As a researcher, you have to consider multiple factors when formulating a research question or hypothesis. Through your clinical rotation, you have been able to observe current interventions or procedures that may differ from what you have read in your textbooks or are being taught in this program. This is a dilemma because of the time it takes to translate research into practice. In pratcie, you might have likely developed clinical questions comparing the effectiveness or usefulness of certain interventions/treatments to another or the gold standard. Think of a time during your most recent clinical and your knowledge about research question and hypothesis from the assigned chapters. Respond to both by answering the questions that follow: • Formulate a research question on (for example) handwashing, patient turning or prevention of the spread of COVID-19. • Identify how a researcher will test these questions • State the research question as a hypothesis • As a researcher, what testable criteria will you consider for this hypotheses? ATLEAST 1 REFEENCE 1. Choose one of the articles posted and read thoroughly. 2. Identify the theoretical framework used in the article you chose (post the name of the theory). 3. Go the reference section of the article and Identify/select at least one primary source and one secondary source (articles) that supports the theoretical framework (list only the reference of these articles). 4. Now, search the electronic database such as Gale-Infotract on LIRN, CINAHL, or ProQuest to identify the primary and secondary source articles you selected. ATLEAST 1 REFERENCE Nurs Admin Q Vol. 32, No. 1, pp. 57–63 c 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright Exploring a Culture of Caring Lisa C. Carter, MA, RN; Joyce L. Nelson, MS, APRN,BC; Beth A. Sievers, MS, APRN,BC; Sarah L. Dukek, BSN, RN; Teri B. Pipe, PhD, RN; Diane E. Holland, PhD, RN Aim: The delivery of patient-centered care is basic to a large midwestern healthcare institution’s mission and highly valued by the department of nursing. Even so, nurses on one medical unit questioned whether caring behaviors were devalued in a technology-oriented environment of providing care. The nursing leadership on the unit responded to the inquiry by conducting a research study. This study explored the state of patient-centered nursing care on a medical unit as perceived by the nursing staff and patients, using Watson’s Theory of Human Caring as a framework. Subjects and methods: The study utilized surveys for both nursing staff (n = 31) and patients (n = 62), and included a focus group of nursing staff (n = 8) to explore ideas for innovation. Results and conclusions: Both nurses and patients perceived a high level of caring on the unit. The overall theme from the focus group was that “caring begets caring,” with 2 subthemes: “relationships of care” and “the context of caring.” NSG 410 Nursing Quality Care Question.

Caring for each other was identified as essential to keep staff energized and able to work lovingly with patients. Nursing leadership brought the research findings to all staff on the unit for discussion and implementation of structural support for the unit culture of caring. Key words: Jean Watson’s Theory of Human Caring, nurse-patient relations, patient-centered care N URSING has a distinguished history of caring for the welfare of the sick, injured, and vulnerable.1 Indeed, caring has been traditionally viewed by the public and nurses as the basis for the nursing profession.2 The delivery of nursing care requires an interpersonal process between the nurse as caregiver and the patient as care recipient. This interpersonal process requires the nurse to both care for and care about the patient. When the interpersonal process includes attentiveness to cues of the affective relationship with the patient, receptivity to the patient’s opinions and expectations regarding care delivery, and involvement of the patient in decisions made about treatment, patient-centered From the Mayo Clinic, College of Medicine Rochester, Minn (Mss Carter, Nelson, Sievers, and Dukek, Dr Holland); and Mayo Clinic, College of Medicine Phoenix, Ariz (Dr Pipe). Funding for the study was received from the Saint Marys Hospital Sponsorship Board. Corresponding author: Joyce L. Nelson, MS, APRN,BC, Mayo Clinic, 7 Marian Hall, Rochester, MN 55905 (e-mail: nelson.joyce@mayo.edu). care occurs.3 However, increases in technology and specialization have contributed to the perception of depersonalization of healthcare delivery in general and nursing care in particular. “Getting the work done” remains a powerful underpinning of work culture in most work settings. This may or may not include the work of caring about the patient. Several experienced nurses on one medical unit at a large quaternary care, referral-based, healthcare delivery system noticed novice nurses overwhelmed by the technological requirements of caring for patients. Some of the novice nurses seemed to focus on the tasks they must accomplish during the day such as the medications, the technology, and the process (eg, “This is my list. What I do as a nurse is check off as accomplished all these things on my list.”).A concern was raised as to whether caring about patients was being overshadowed by lists of tasks required to care for patients on the unit. Therefore, a study was conducted to describe the current state of patient-centered caring on the nursing unit as perceived by the nursing staff and patients, and explore whether change in the delivery of 57 58 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2008 patient-centered nursing care would be perceived by the nursing staff as beneficial. The framework chosen for exploring the state of patient caring was the Theory of Human Caring described by Watson.4 This theory best fits the vision, mission, and values of the institution. NSG 410 Nursing Quality Care Question.

The focus of the Watson’s Theory of Human Caring is the interpersonal relationship between the patient and the nurse. This transpersonal relationship is regarded as a key component of creating and sustaining a caring and healing environment. Watson has described the clinical caritas processes to delineate what caring consists of, and integrated the elements of caring into a worldview that weaves together quantum mechanics, spiritual connection, and philosophical positioning. Caring is a science that is a transpersonal process between the nurse and patient with the capacity to expand human consciousness, transcend the moment, and potentiate healing.5 (E. M. Caruso, N. Cisar, T. Pipe, unpublished obsservation, 2007). Watson’s theory and Swanson’s practical application of caring6 can provide nurses with insight into what is required to create a caring, healing relationship. Among the suggestions is that a supportive peer culture can provide mentorship for novice nurses in development of therapeutic behaviors. To articulate the value of a culture of caring, it must be witnessed and described. To sustain the culture, it must be celebrated. To enrich the culture, creativity must generate new ideas. THE STUDY A descriptive, comparative survey design was utilized to capture the nursing staff and patient perceptions of caring on the nursing unit. Descriptive qualitative design and methods (focus group) were utilized to explore ideas for innovations in delivery of patient-centered nursing care on the nursing unit. The study setting was a 36-bed medical specialty unit whose patients have a variety of acute or chronic health problems. Relationship-based care is the nursing care de- livery model. This means that nursing staff put at the center of their work a personal relationship with patients and family, prompting a committed involvement with patients on multiple levels, ministering to body, mind, and spirit. The unit also operates utilizing a shared decision-making framework such that practice is reviewed and improved upon by staff reflection and consensus. At the time the study was conducted (May, 2006), 63 registered nurses, 1 licensed practical nurse, and 16 patient care assistants provided care on the unit. Staff experience ranged from novice (less than 1 year of experience) to expert (up to 30 years of experience) and their ages ranged from 20 to 60 years. All members of the direct care nursing staff were invited to participate with a 50% response rate anticipated. A limited number of nursing staff members were purposively invited to participate in the focus group. After approval by the hospital’s institutional review board and obtaining informed consent, data were obtained from the nursing staff participants using the Caring Efficacy Scale (CES). NSG 410 Nursing Quality Care Question.

7 The CES was developed on the basis of Bandura’s concept of efficacy and Watson’s theory of transpersonal caring. It assesses a person’s belief in his or her ability to build caring relationships and communicate a caring environment with patients. The CES consists of 30 self-report statements on a 6-point Likert-type scale anchored by “strongly disagree” and “strongly agree.” The CES has been tested with convenience samples of graduating students, their preceptors, and employees from 3 academic nursing programs including the baccalaureate, master’s, and doctorate levels. Content validity was established by expert nurse judges. The CES was found to have high levels of internal consistency. Faculty associates from the Center for Human Caring concluded that the majority of Watson’s carative factors are assessed in the CES. Patient participants were asked to complete the Client Perception of Caring (CPC) Scale.2 The CPC scale was developed to measure patients’ responses to caring behaviors Exploring a Culture of Caring demonstrated by nurses. Caring behaviors are defined as nonverbal and verbal actions signifying that care was carried out by the nurse as perceived by the patient. The conceptual model for the instrument included 4 levels: acknowledgement of the need for care, the nurse’s decision to care, the actions and behaviors of the nurse that were meant to promote the welfare of the patient, and actualization of the caring experience. The CPC selfreport tool is consisted of 10 items on a 6point rating scale. The potential score range is 10 to 60, with higher scores indicating a higher level of perceived caring by the patient. The standardized item α coefficient was calculated at .81. The focus group was facilitated by a doctorate-prepared nurse researcher with experience in leading and data analysis of focus groups. A nursing research specialist with advanced training and experience in focus group methods and analysis served as the observer for the focus group. The facilitator worked with the research team to understand the aims of the study and identify the objectives and prompts for the focus group, but had no other relationships with the focus group participants. Members of the research team were not present during the focus group interview to allow the participants to express themselves freely. A focus group interview guide was used. The guiding question was “What, if anything, needs to be changed in the ‘caring environment’ on this unit?” Survey responses were analyzed with descriptive statistics. The analysis of the focus group data followed that of qualitative descriptive methods. Following verbatim transcription of the audio recordings, the transcripts were compared to the audiotaped recordings and revised where necessary. NSG 410 Nursing Quality Care Question.

The transcripts were then read as a whole and a general impression of the data gleaned. The transcripts were then coded and categorized. The coding and categorization of transcripts were validated to ensure reliability of the interpretation. One Hundred percent agreement was found in the coding scheme. 59 RESULTS Thirty-one staff members volunteered to complete surveys. This represented 39% of the total nursing staff on the unit. The majority of the participants were registered nurses (87.1%) with the remaining participants were licensed practice nurses or patient care assistants. Participants’ ages ranged from 20 to 60 years. Number of years of experience in a direct care role ranged from less than 1 year to 30 years (mean 6.77 years). There were 29 women staff members who participated. Scores on the CES ranged from 4.50 to 5.90 with a mean (SD) of 5.18 (0.41) on a 6-point scale. Higher scores indicate more caring efficacy. Survey items on which staff scored highest included “I am able to tune into a particular patient and forget personal concerns,”“I use what I learn in conversations with patients to provide individualized care,” and “I can usually establish close relationships with patients.” Other high-scoring questions included feeling strong enough to listen to fears and concerns of patients, having an ability to introduce a sense of normalcy in stressful situations, and creating ways to relate to most any patient. Nursing staff scored lowest on the item, “I feel comfortable touching my patients in the course of care-giving.” Sixty-two patients volunteered to participate. The mean (SD) age of the patients was 64.92 (16.68) years. Twenty-five were men (40.3%) and 37 were women (59.7%). Of note, 45% had at least some college education or completed a degree, 30% were high school graduates only, and 25% had not graduated from high school. There were 60 completed CPC surveys from this group of patients with scores ranging from 39 to 60. The mean (SD) score was 54.68 (5.46). Higher scores indicate greater perceptions of nursing staff caring behaviors. Individual items that were high scoring included “I felt this nurse really listened to what I was saying,” “I felt this nurse really valued me as an individual,” “I felt free to talk to this nurse about what concerned me,” and “I could tell this nurse wanted me to be comfortable.”One item that patients scored lower 60 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2008 was “I felt this nurse could tell when something was bothering me.” The focus group was convened with the objective of garnering ideas for innovation. The group was to reflect on what contributes to the high level of caring and what could enhance the caring environment. NSG 410 Nursing Quality Care Question.

The group consisted of 8 staff members; 7 registered nurses, and 1 patient care assistant; 6 were women, with wide ranges of ages and experience. The questions focused on “What, if anything, needs to be changed in the caring environment of the unit?”The overarching theme that emerged from the focus group was “caring begets caring.” Participants described how they were inspired to care by being cared for themselves. Descriptions included “Seeing others care encourages me to go forward.” “Celebrating and recognizing caring gives it value.” This theme had 2 subthemes: “relationships of care” and the “context of caring.” Elements within each subtheme were also explicated. Relationships of care involved 4 elements. The first was “teamwork.” “I think our unit as a whole is really, really good at teamwork, at working together and helping each other out.”“Our coworkers are there for the patient, and they understand what job needs to be done . . . .” Communication was one aspect of teamwork that participants identified as an opportunity for improvement. In particular, discharge planning between nurses, physicians, and patients and families was felt to be an issue that could be coordinated with more focused discussion early in the hospital stay. A second subtheme was “building expertise.” The more experienced nurses “have that experience and they know where the resources are . . . and I think that makes a tremendous advantage.”One nurse suggested, “. . . doing more to balance experienced and less experienced or newer people on shifts . . .”as one opportunity to enhance caring. Another way to achieve this is “some sort of mentoring,” which participants went on to define as a program that is not educational in focus, but rather a recognition and celebration of caring. Focus group participants with less ex- perience validated the need for support of this type. When staff are new, we could do more to “recognize and celebrate the wonderful, caring things you do for your patients, because you probably lose sight of that because you’re so focused . . . that’s where I think mentoring could make a difference.” Another element—personal support from peers—was expressed as critical to caring on the unit by the participants. They suggested that in feeling supported by their coworkers, they were better able to care not only for their patients but also for themselves. “. . . we know each other well enough to know that, you know, this is not really my area of expertise but so-and-so . . . so I’ll bring her in to talk to you.” “. . . your coworkers will see that you’re stressed out or see that things aren’t going very well, so they’ll say can I help you, what can I do or lets talk or something like that.” “I couldn’t have made a lot of changes that I’ve made in my life without the support of the people I work with.” The last element identified by participants was “connecting with the patients” as a key characteristic of a caring environment. NSG 410 Nursing Quality Care Question.

Connecting was described by the focus group participants as not only spending time with the patient but also being present with the patient or family. “. . . a genuine concern to what’s going on with that person and really doing the real active listening, not just ‘uh huh’ and head nodding, but trying to just be there in the present and just try giving of yourself.” One nurse summed up this opening of self to the patient as, “The patient will know that you’re really there for them. The patient will know that the nurse values them, and they feel safe.” The second subtheme, the context of caring, described the organizational and unit infrastructure. These included the organizational culture, the unit physical environment, and workload. The organizational culture of caring was identified by participants as evident from their initial orientation to the organization. “Housekeepers, cook staff, it was everybody” who was concerned “about patient centered care and the patient comes first.” Exploring a Culture of Caring Similarly, the unit physical environment emerged early in the discussion and reemerged as participants discussed opportunities and challenges related to patientcentered caring. In particular, limited access to bathrooms was expressed as a “small thing that just brings it (patient centered caring environment) down.” Another context of caring was the work of caring as reflected in workload. In addition to sharing exemplars of situations where they were able to spend time with the patient to make connections, the participants also expressed concern about the ability to meet this need because of workload issues. One participant described how the patient classification system impacts provision of patient-centered caring, “It usually provides a reasonable assignment so that the patients can be treated holistically.” In summary, while technology has increased the pace of a nurse’s work, the participants of this focus group valued caring as the inspiration for development of quality patient care and for quality work teams. Caring was influenced in the organizational context as well as in the relationships of caring. Key elements of a patient-centered caring environment included teamwork, personal support from peers, building expertise, connecting with the patient, culture, physical environment, and workload. RELEVANCE FOR PRACTICE While scores on the surveys indicated a high level of caring perceived by both nursing staff and patients, the focus group gave additional insight into what creates and supports a caring culture. In analyzing the data, the comments and themes reflected Watson’s clinical caritas in action.8 Participants were indeed recognizing the underlying culture of loving-kindness that keeps a group sustained through periods of time when the environment of caring was stressed by demands and changes. They were recognizing caring consciousness, authentic presence, transpersonal connection, and creative use of self, directed 61 toward one another, and toward patients and families. There was an underlying perception of a caring-healing environment that supports people holistically, practiced on a daily basis, and taught to new staff. “NSG 410 Nursing Quality Care Question.

Caring begets caring” was the overarching theme voiced by the study participants in the focus group. Caring for each other was identified as essential to keeping staff energized and able to work lovingly with patients. Practicing the caritas processes was an essential starting point, but supporting one another in the application of them kept the culture alive and strong. Participants talked of drawing upon one another’s strengths, supporting one another when challenges were encountered, and gaining support from the group ethic. They spoke of transforming one another’s practice by celebrating caring interventions. Watson’s theory illuminates the essential elements of caring relationships such that nursing staff care for themselves, one another, and patients and families with the energy generated by caring connections. When asked about what would enhance their ability to care, staff responded that the unit should continue to recruit individuals who embrace caring values. This implies a closer connection with students on clinical rotations assigned to the unit. Staff also noted the importance of retaining experienced nurses who can care for the newer staff as well as for the patients. Several talked of the value of having staff mentor one another and continue to support each other after orientation. Celebrating and recognizing caring were advocated. Talking about what they do gives the caring value. They wanted to enhance programs to highlight caring exemplars. Viewing the team as cohesive and supportive of each member was promoted. Charge nurses who round frequently and affirm team contributions were celebrated. As one nurse reports to the next at shift change, reframing the questions could show care for one another, respecting priorities, and judgment. Witnessing authentic care encourages all to engage more authentically, more creatively with patients. 62 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2008 The focus group participants also discussed how continuity of assignments helps them form more therapeutic relationships with patients and families, and how thorough communication in patient care hand-offs such as those found in the discharge planning process contributes to enhanced patientcentered care. Nurses also discussed the value of enhancing communication with other disciplines, knowing that matching patient expectations with what actually occurs contributes to patient satisfaction. IMPLICATIONS FOR NURSE LEADERS Nurse leaders are responsible for implementing the vision, mission, and values of the institutions and departments for which they work as well as promote efficient, effective, safe, and compassionate nursing care. NSG 410 Nursing Quality Care Question.

This study was a valuable exercise in assessing a unit’s consistency with overall institutional values as well as its current caring environment. The results from the focus group invite nursing leadership to consider how leadership and staff can keep alive the insights and reflections that gave the group cause to celebrate their ability to care. On this nursing care unit, the study findings were shared in group sessions and staff, and patient responses examined and discussed. Among the individual survey items reviewed was the score reflecting staff discomfort with touching patients. In discussions, staff identified issues such as some patients are uncomfortable with touch; some female patients request no male staff as caregivers, and pain as a barrier to touch. Follow up on the therapeutics of touch is planned in upcoming team sessions. In addition, several staff members have elected to learn more by attending a class devoted to experiencing the basic elements of Jean Watson’s model. Charge nurses have worked in educational sessions to further develop leadership skills necessary to foster an environment of care. Therapeutic communication, workflow facilitation, and mutual support were topics discussed. Preceptors have generated ideas to enhance their caring practices. Caring exemplars have been elicited in evaluations as well as in team sessions. Caring for one another in mentoring relationships will be evaluated in staff committees as an area for further development. Ideas for caring enhancement for patients will continue to be shared in unit council and practice committees. Patient satisfaction data are collected quarterly and available to all staff. These data will also be examined routinely in team sessions. The questions asked of patients focus on perceptions of caring behaviors. Their responses often direct our priorities for new projects. Caritas Circles are planned as a voluntary quarterly connection of spiritual renewal and dedication to caring by nursing staff who want to learn and apply more of Watson’s theory to their practice. The charge to nurse leaders is to acknowledge, refresh, and feed the energy of each staff member to keep a caring environment aglow. IMPLICATIONS FOR NURSE ADMINISTRATORS Caring has been directly related to healthcare economics, patient outcomes, administrative practices, and nurse and patient satisfaction.9 This study reinforced the value in having nursing administrators as well as institutional leadership embrace and role model the constructs of caring and maintaining a culture that is built upon recognition of individual worth, shared decision making, accountability, continuity of care, and professional practice. Employees who are empowered by the institution’s leadership act in the interests of patients. They establish a group ethic that drives common expectations of care and creates new ways to bring a healing environment to patients. NSG 410 Nursing Quality Care Question.

They have a reflective practice that audits the culture to ensure that it supports the best interests of patients and staff. At this institution, the Department of Nursing has spent the last few months talking about an evolved caring model that puts at the Exploring a Culture of Caring center the ability to care and make connections with patients. The caring science of Jean Watson supports this model, as does our institution’s tradition of caring. The findings of this study support the model by showing that patients can identify nursing staff who truly care about them and that patients value this richer connection. Patients expressed a sense of comfort and safety, felt cared about as individuals, and felt free to communicate their needs. Since this research was conducted, caring interventions have been shared and celebrated in discussion on every nursing unit. Every nurse has a description of relationshipbased care and the principles, roles, and interventions that support that care. Common vision, language, and mission promote a culture of caring in orientation, staff development, and ongoing practice. CONCLUSIONS This study examined the foundation for practice on one nursing unit in an institution, 63 which has a caring tradition. The results confirmed that there was a high level of caring behaviors in evidence. The further examination of our institutional and unit nursing culture revealed that the caritas have been held up as ideals in the leadership, communication, and education within the Department of Nursing for many years. Our research study and subsequent discussion of results provided an opportunity to talk about what we value, invited keener consciousness of caring, and provided a forum to suggest improvements. By relating our tradition to Watson’s theory and providing evidence through research, we were able to articulate the art and science of caring at the center of nursing on the unit and give it the importance and distinction it deserves. By asking questions about perceptions of care, we were able to evaluate whether caring was intentional by staff and tangible to patients. We found nurses’ perceptions of care and patients’ perceptions of care were positive and in alignment—even as the technology of providing care advances. REFERENCES 1. American Nurses Association. Standards of Clinical Nursing Practice. Washington, DC: American Nurses Publishing; 1991. 2. McDaniel AM. Measuring the caring process in nursing: the Caring Behavior Checklist and the Client Perception of Care Scale. In: Strickland OL, Dilorio C, eds. Measurement of Nursing Outcomes. Vol 2: Client Outcomes and Quality of Care. 2nd ed. New York: Springer; 2003:233–242. 3. Winefield H, Murrell T, Clifford J, Farmer E. The search for reliable and valid measures of patient-centredness. Psychol Health. 1996;11:811– 824. 4. Watson J. Nursing: The Philosophy and Science of Caring. Boulder: University Press of Colorado; 1985. 5. Watson J. Postmodern Nursing and Beyond. Edinburgh, UK: Churchill Livingstone; 1999. 6. Swanson K. Nursing as informed caring for the wellbeing of others. Image: J Nurs Sch. 1993;25(4):352– 357. 7. Coates CJ. The Caring Efficacy Scale: nurses’ selfreports of caring in practice settings. Adv Pract Nurs Q. 1997;3(1):53–59. 8. Watson J. Dr. Jean Watson’s Theory of Human Caring. University of Colorado Health Sciences Center. Available at: http://www2.uchsc.edu/son/caring/ content/. Accessed May 30, 2007. 9. Watson J. Caring theory as an ethical guide to administrative and clinical practices. Nurs Adm Q. 2006;30(1):48–55.