never any teaching, only examining. You never got any feedback about all the things you did know. It was almost like there was a gleam on her face when she found out what you didn't know." Tess described a no win situation in which she was placed. "And either you knew too much or not enough when you came in. She would drill you until there was something you didn't know and it was like 'you didn't look that up' or 'you didn't do that.' There didn't seem to be any criteria for what needed to be learned." Uncaring faculty members were satisfied only when they found problems. Sheila pointed out that "if you think someone is looking at you to find fault or to find something wrong, it, almost drives you to that point of doing something wrong." Trying to prevent students from making mistakes was identified as a primary focus of the teaching of uncaring faculty members. For participants, it was one thing to be concerned about caring for clients and students but another to become totally preoccupied with error avoidance, when errors were bound to happen. Students felt they were expected to do things right all of the time. Wenda indicated that her instructor "was there to assign patients to make sure you didn't screw up while you were there." Paula felt she could 110 not make mistakes and also had to know everything. She would spend hours preparing for clinical because she was afraid of being asked something she didn't know. When asked why she thought that would happen, she replied "because it happens. And it might, if it doesn't happen to you, you are going to see one of your classmates put on the spot in tears. And I believe there has to be a level of anxiety to learn. But... there has to be some sort of balance there." Of course, the interviews cannot tell us whether faculty, in fact, expected the perfection students thought they did. Uncaring faculty members were seen as instructors who perceived students' errors as negatively reflecting on them as an educator. Peter stated "it was almost as if she didn't care about us as much as she cared about making an impression on everyone in the school of nursing." Sandra summarized it this way. "I get the feeling that she is very worried about us . making a mistake that she is going to have to pay for, that it's going to go against her and I get the feeling she doesn't trust us so then, I don't trust myself." When students thought faculty members expected them to make no errors, students became anxious. This anxiety impeded learning and it diminished their ability to be caring. Kathleen voiced concern that student anxiety kept a person from functioning in a caring manner. "You see them functioning and they get very wooden and you feel like saying 'knock, knock, knock, is there anyone in there?' " She attributed the blocking of caring emotions to the degree of anxiety people experience. She felt that when students concentrate only on performance, they may have little energy to devote to the needs of others. Kathleen talked about how this performance pressure impeded caring. You have so many things on your mind that you are trying to do, [finding I l l out] what the expectations are. You are so busy concentrating on what you are trying to get accomplished that sometimes you miss out on the opportunities for caring. You don't come across as caring at times when you really wanted to. Paula discussed how anxiety about going into the clinical setting made her want to avoid chnical experiences altogether. "Honestly, there [are] days when I wish I could phone in sick because I don't feel like dealing with the anxiety I'm going to be put through to get there." Uncaring faculty members were also perceived as having unrealistic expectations of students. At times, trying to complete the necessary tasks in a clinical day left students feeling as if there was no room for learning about caring. Sandra recalled that her instructor's expectations for the physical care of a client were high and that the instructor was not available to assist or observe Sandra when needed. This occurred in spite of Sandra trying to plan time with the instructor. In addition, the instructor also took no responsibility for Sandra floundering all day long. I had had a lot to do that day and we hadn't really arranged a schedule of when to do it so I found myself waiting for her a lot of the time and I couldn't get things done when I wanted to do them and everything was getting pushed and so she said to me "I suggest you go home tonight and arrange your schedule so that you can get all of these things done in a proper amount of time." And I was really affected by that. ... And it didn't matter that I had taken the staples out perfectly you know. She felt she had to be able to do everything and when she couldn't, it ended up being her fault. "I find there's a lot of pressure because ... it's not automatic to do the things a nurse does. You can't really make mistakes because you have real patients and yet everything you do, you really have to 112 think about." Students not only felt the pressure to make no mistakes and meet unrealistic expectations, they also felt that uncaring instructors forced students to get along with them. Peter described a situation where he and his instructor disagreed about his performance. He recounted "finally, I just decided to do what she wanted and jump through the hoop. It made it a lot easier to get along with her [by] doing what she said." Getting along with the instructor was also important to Charlotte because in the end, the instructor evaluated her work. "You see them all day for two days and they evaluate you and they mark all your papers for the term and basically you have to get along with that person or that term is on the line." For Martha, getting along meant conforming to each instructor's way of doing things. "All instructors are different and instead of being able to form your own methods, it seems like you have to change from one to the next, to be competent in the eyes of that instructor. So I think it's really hard to develop a really good working relationship with instructors." Faculty members who caused students to concentrate primarily on performance and the relationship with their instructor were described as uncaring by participants. Students felt interactions with these instructors left them with little time or energy to think about how to show compassion and concern for their clients or other people. Attitudes towards students which were uncaring. Caring attitudes towards students were exemplified by equality and respect. Caring instructors were sometimes referred to as empowering because they chose to give students control of situations; uncaring faculty members held on to any power they possessed. Participants in the study described uncaring instructors as projecting an attitude of superiority based on the knowledge 113 they possessed. Tess expressed it this way. It's more like the student is a student and they are somehow lesser or unable to give. The teacher somehow thinks they are not on an equal level. It was basically the power thing. We had no input on what we wanted to see. She had a set agenda and that was how things went and what you wanted was not relevant. Paula said "I didn't feel it was caring,... she wanted to keep the power. She didn't really want to share her knowledge I think." Such approaches where power was not shared, and where students were disempowered were seen as uncaring. They resulted in negative feelings towards instructors and left students feeling badly about their performance. Participants also described how uncaring faculty members were disrespectful. References made were not to students but to their clients. Uncaring interactions between faculty members and clients revealed manipulation, misinformation, and a lack of respect. Peter described this encounter. She went in and she's pretending to do some sort of treatment on him and is trying to do a therapeutic interview, right? "I hear your wife's in the hospital too, how does it make you feel?" ... And she is doing it not out of any sort of caring for him, but to get information. And I just thought it was such a blatant intrusion. It was wrong. Tess equated not giving a client correct information upon hospital discharge as being uncaring. "She was a nurse, she knew what was right and what they [the client] thought, wasn't relevant. ... My client deserves the right stuff. They [instructors] are expecting us to give the correct information and they turn around and say 'well, we're not going to bother looking that up, we'll just leave it at that.' What is that saying?" Students were alert to and 114 critical of the performance of their instructors when their clients failed to receive the attention and respect students felt they deserved. Responses that were uncaring to students. Just as caring responses to students referred to actions which promoted growth, uncaring responses were illustrated through actions which inhibited growth. Sheila illustrated this well through her comment "it's like even if you knew it, you didn't feel like you knew it. She made you feel like you didn't know what you were talking about even if you did." Being unable or unwilling to communicate caring to students was identified as a characteristic response of uncaring faculty members. Comments revolved around the non-verbal component of communication. Wenda recalled. "I guess she didn't appear to be very comfortable. She didn't want to stick around and chat. It was more subtle, she was closed. There was a lack of eye contact. And she cast her eyes down." Dianna described the insincerity expressed non-verbally by a faculty member. "But the thing is she was never harsh, she was always pleasant and smiling and telling me I was out of control and I thought it was even less caring because she was always smiling." Students recognized the incongruity between what people say and what they do. They picked up on cues which demonstrated insincerity or lack of understanding. Students in this study didn't like it and saw it as uncaring and ineffective. Failure by faculty members to preserve the dignity of students was perceived by participants as uncaring. Stripping students of their dignity occurred through embarrassing them in front of clients, classmates or members of the health care team. Martha relayed this story. I don't know if the instructors don't realize it or they just don't care. I had one instance, and this happened to everyone in the group at certain times last term. It was being grilled in front of the nursing station, in front of 115 doctors, medical students, the unit clerks and that's not fair to a student. I think that sort of thing should be done away from the crowd, especially if the student doesn't know. Diminishing a person reveals a lack of understanding about what they are experiencing. Intuition or it's absence in uncaring instructors. Lacking understanding of a student's situation may be the result of a lack of intuition in a faculty member. Caring instructors' intuitions were described as being sensitive, having the ability to keep circumstances in perspective, and possessing instincts to guide interactions with students. A lack of sensitivity set uncaring instructors apart from the caring ones. Kelly cited a situation where she felt the instructor lacked sensitivity. "Watching you flounder is being uncaring. Or asking you questions until you don't know what is up and what is down. She doesn't see the non-verbals you are sending out. She just doesn't care how you are feeling or what you are going through." Dianna explained a situation where she asked to discuss an issue with her instructor but her instructor didn't attend to the issue in a way Dianna saw as positive or caring. "Three times I was in the middle of speaking with her and she saw someone walking in the hall and she interrupted me. I have something important to speak to her about but it is not important to her. She doesn't see things that are maybe important to other people." That instructor lacked sensitivity about what was important to her student. As a result, the instructor was described as uncaring. In contrast, caring faculty members identified what was important to the student, and acted upon it. The nature or personality of an uncaring faculty member. Caring faculty members were accepting, empathetic, and real. By 116 comparison, the most noteworthy personality flaws of uncaring faculty members were that they lacked empathy, did not accept students, or were not genuine. The general statements about the personality of uncaring faculty members emphasized they were tense, harsh, or intimidating. Kelly communicated her experience with an uncaring instructor in this way. She is kind of unapproachable and she is kind of harsh. And a perfectionist. Like even her facial expressions, like her eyes they were always staring right though you. I don't know. Intimidating. That's the word I had for her. ... She was just really, really intimidating. And I don't think she needs to be intimidating. I think she could put her smarts to use better if she was a bit more gentle and relaxed. Uncaring faculty members were characterized as being anxious. When faculty members were anxious, students often reacted in the same way. Sandra considered the impact of her instructor. She is uptight and that makes me uptight and so there's a lot more pressure when I'm in the clinical setting too, because I know she's uptight and if I deviate from her expectations, then it's all blown off. I get the feeling that she doesn't trust me so then I don't trust myself. This illustrates how anxiety in an instructor affects the clinical performance of students. Keeping their own anxiety controlled seems to be an important task for faculty members. If these aspects are not considered, tension sets in, learning is impeded, and caring is not perceived. Generosity lacking towards students. In the final area, the perception of uncaring faculty members is examined under the heading of generosity towards students. Caring instructors were seen as being generous with their time and concern for students. Uncaring instructors were seen as the reverse. This was made evident through 117 excerpts which talked about the distance uncaring faculty members placed between themselves and their students. Being distant with students meant that faculty members/ for whatever reason, did not get close to their students. Kelly discussed this distance. "She [the faculty member] seemed like she was trying to hold herself apart, you know? In clinical she was a bit more distant." Being distant implies a lack of generosity because individuals are not willing to sacrifice their time or make an emotional commitment. In addition to being distant, uncaring faculty members did not give students the time they needed to feel comfortable with their performance. Martha remembered feeling uncared for when she was giving her first injection. "Everyone was giving them [the injection] at the same time ... it was really busy and you know, ... [you felt] like you had to rush through it because the instructor had to get somewhere else." Being free with time has consequences for students. It enhances learning because students feel they have the time necessary to effectively and successfully complete tasks. It helps students to relax. It also helps them see their instructor as someone who makes time for things that are important to students. When faculty members did not make time for students, they were seen as uncaring by participants. I have revealed a number of details about caring and uncaring faculty members in this chapter. I now will address students' perceptions of role models of caring and ideal instructors. Role Models of Caring and Ideal Instructors Relevant data about caring continued to emerge when students were asked questions about who they believed were positive role models, what they saw as an ideal instructor, and how they would enact the role of a caring faculty member. I address five characteristics associated with role models of caring and ideal instructors. These are: teaching skills, enthusiasm, advocacy, 118 communication, and their holistic interest in students. An interesting footnote to this data, which included over 60 excerpts, was that these types of instructors were analogous with good instructors. Students did not always say this directly, however they did associate effective teaching and learning with instructors they viewed as caring. Teaching skills. Teaching skills addresses the abilities, skills, and approaches employed by caring instructors. The ideal instructor was seen as creative, flexible, and open to evaluation by students. These instructors were seen as those who personalize teaching and modify their way of doing things when necessary. As Kelly said "I think it is important for them to realize that not everytiiing is [ideal], to be someone who is trying to individualize her own teaching, [and] someone who is wanting you to learn and not just wanting to teach." Ideal instructors were seen as people who thought asking questions and making mistakes were methods of learning. Wenda indicated that as an instructor "I'd be understanding of the fact that I know they don't know everything and I'm there to supposedly help with the knowledge." She would help with knowledge by "being available and coming across as being knowledgeable but not overpowering, not having all the answers, like 'I know everything, you know nothing.' " Anthony said the ideal instructor was able to communicate that "it was okay to ask questions and they [students] would have permission to make mistakes." Dianna felt evaluation could be more caring if instructors were more encouraging and positive in their feedback. "They have to be able to encourage you and tell you that this can be conquered, this is not life and death. ... And I think they should focus more on the positive aspects." Ideal instructors provide students with opportunities to learn by their willingness to be observed and to interact cooperatively with students. 119 Instructors who role model caring provide students with examples of caring from which students can learn. Peter identified it in this way. It's not like someone has sat you down and said "to care for someone you do this, this and this. And then you are caring." It's more by watching your instructor and how they interact with the patient and their family and how they interact with us. That is where you get the real sense of "yes, they care for us." Kathleen alluded to the cooperative learning that occurs when caring instructors work with students performing various skills. Teaching and learning are interactive processes. "Doing it with you, where you are together and they [the faculty member] are doing it with you. Those are the best learning experiences I have had." Working with students to problem solve a variety of issues demonstrated caring and a willingness to share knowledge and skill. Enthusiasm. Willingness to share springs from an excitement about knowledge, teaching and learning. Ideal instructors were viewed by participants as being enthusiastic. They were energized by the learning that students experienced. Charlotte explained "when they are excited about it, it seems they are excited for you to learn. They care that you are learning this." Charlotte went on to say that in an ideal world, faculty members would remember the thrill of doing things for the first time, and not take anything away from that. Anthony put it this way "if I were an instructor, I would like my students to be excited about learning and that's something they will take with them long after I'm gone, wherever they go. I would like to put a certain amount of energy into the teaching part, so they could enjoy the learning part." Being able to enjoy the learning part is also influenced by the instructor's attitude 120 towards the student's abilities. Advocacy. According to the participants, ideal instructors saw students in a positive light and expected them to succeed. Kathleen referred to this as "a self-fulfilling prophecy that if you convey to people. ... You trust them and believe in them and you know that they are going to do the right thing. You get the feeling that the person is on your side." Sheila said if she were an instructor she would verbally let students know that she expected them to succeed, not fail. This translates into advocacy because a student is enabled and empowered through a faculty member believing in student abilities and supporting them especially when the student loses perspective. Of course, the challenge arises when faculty members are dealing with students who are unable to meet course requirements. Advocating for a student in this case may involve helping them leave the program with an intact sense of self-esteem and worth. Communication. Teaching skills, enthusiasm and advocacy require communicating with students. Participants described ideal faculty members as those who openly discuss concerns and abilities with students. Communication has been identified as an essential component of caring throughout this discussion. Communication was present in the previous chapter on definitions of caring and has been present when participants described caring instructors, uncaring faculty members and now ideal instructors. Ideal instructors were seen by students as effective communicators. These instructors listened and talked about the issues students were encountering and this resulted in these faculty members understanding students' feelings. Charlotte expressed it in this manner. "Overall, they are willing to communicate with you. They are 121 willing, when you are stressed, to say 'how can I help you?' They are willing to put it to you and have confidence in you and not have the control." Listening to students and the tone of an instructor's voice were also identified as important components of communication in ideal instructors. Holistic interest in students. The final characteristic of ideal instructors identified by participants was faculty members' interest in their students' well-being. Ideal instructors were described as being interested in the overall development of each student, not just the specific area being taught by that faculty member. Paula described it. "It sounded like she cared that we were experiencing nursing or developing as a nurse outside what they were offering at the school. I really felt that she cared that we were doing that." Paula also discussed how several faculty members took an interest in her by helping her out on projects and papers when she was no longer their student. For Sharon, interest spread beyond her studies. The ideal instructor was viewed as "one who is genuinely interested in you and your problems and wants you to work them through and get answers." The ideal instructor got involved in students' lives by taking an interest in them. Participants in this research thought ideal instructors had an appreciation for the complexities associated with their personal and professional lives. This portion of the chapter has revealed characteristics of instructors who were seen as ideal examples of caring. Some of these references were to faculty members students knew, but most were to instructors they had not yet encountered, but hoped for, in the future. Caring, uncaring, and ideal faculty members have been the focus of this chapter. By addressing their capabilities, attitudes towards students, responses to students, intuitions about students, nature or personality, and the generosity shown to students, I have attempted to clarify what the respondents in this study had to say about the people from whom they learn about caring. As I explored each of the headings of the acronym, it did not take long to recognize the complexity of descriptions of caring and uncaring instructors in nursing. The characteristics of caring and uncaring faculty members can be summarized through the following prototypes. Caring Instructors: A Prototype of Possibility Instructors who cared about students follow intuitions about students. They also believe in people. They believe in the ability of students and see their job as facilitating students' growth. Caring faculty members are empathetic towards students. They are encouraging, empathetic and help students learn. Caring faculty members respect the position of the student and do not hoard knowledge by not sharing it with them. They see the good in most situations which results in the enablement of students. Caring instructors react towards students with gentleness, kindness and respect. They choose to see the possibility rather than the impossibility in most every situation. Uncaring Instructors: A Prototype of Negativity Uncaring instructors, on the other hand, seem to focus on the negative aspects of experiences. The inability to share power describes these faculty members. Uncaring instructors use intimidation with students. They also emphasize errors. They are hard to please because their standards are unrealistic and unattainable. This is reflected in always finding something wrong with their students' performance and focusing on this, rather than on the positive aspects of students' performance. Uncaring faculty members lack sensitivity or empathy towards students. They display a lack of belief in what students say or do. In summary, uncaring faculty members lack sensitivity to the student's role, has unattainable expectations, are critical, and react to students using intimidation. Conclusion In this chapter, I have investigated what participants in the study had to say about caring and uncaring faculty members. Six broad categories were used to consolidate the descriptors about these faculty members. Each of these categories were explored in depth as they related to caring and uncaring faculty members. Five separate categories described the role models of caring and ideal instructor. In the following chapter, I will discuss four conclusions made from the data and their implications for nurse educators, nursing education administrators and nursing students. 124 Chapter Six: Conclusions and Implications This research was designed and implemented to determine students' perceptions of caring and their experiences of caring during their nursing education. The literature review assisted my understanding of the concept of caring in nursing education by supporting a view that caring is a blending of attitudes and actions which promotes understanding another person and results in their growth. The literature also identified how nursing education is embracing a more humanistic approach towards students' acquisition of knowledge and skills. This may result in a greater appreciation and practice of the affective aspects of learning such as caring. This focus is important for educators as well as students. Students' descriptions of caring allowed me to learn how nursing students perceive caring. Participants associated caring with empathy, helping others, compassion, being professionally caring, and holism. In addition, participants discussed how caring, in their eyes, was affected by contextual influences on their education. The influences identified by students were their perceptions of progress through the program, emphasis on particular content, transfer of theory to practice, their interactions with clients and other students, leadership in the school, and a caring environment within the educational setting. Inextricably tied to students' descriptions of caring were their perceptions of and experiences with faculty members. Participants spent a great deal of time discussing positive and negative interactions with faculty members. Students identified characteristics of caring and uncaring instructors which I placed into an acronym. The characteristics included capabilities or skills, attitudes towards students, responses to students, intuitions, nature or personality, and generosity towards students. Students also explored ideal 125 instructors and positive role models of caring. These faculty members were described as possessing effective teaching skills, being enthusiastic, acting as a student advocate, using communication skills, and taking a holistic interest in students. In this chapter, I discuss a number of conclusions drawn from the findings. The conclusions I make are not separated according to descriptions of caring or experiences with faculty members because the conclusions overlap these two areas. Perceptions and experiences go hand in hand with caring and uncaring encounters with faculty members. Implications are addressed following each conclusion. In most cases, there are implications for nursing educators, nursing education administrators, and nursing students. In developing implications from the research, I reminded myself that the participants were volunteers and are not representative of all nursing students. I conclude the chapter by addressing areas for further research. The First Conclusion: The Importance of Empathy A recurring concept in students' descriptions of caring and caring instructors was empathy. Empathy, or understanding, was a key component of the definition of caring I offered in the introduction to this thesis. Having empathy for another individual involves seeking to understand what he or she is experiencing. Empathy is critical to caring because it acknowledges and values the thoughts and feelings of another person. According to the findings, empathy is accomplished through listening, being emotionally or physically present, appreciating the other person's point of view and offering reassurance. Through being understood, an individual feels validated, affirmed and enabled. That person is more capable of growth, the ultimate outcome of caring. The findings also indicated that having empathy distinguished caring 126 instructors from uncaring ones. A faculty member was unmistakably seen as caring when the instructor took the time to put himself or herself in the student's position. The instructor remembered the excitement and the fear associated with a novel situation when he or she thought back to their first experiences with new skills as a nursing student. Paula, for example, felt cared for by faculty members who could remember their initiation into nursing. "A student gets the feeling that the faculty [member] remembers what it was like to be in that situation because everyone's been in that situation to get to where they are now and it's always nice when you meet people you are trying to learn from, that realize that you have a common interest." Empathetic instructors were also seen as having greater flexibility in their approaches towards students. This was not only reflected in their approaches to learning content or skills. An empathetic faculty member was also able to take a student's circumstances into consideration by offering extensions on papers or rescheduling of exams. Students described how, in order to be caring, a person had to have empathy. They described caring as being empathetic towards their clients and faculty members being empathetic towards them. There are clear implications of the findings related to empathy for students and faculty members. I begin by addressing the implications for students. Understanding other human beings requires energy (being emotionally present), time (listening and being physically present) and effort (reassuring and validating). There are personal costs associated with each of these things. If people are constantly giving all of the time, receiving little in return, they can lose the capacity to care because they are not being cared about by others. Furthermore, caring for ourselves is a necessary prerequisite to caring for others. 127 The concept of reciprocity addresses this. In simple terms, reciprocity refers to "a mutual exchange" (Random House, 1991, p. 1125). When referring to caring, it means that in addition to giving to others, something needs to be received in return. Students maintain their ability to care for and about others as they learn the benefits of what others can give back to them. Anthony briefly addressed this. "Sometimes you respond to the little victories they have too. And if that weren't part of it I don't know if I could respond to the distress all the time." Reciprocity is also necessary for empathy to be exchanged between faculty members and students. Students discussed how faculty members were empathetic towards them. Only one student discussed how she cared for her instructor. Charlotte associated respect with having empathy for her instructor. "You have to have respect for them and it just helps by showing some concern and caring for the instructor. When you show them that you are concerned about them, that you care about what they say, ... then I think you get a lot more from them." Students can reciprocate empathy to their instructors. One example is to consider the instructor's point of view about a situation instead of becoming defensive. A second example is to develop an appreciation of the instructor's responsibilities, particularly in the clinical setting. A final example of how students can reciprocate caring to faculty members is by avoiding judgment based on a few instances of poor judgment or behavior and trying to evaluate faculty members' overall performance. When faculty members empathize with students they are reminded of how fragile they were as students. They can then guide their own instruction accordingly. Trying to be empathetic towards students is worthwhile for faculty members because, from it, they can learn to be caring through 128 understanding other people's feelings and experiences. One method for empathizing with the student position may be to reflect on initial experiences as an educator. Much of the fear, excitement and pressure is transferable from the situations of a beginning student and a beginning educator. Faculty members can also have empathy towards students when students' circumstances make it next to impossible for them to learn. In such instances, caring instructors may choose to show greater flexibility with deadlines and academic requirements. I am in no way suggesting that a faculty member tamper with standards, I am merely suggesting that they occasionally examine and understand the student's perspective prior to making decisions about necessary requirements. Students and faculty members alike could improve the skills associated with empathy by participating in empathy training programs. LaMonica (1983) developed an in-depth program to improve empathy for individuals in helping professions. She identified strategies to improve the two main dimensions of empathy: being more empathetic with oneself and being more empathetic with others (p. 20). Students or instructors may learn more about reciprocating caring by understanding their own emotions in addition to understanding how others feel. For example, a student may not identify their own anxiety in a situation and lash out at an instructor. If more aware of his or her feelings, he or she may be able to interact more constructively. The same may be said of an instructor. Thus, programs to enhance empathy are relevant for both groups. The Second Conclusion: Caring Requires Effective Communication Communication was an important component of caring throughout the interviews. Students used effective communication to define caring in nursing as well as caring and uncaring faculty members. An important 129 conclusion from the findings is that caring requires effective communication skills. These skills include careful listening to whatever is important to the other person. As Sheila said "she [her instructor] really listened well too, and she heard as well as listened." Listening involves hearing and in some way communicating that you understand what the other person has said. When someone communicates in a caring manner, after listening, they respond with words and actions that display understanding, compassion, and respect. These responses or expressions of caring were identified in the interviews as being supportive, accepting, and sincere. Caring faculty members were seen as effective communicators. Caring instructors said things, even critical things, in a way that made students realize it wasn't the end of the world. As Kelly indicated that "the one instructor who told me I was failing an objective, first told me some positive things and then she led into what was wrong. ... She said 'you can do something about this and it is not irreversible.' " Martha and Charlotte agreed that receiving negative feedback was valuable to students if it was offered in a caring manner. Students also identified how caring and uncaring faculty members used verbal and non-verbal aspects of communication. What instructors said non-verbally was just as important as their words. Caring instructors demonstrated openness, friendliness and approachability. In the eyes of the participants, the non-verbal communication of uncaring instructors betrayed them as uncomfortable, closed, and insincere. Being understanding is one thing, communicating understanding is quite another. Greater dialogue promotes communication. Students and faculty members could communicate more effectively with each other if opportunities to dialogue were established both inside and outside formal 130 learning situations. One method of promoting this could be through an orientation program. Wenda discussed this. Maybe having an orientation at the beginning of the program where instructors work together with students to introduce them to the faculty, the workings of the school, what it has to offer, and getting students comfortable with everything. ... Working with the faculty gives you a sense of familiarity and that is what can foster caring. Because it is really hard to show someone you care about them if you are not familiar with any aspect of them. This type of orientation could foster caring between students and faculty members by removing some of the barriers between students and their teachers. There is support for orientation programs for nursing students in the literature (Heinrich & Gladstone, 1992). These authors developed an orientation program designed to promote community building which in turn promotes caring. Their program incorporated the complexity in students' lives, their fear of failure as well as the identification of support systems into the orientation to the school of nursing. In addition to an orientation program, a second method to promote dialogue could be an informal social gathering between students and faculty members at the beginning of each semester. Tanner (1990) identified the need for egalitarianism between faculty members and students where diversity is acknowledged and embraced. A goal for students in an orientation or informal social gathering, would be for them to recognize that instructors are not the enemy. Students must recognize that faculty members are there to help students learn, are approachable and enjoy interacting with their students. Through conversations with faculty members, students can also realize that instructors have interests outside of academia and enjoy discussing these. Informal 131 settings may promote dialogue between faculty members and students resulting in each having a greater appreciation of the other. A goal for faculty members and students alike would be to learn about and improve communication skills. There is always room to improve communication, regardless of a person's comfort with communication skills. Effective communicators are constantly looking for better means of sending or receiving verbal or non-verbal messages. An article by Forsyth, Delaney, Maloney, Kubesh and Story (1989) identified non-verbal characteristics of caring used in therapeutic interactions as part of a curriculum revision where there was a greater emphasis on caring. Implementation of information such as this would be valuable in any program trying to promote caring. Awareness of communications skills and commitment to improving them will help educators and students interact with, and care about, each other and their clients more effectively. Communication skills can be improved additionally as feedback is sought from colleagues and classmates and as they practice carefully listening to and responding in caring ways. The quest for effective communication skills should never end. This may be seen as a goal for nursing education administrators. Effective and caring communications between faculty members can be promoted through an acknowledgment of the need for caring in the faculty and by faculty members being made accountable to each other in this area. Administrators may choose to offer workshops to faculty members. These workshops could address communication skills in general or communicating caring to others. Developing methods to communicate caring is essential to the next conclusion from the data. The Third Conclusion: Emphasizing Caring in Nursing Programs Overall, students offered more positive than negative comments about their experiences of caring throughout the nursing program. It is important to note, however, that the first two years were trying and difficult for students. The difficulties verbalized by students as they passed through the early years of the program reveal overall perceptions about a lack of caring from faculty members. A conclusion is that additional emphasis on caring must be communicated more convincingly to students in these beginning years. Although junior and senior students indicated that passage through the program eased with time, they also emphasized that caring could be given more consideration throughout the program. Students working their way through a threatening yet exciting system need to feel understood by faculty members who confidently and compassionately anticipate and address students' needs. Therefore, lessons apply not only to those faculty members working with beginning students. There are lessons for all faculty members interested in learning how to keep caring a central focus in the educational process. I would like to address methods in which caring can be established and maintained as a central focus of a nursing program. I do not address curriculum issues because these were not the focus of this research. Promoting caring in a nursing program starts with an administration in the school that is committed to caring. Nursing scholars agree (Diekelmann, 1990; Paterson & Crawford, 1994). "Authors who have investigated the nature of caring in nursing education have concentrated on the individual teacher, rather than on the need to foster communities of care within nursing faculties" (Paterson & Crawford, 1994, p. 171). Fostering caring must be supported from the top and filter down to educators and support staff in the faculty. Administrators can encourage dialogue about caring formally through forums and informally at coffee or lunch breaks. Administrators 133 must focus not only on faculty and students being caring in their educational settings. They must have a vision for future nurse educators and nurses who can take caring out of school settings and into hospitals, communities and society (Bevis, 1993; Moccia, 1990). One approach to cultivate an atmosphere of caring, especially in the early years of the program, is to closely examine the experience of faculty members teaching in those years. Inexperienced educators may obtain their initial teaching experiences with beginning students. This may result in educators who lack skill and insight into sound educational practices working with students who require exactly this skill and insight. I recall Sheila's comment about this. I used to teach at a Waldorf school and they thought the oldest and wisest should teach the youngest. They think that is the most important age to teach. And it is like they [instructors] all get their six students and it doesn't matter if they are new or inexperienced or ... I think that first year is so important, like that is where you get your steam up to get you through the next three years. And if you have a good experience in first year, then you have so much more incentive to go on. But if it has not been positive and generally it is not positive ... maybe they should look at this. Inexperience may also result in greater anxiety for the educator which in -turn is reflected in how they deal with their own anxiety and students' stress. The importance of helping students deal with anxiety is significant. Beginning instructors may not have the skills to effectively address and defuse students' anxiety. More seasoned faculty members may have a greater repertoire of skills as well as experience, resulting in greater confidence in dealing with anxiety and other impediments to student learning. Students 134 also identified an overwhelming emphasis on skills by instructors in the first two years of the program. Perhaps the emphasis on psychomotor skills needs to be examined and a more global definition of skills, such as that articulated in the literature (Metcalfe, 1990), needs to be adopted. An administration committed to having a caring faculty for students in each year of the program could approach this by placing new instructors with more experienced faculty members in each year. In addition, role models of caring could be provided at the team leader or coordinator position. Junior faculty could thus interact with experienced faculty who have acquired a number of skills associated with caring and have learned to blend caring into academic demands. Administrators need to be aware of faculty characteristics of caring because experience and age do not always equal caring. There are implications for individual faculty members as well. Faculty members can stimulate caring in the ways they interact with students. An example of how faculty can accomplish this is through evaluation. Students in this study realized that caring feedback from faculty members was for their benefit and intended to stimulate learning. Nursing educators who carry out evaluations in a caring manner do so by providing feedback which is ongoing, specific and considerate of the student's perspective. I acknowledge that this is not always possible, as in the case of a failing student, however, by attempting to evaluate in a caring manner, instructors show students that they are cared about and promote a caring environment. Instructors promote caring by consciously striving towards caring interactions with students. Strategies that diminish competition and promote cooperation between students were viewed as caring. Examples students cited included small group work, pairing for learning new skills, and seminars. Many of these implications require faculty members to sacrifice more time, energy and 135 effort. This may imply that faculty members have little better to do with their time. This is not the intent. Students can also collectively promote caring within a school of nursing. They discuss caring and uncaring interactions with each other. They talk to one another about their instructors. To promote caring within the school, students must remember that if they are having difficulties with a faculty member, they should directly approach the person prior to taking complaints to the other students, the administration or outside the school. If a faculty member is labeled as uncaring, new student groups may approach their experiences with that instructor from a negative mindset. By approaching an instructor directly with a conflict and avoiding bad-mouthing a faculty member, the bias that the instructor is uncaring can be minimized and caring can be promoted through acceptance and compassion. Students also need not hesitate to express caring towards each other and towards their faculty members. Providing positive feedback and encouragement show that students care. The Fourth Conclusion: Unrealistic Expectations of Faculty Members The most striking observation evident from the findings was that in order to be a caring instructor, faculty members had to be everything to everyone. Caring instructors were described as having excellent teaching skills, being great communicators, consistently showing respect and understanding of students' positions, and being intuitive about what students needed. They were always available to students. Faculty members were seen as caring when they helped students diminish stress by keeping a tight reign on their own anxiety. An important conclusion drawn from this research is that every faculty member cannot be caring all of the time to all of their students. That is reality 136 and must be accepted. Faculty members who make choices about caring demonstrate that they are caring for themselves by realizing their limitations and accepting them. This self-care is a necessary component of caring for others. Faculty members were seen as caring or uncaring through their interactions with participants. At some point in each participant's education, students and faculty members were able to connect with each other. The interactions of personality traits are largely the reason some people get along better than others. One sharp look or harsh word can sour a student's relationship with a faculty member. This may later be reversed through a kind word or soft touch on the shoulder. Conversely, the faculty member may be type-cast as uncaring. Trying to consistently model caring to students is extremely challenging. The challenge of meeting these demands on a consistent basis caused me to contemplate faculty members' management of the demands of their academic, professional, and personal lives. The ensuing tension that arises may be eased by faculty members finding a comfortable, or at least workable, balance between all of the things they are forced to juggle. Acknowledging the tension and seeking balance between personal, professional, and academic demands are ways faculty members care for themselves. Faculty members must learn to temper students', administrators' and their own expectations of themselves with the personal satisfaction, that given the circumstances, they have done the best that they can do. One method to promote a balance between these expectations is for the administration to acknowledge, appreciate, and then promote open dialogue about this tension. By bringing the need and difficulty for balance out of the closet, so to speak, the tension created by it is legitimized and 137 strategies identified by faculty can be shared. Administrator's may need to more carefully consider teaching assignments, committee demands and scholarly activities. Often the most competent faculty members are those who have the most demands placed upon them and are prone to collapsing underneath the pressure. They simply burn out. Administrators may also need to assess allowing faculty members to say "no" to the additional demands constantly being placed upon them. Administrators promote caring when they respect their faculty's judgments and when they apply holistic approaches to instructors' complex lives. Because of all of the directions in which faculty members are pulled, choices must be made, tried and revised. The literature in nursing education has seemingly not addressed how to be humanistic with students while maintaining a humanistic perspective with oneself. This study seems to support existing research (Bauer, 1990; Diekelmann, 1993b; Gallagher, 1992; Paterson & Crawford, 1993) that encourages faculty members to spend enough time with students in order to know them on a personal level and to be available to students on an unlimited basis. Effective faculty members however, are those who feel good about who they are and what they do. Striving to please everyone by giving unselfishly all of the time does not create effective faculty members. Faculty members practice caring in their lives when they try to take a holistic view of what is important and what they can realistically accomplish. There are implications regarding the expectations of faculty members for students as well. First of all, students must be made somewhat aware of the responsibilities of faculty members. This can occur through dialogue between the students and faculty about scholarly writing, community work, professional obligations, and committee involvement so that students can 138 appreciate the importance of these responsibilities as they pertain to their education. While students should not feel guilty about requests for time, they need to be made more aware of the variety of demands made upon faculty members. Students also need to learn to respect faculty members' time and not abuse it. Although lengthy telephone calls are acceptable occasionally, they should not be expected routinely. Students must consider the planning of their academic work in an attempt to avoid issues arising at the last minute. This would decrease faculty members having to be available on an unlimited basis. Finally, students need to incorporate fairness in their evaluations. Students must realize that faculty members have inconsistencies just as they have inconsistencies. Minor discrepancies should not negate generally congruent behavior. Everyone has bad days. Students need to be more forgiving and accepting of minor inconsistencies in their instructors. I have identified several conclusions drawn from the research findings. I have addressed the implications of these for administrators, faculty, and students. Further research is indicated to support or refute a number of these findings. Areas for Further Research As a result of conclusions drawn from this research, further studies are needed to develop knowledge and understanding of the concept of caring in nursing education. The concept of empathy in nursing and in nursing education requires additional development. Various components of empathy could be explored in greater depth and with a variety of participants such as practicing nurses and educators. It would be interesting to investigate student/ client interactions in greater depth. Reciprocity in the student/faculty member relationship also warrants exploration. 139 Administrators would benefit from additional research that addresses administrators' expectations towards faculty members. In addition, the way administrators reflect caring towards students and the relevance of this to student learning of caring is worthy of study. Investigating exactly what students need to know about faculty responsibilities and how faculty responsibilities affect student learning would be illuminating. It would also be beneficial to more closely examine student perceptions of caring as they relate to curricular issues in an undergraduate program. An effective method for this type of investigation would be to follow students through a program longitudinally and frequently assess their views on caring as they obtain their education. Conclusion I have explored what caring means to students by examining their perceptions of caring, the experiences of caring during undergraduate education, and their interactions with caring and uncaring instructors. The finding are important to nursing educators because their understanding about students' perceptions of caring are increased. The findings help faculty members understand students' expectations of them. They help students, nursing educators and nursing education administrators better understand what caring means to students, how they experience it and hope to experience it, and what is perceived by students as caring throughout an undergraduate program. The implications of these findings give nursing educators direction for improving nursing programs. What I have done to investigate caring in nursing education has been valuable and important to myself and hopefully to the broader community of nursing education. 140 References Appleton, C. (1990). 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Watson (Eds.), The caring imperative in nursing education (pp. 267-276). New York: National League for Nursing. Pugh, E. (1988). Soliciting student input to improve clinical teaching. Nurse Educator, 13, (5), 28-33. Ray, M. (1981). A philosophical analysis of caring within nursing. In M. Leininger, (Ed.), Caring: An essential human need, (pp. 25-36). Detroit: Wayne State University. Roach, S. (1984). Caring: The human mode of being, implications for nursing. Toronto: University of Toronto, Faculty of Nursing. Scudder, J. (1990). Dependent and authentic care: Implications of Heidegger for nursing care. In M. Leininger & J. Watson (Eds.), The caring imperative in nursing education (pp. 59-66). New York: National League for Nursing. Slevin, A. & O'Dell Harter, M. (1987). The teaching of caring: A survey report. Nurse Educator, 12, (6), 23-26. 147 Smith, P. (1991). The nursing process: Raising the profile of emotional care in nurse training. Tournal of Advanced Nursing, 16, 74-81. Symanski, M. (1990). Make room for care: Challenges for faculty of undergraduate nursing curricula. In M. Leininger & J. Watson (Eds.), The caring imperative in nursing education (pp. 137-144). New York: National League for Nursing. Tanner, C. (1990). Caring as a value in nursing education. Nursing Outlook, 38, (2), 70-72. Tatano Beck, C. (1991). How students perceive faculty caring: A phenomenological study. Nurse Educator, 16, (5), 18-22. Unger, M. F. (1957). Unger's Bible Dictionary. Chicago: Moody Press. Watson, J. (1985). Nursing: Human science and human care. A theory of nursing. Norwalk, Connecticut: Appleton-Century-Croft. Wilson, M. (1994). Nursing student perspective of learning in a clinical setting. Tournal of Nursing Education, 33, (2), 81-86. Appendix A Interview Themes and Questions The following was taken to each interview and referred to as necessary throughout the interview. Thank you for agreeing to be a participant in this research project. As you know, I am interested in learning more about how you as a student experience caring in your nursing education. Of greatest interest to me is how you have experienced caring through contacts and interactions with faculty members. Does that give you enough to go on? To get us started, begin by telling me what you think caring means in nursing. What does it mean to be caring as a nursing student? Think about the relationship between the caring you exhibit in your personal life and the caring you associate with nursing. How do you think caring for clients differs from caring for family and friends? How do you feel cared about? How do you experience caring. Probes to continue the interview could include: Have you learned about caring in the nursing program? Describe the characteristics of a caring faculty member. You may be describing someone you know or you may be thinking of how someone should be. How do nursing faculty in general demonstrate they care about you as a student? Describe a specific encounter or experience with a faculty member where you felt they cared about you. Conversely, describe an uncaring encounter. Do you learn about caring through role modeling? Tell me about how faculty members role model caring behaviours and/ or attitudes of caring in the clinical setting? in the school of nursing? If you were an instructor, how would you let your students know that you cared about them? How do you feel when you are being graded or evaluated? Do you think it is a caring thing to do? How do you think a faculty member shows they care about students when the student is having difficulty? Tell me about the emphasis you think nursing faculty members place on caring in your course? in clinical ? in labs? Do you find the school environment competitive? If you do, describe how competition between students has affected your learning about caring. Do you think there is a difference between how faculty members act in clinical settings and how they act in the school of nursing? If there is a difference, tell me about it. Tell me about your ideas of caring when you first entered the program and if they are different now. If they have changed, tell me what about the experience of your schooling caused them to change. Do you have any additional comments of ideas you would like to explore that are important to how you have experienced caring in your nursing education? C . C D OH OH < H cu T3 rH cu a' cu rH cu O): 2! C O C O SH 0); H. IT) C O C N O N 00 CO CN u Q l <->! M c« CO! >l ctf CN CN a. •21 C O n 3, Qi col CN CN i n CN CN CN CN o 64 CO mi C O CN CN C O C O m 3 4-t. Si cu i n co C a I n : EH 4 QJ cn, CO H-» C cu 6A CN C N C N 00 CO cu o rC O N 64 rT CO! CN 64 • & 13! 0 • r H C O C O 01 O CO; CN ol cu rH CN CO: cu 64 r f •rH r^ C O ZSl < o CM CO ON CO CM ON CM CM CO CM CO CO CO CM 00 co CM x TJ O J OH OH < S H ro cu S H CU O , > CM CO CM CM CO 0) a 1 cu S H HH TJ CU id ns U 03 0) CO as S H PH TJ ro S H CU H VH « cu TJ S H S H flS CU CO • T-H S H I* S H o PH CO -tf '• * H cu TJ o cu cu CO CM co CM CM w •H 0) u ro o, cu u u ro tS u o > TJ CMI o • T H 1/! co ro o, co t H cu col U i "cu ^ 1 4-J ro O , s cu ml cu 6 S H CU o o, s cu CO CO cu cu i - H cu O 001 CO cu C o OM U i • iH S H H - t S H U i • iH S H ro *ro o -,-H CO CO cu V4H o S H O , o cu O , C O cu S H CM CO cu S H CU cu U i -i—t ro co 154 Appendix F Characteristics of Caring Faculty Members as Located in C. A.R.I.N.G.. Acronym C=Capabilities 1. allowed mistakes 2. articulated thoughts and concepts well 3. brought out students' ability and confidence 4. committed to his/her work 5. • considered clients' wellbeing 6. employed constructive criticism 7. guided students with learning 8. helped students problems solve and learn from errors 9. modified approaches with content as necessary 10. showed enthusiasm 11. sought cooperation with students to enable learning 12. sought student feedback about his/her performance 13. was competent as a professional nurse and educator 14. was thorough 15. was tolerant of students' deficiencies A= Attitudes towards students 1. did not patronize students 2. did not threaten students 3. empowered students 4. holistically viewed students 5. respected students 6. treated students as equals 7. trusted students 8. was approachable 9. was non-judgemental towards students R= Responses to students 1. effectively used verbal and non verbal communication 2. encouraged students' professional and personal growth 3. maintained confidentiality 4. preserved students' dignity 5. was sincere when interacting with students 1= Intuitions 1. acknowledged students feelings 2. acknowledged students' high expectations of themselves 3. helped students maintain perspective 4. personally connected or "got to know" students 5. used humour to help students decrease stress 6. used intuitiveness with students 7. were concerned about students' wellbeing N= Nature of the teacher 1. accepted students 2. acted kindly towards students 3. appeared relaxed in the clinical setting 4. came across as very human 5.. comforted students 6. empathized with students 7. had a quiet, soothing demeanor 8. was flexible when interacting with students 9. was gentle as a person 10. was genuine as a person G= Generosity shown towards students 1. acted in an unrushed manner when approached 2. gave students home phone number 3. invested in students' lives 4. shared his / her own life with students 5. shared knowledge willingly 6. were generous with time, in and out of the clinical setting 156 Appendix G Characteristics of Uncaring Faculty Members as Located in C.A.R.I.N.G. Acronym C=Capabilities or lack of skills 1. acted in a rushed manner 2. cared about making an impression 3. could not be pleased 4. did not share knowledge 5. disorganized 6. emphasized errors 7. flustered 8. found things wrong 9. "grilled" or "drilled" students 10. held high and unrealistic expectations 11. lacked thoroughness 12. made students uncomfortable 13. offered no positive reinforcement 14. perfectionistic A= Attitudes towards students 1. appeared power hungry 2. did not treat students as equals 3. had large ego 4. mistrusted students 5. talked "down" to students 6. was condescending 7. was not approachable R= Responses to students 1. avoided eye contact 2. embarrassed students in front of other people 3. lacked verbal and non verbal communication skills 1= Intuitions 1. violated confidentiality 2. was insensitive to students N= Nature of the teacher 1. "harsh" 2. inflexible 3. insincere 4. intimidating 5. invalidated students' feelings 6. lacked self confidence 7. tense 8. was not nurturing G= Generosity shown towards students 1. distant with students 2. lacked interest in students 3. took little time with students 

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