Caring is often considered a synonym for nursing. Interest in caring has grown exponentially from nursing theorists, researchers, clinicians, and educators.1 Caring has been directly related to quality of care, healthcare economics, patient outcomes, administration practices, and nurse and patient satisfaction.2,3,4,5,6,7 Nurse mangers play a pivotal role in nursing care, and they are responsible for promoting efficient, effective, safe, and compassionate nursing care.8 Nurse managers are in positions between doctors and nurses, between hospital leaders and nurses, and between other nurses. They have been at the top, the bottom, and in between, where they must make appropriate decisions while continuing their nursing management.2,9 Nurse managers have sufficient power and organizational influence to obtain the resources necessary to promote nursing caring practices.10,11 Leininger12 believed that nurse managers and administrators can embody caring and improve patient care by insisting on a caring philosophy from top to bottom within the nursing service. Results from phenomenological study10,13 also revealed that staff nurses experienced difficulties in caring for their patients when they, themselves, have not felt cared for or appreciated by their nurse manager. Similarly, quantitative research of Wade et al.14 also showed that caring attributes of managers was a statistically significant predictor of nurses’ job enjoyment. Thus, some authors argued that nurse managers needed to have enough caring knowledge, caring ability, and caring skills to make sure that they can better portray their role, care for their staff, take care of their patients and families, and also enhance the organization culture.15,16,17
It is regretful that nurse mangers are faced with the dilemma of how to take good care of their first-line nurses,2,17,18 and there are also evidences in the recent literature that clinical nurses consider that they do not generally get enough support from their nurse managers.13,19,20,21,22,23,24 It prompted us to explore a practical and effective way to solve this problem. In a previous study, we also explored the caring training experiences and expectation of 453 nurse managers in 14 hospitals in the Hubei Province in China. Results showed that 96.9% nurse managers need caring training and 37.7% nurse managers have not been trained in the caring field. Although it is widely accepted that a caring training is integral to nursing continuing education,6,25,26 there is an apparent dearth of a standardized caring training for nurse managers. It is urgent to develop consistent training content for nurse managers to acquire caring knowledge, improve caring ability and skills, inspire caring behavior, enhance the organization climate, and improve nurse and patient satisfaction.
2 Literature review
Caring in education has been emphasized as the first place for teaching and learning the values of the nursing profession.27 In the past several decades, caring in nursing education was conspicuously identified and adopted by schools and hospitals. Many countries initiated the efforts, such as Canada, Japan, and China, especially the United States. Many organizations in America made great efforts on developing nursing caring education. A literature review revealed that the majority of nursing caring education programs were based on Waston’s theory, and grounded in American, they could be classified into four groups according to the target audience: most of them focused on nursing students,25,28,29,30,31,32,33,34 several of them focused on clinical nurses,26,3536,37,38,39 and a few of them focused on nursing educators40,41 and nursing administrators.42 Some paradigms exist. The Weber State University, USA, offers a BSN course focused on Jean Watson’s definition of caring. It includes caring for self, others, peers/co-workers, nursing leadership, local/world communities, the environment, and Web-based interactions.28 The course created for nurse educators at Inova Alexandria Hospital41 was a noteworthy exception. It not only focused on offering a caring training for nurse educators to help them influence nurses in their wards but also had a continuing caring training last along for 3 years to make sure that affective growth occurred for both clinicians and educators. Implementation included core content in a 30-minute training session, large-scale leadership conferences, and consistent educator support (pilot units in patient areas and outpatient areas). Nursing researchers also had described some theoretical aspects of caring education. More and more scholars were committed to develop the online courses and video courses.43 Through the literature review, it was not difficult to find that most literature concentrated on caring education for nursing students and clinic nurses, with little description of the education program for nurse managers. Summarizing the caring program content in nursing education, we found that caring education was a gradual, systematic, and continuous process that causes the caring education effectual. It was regrettable that still no literature identified what content and skills should be included in caring training content for nurse managers.
3.1 Development of the questionnaire
We preliminarily drafted the questionnaire, which contained three parts: (1) a cover letter detailing the aim and background of this study; (2) a demographic questionnaire including gender, age, degree, years of experience, position, and discipline; and (3) a questionnaire, which was the preliminary designed training program from literature review and the cross-sectional study.44 Participants were asked to rate the importance of each item that was regarded as an essential component using a 5-point Likert-type scale (l=not at all important, 2=not very important, 3=neutral, 4=fairly important, and 5=very important). If there was any disagreement (1 or 2), experts should give their comments. Additional space was provided within the tool for participants to suggest items that they felt were important but not contained in the tool.
Prior to mailing the surveys to participants, five experts in the related field had finished the pilot tested for feasibility and content validity. Their suggestions were related to wording changes intended to increase the clarity of the questionnaire. Based on the results of the pilot, minor changes were made to the format of the questionnaire.
3.2 Identification of the expert panel
According to the purpose of the research subjects and the Delphi method, we established the inclusion criteria: (1) knowledgeable about nursing caring and held academic influence in caring field; (2) devoted in the field that related to humanities, nursing administration, nursing education, and hospital management for more than 10 years; (3) associate professor and above or associate director of nursing and above; (4) bachelor degree and above; (5) being able to offer comprehensive opinions; and (6) willing to participate in our survey. After initial screening, we involved a multidisciplinary panel to support the study and also balance the potential bias produced by specialists about their own field. We identified panel members through searching the database named China National Knowledge Infrastructure. In the database, when we typed key words such as “caring”, relevant scholars appeared. We followed this with a combination of purposive and snowball sampling.
The multidisciplinary panel consisted of 24 experts, two medical humanities specialists, 15 nursing administrators, five nursing educators, and the last two experts engaged in hospital management. The expert panel did not contain the first-line nurse managers because we have been had a cross-sectional survey to explore nurse managers’ experiences and expectation for caring training content before. There was also no first-line nurse manager who met our requirements.
3.3 Consensus level
The required level of consensus was defined in advance. Three necessary conditions had to be fulfilled: (1) an average score (mean) of 4 or above, (2) a consensus percentage of at least 80%, and (3) a coefficient of variation of 0.2 or below. In the consensus calculation, the consensus percentage was calculated by classifying the values 1–3 as not important (0) and 4–5 (1) as important.
3.4 Ethical approval
The research proposal was submitted to and approved by the ethics committee of Tongji Medical College, Huazhong University of Science and Technology (IORG No: IORG0003571). All participants were informed about the purposes and the methods of the study. Participants were anonymous and not known to each other. The record of participants’ contact details and response status for each round was stored separately from their responses. Moreover, the participants were reassured that their responses would be kept confidential, the results of this survey would not be used for any purpose other than this study, and their identities would not be revealed in any research reports and publications of the study. Experts have the right of quitting at any time during the research.
3.5 Data collection
3.5.1 Round 1
The questionnaire was sent electronically to a multidisciplinary panel of 24 individuals in October 2014. Sets consisting of a written request for cooperation in the survey and a request to send back their responses within about two weeks, together with the questionnaire we introduced before. Approximately 2 weeks later, nonresponders were contacted a second time electronically. Frequency, mean, standard deviation, and coefficient of variation were calculated for each item. Content analysis was performed by researchers, and expert words and phrases were used as often as possible when constructing the round 2 survey.
3.5.2 Round 2
There was a one-week interval between the two rounds. In November 2014, experts who agreed to participate in the first round and sent back responses were sent a second survey. In the second round, we added some items according to the opinion of the multidisciplinary panel. Experts were only asked to rate the importance of each items. Weight would be calculated based on their score. Nonresponders were contacted a second time electronically within 1 week of the survey due date.
We used e-mail to invite 24 experts for participation in the study. In all, 23 people agreed to participate, and 22 experts (a response rate of 91.7%) from 14 provinces (Hubei, Jiangsu, Henan, Beijing, Shanghai, Guangdong, Yunnan, Sichuan, Hunan, Liaoning, Shaanxi, Shanxi, Shandong, and Fujian) completed the second round. Dropout occurred between the first round and second round among the groups of nursing administrators and females.
4.1 Sample characteristics
The sample included 22 experts who responded to all two rounds of the Delphi survey. The age of the participants ranged from 37 to 61 years, with a mean of 48.35 years. The average working time was 27.96 years (ranged from 11 to 46 years). Years of experience in management or education was 12–35, and the average was 22.4. The demographic information supported that they were experts in their own field. Other information of these experts is listed in Table 1.
Demographic information of experts (n=22).
|Years of experience|
|Director of nursing||10||45.5|
|Associate director of nursing||3||13.6|
|Nursing Education and Administration||6||27.3|
4.2 Round 1 survey results
All the items were conformed to the selection principle and preserved, which means that these items were very important or important. Experts suggested separating the item ‘Caring for Patients and Their Family Members’ into two themes. They believed that some items should be increased or adjusted. Adjustment included items changed into another module and words adjusted. Finally, we added four items and adjusted six items according to the opinion from these experts.
4.3 Round 2 survey results
During the second round, no suggestion had been proposed and all the 23 items met the selection principle. We used analytic hierarchy process to calculate weight of each item according to the score. Details are listed in Table 2.
Caring training contents for nurse manager
|Caring Knowledge and Caring Ability||4.86||0.35||0.07||0.4490|
|The caring overview||4.45||0.51||0.11||0.0176|
|Belief and spirit in caring||4.95||0.21||0.04||0.0852|
|Courtesy in caring||4.55||0.67||0.15||0.0245|
|Caring in communication||4.82||0.50||0.10||0.0589|
|Strategies for self-care||4.82||0.40||0.08||0.0589|
|Caring for patients||4.81||0.40||0.08||0.0494|
|Caring for family members||4.64||0.49||0.11||0.0343|
|Narrative medicine in human caring||4.45||0.67||0.15||0.0176|
|Creating caring culture||4.73||0.46||0.10||0.0449|
|Organizing caring activities||4.59||0.59||0.13||0.0305|
|Caring for nursing working environment||4.73||0.46||0.10||0.0449|
|Caring responsibility for nurse mangers||4.41||0.67||0.15||0.0131|
|Caring standards, criteria, and patterns||4.50||0.51||0.11||0.0213|
|Assessing and measuring caring in nursing||4.50||0.51||0.11||0.0213|
|Selecting education contents||4.64||0.49||0.11||0.0904|
|Evaluating the training effect||4.50||0.51||0.11||0.0452|
|Selecting topics for research||4.45||0.51||0.11||0.0401|
|Research methods in caring||4.27||0.63||0.15||0.0180|
|Evidence-based caring practice||4.68||0.48||0.10||0.0621|
5.1 Validity of the survey result
In this study, we used a Delphi technique to seek consensus on the importance of different topics in the content of caring training for nurse managers. It was useful for achieving consensus in areas that were lacking empirical evidence.45 Recognized experts in nursing education, administration, medical humanities, and hospital management participated in this study. The multidisciplinary panel with different years of work experiences came from 14 provinces, which balance the potential bias produced by specialists about their own field. A high level of cooperation was obtained with respective response rates of 95.8% and 95.7% from people who received the surveys in the first and second rounds. All the experts who engaged in two rounds of survey gave their comments and suggestions, which means that they were closely involved in the survey. The Delphi result correlated with the cross-sectional study,44 indicating that the results were a valid consequence. The above results suggested that the present study achieved an adequate level of reliability and validity as a Delphi study.
5.2 Twenty-three training items for which consent was obtained
This study has identified 23 caring training contents belonging to four modules, which should be achieved by nurse managers. The modules were progressive and followed the logic flow. The Caring Framework for Excellence in Nursing Education was found by a review of the related literature. The Framework contained three parts: Practice, Scholarship, and Leadership.46 The presenting characteristics showed a striking resemblance to our findings. Practice corresponded to caring knowledge and caring ability. Scholarship and Research were similar. The last part, Leadership, was clearly the same. It has been stated that nursing caring education was not something that should end up with the discontiguous and sporadic.34 Our research got a systematic, scientific, feasible caring training content for nurse managers.
5.2.1 Module I: Caring knowledge and caring ability
The weight of caring knowledge and caring ability was much higher than others because this module contained 10 items. Nurse managers used knowledge and ability of caring to perform their job.2 Apparently, it was the most important and fundamental part. The first step to be an eminent nurse manger was to be a good nurse. However, there were still significant differences between nurses and nurse managers. So, this module based on caring knowledge and caring ability for a caring nurse, but not exactly the same. The caring overview helped nurse managers have a rough idea of caring. Nurse managers would devote themselves to caring when they finished learning belief and spirit in caring. Caring theories was the foundation. Human-based management, caring in communication, strategies for self-care, caring for patients, and caring for family members were the core of nursing caring. Combined with the hot topics in China, we added narrative medicine in human caring. As China was a land of courtesy and Chinese nurses took much count of courtesy, so we confirmed courtesy in caring in caring knowledge and ability module.
5.2.2 Module II: Caring leadership
Nursing managers were responsible for caring in their unit. They had to translate caring to the systems level and set the stage for a caring organization.2 So they needed to create caring culture and caring environment and organize caring activities. Nurse managers were always confused about how to implement caring into clinical practice,2,17,18 so we selected the caring standards, criteria, and patterns to guide them. It was also an issue to realize the basic thing a nurse manager should do, thus, caring responsibility for nurse mangers came into view. When all items were finished, we assessed and measured it in order to make sure whether they had been promoted.
5.2.3 Module III: Caring education
The learning procedure of nurses was divided into two parts: schools and hospitals. Obviously, hospital was the key part, where nurses could have their systematic, specific, and long-term learning. A nurse manager was the principal of education in hospital and also the person who was acquainted with every nurses. Hence, they should organize targeted training for individuals according to the department situation. In the process, teaching approaches and effective evaluation were two issues of crucial importance.
5.2.4 Module IV: Caring research
Nursing research was the backbone to improve and promote nursing work. Nurse managers played an exemplary role to other nurses. In all, 78% articles in the nursing field belong to nurse managers.47 Caring research helped nurse manager understand caring not only from the practice phase but also from theoretical height. When you select a topic for research, you should master the research methods, draft the manuscript, and finally, transform caring science into practice. The four items were the key steps in nursing research.
A multidisciplinary panel has identified the necessary items for nurse managers in the caring training field, which was the first step for caring education for nurse managers. The contents would serve as a guideline to healthcare institutions. Nurse managers can choose any module to have a system learning according to their practical needs, totally or separately.
Based on the training contents, there is still need to explore the effective teaching method and the appropriate way to measure the effect of the training. An empirical study should be conducted in the future. Additional research is required to revise the contents to make sure the integrity and integration of the content.
There were two limitations existing in the present research: one was the selection of experts and another was the questionnaire. At present, the Chinese nursing experts in human caring are rather limited, and the academic level of Chinese nurses is lower than that of nurses from other countries, so the resource of expert selection was limited in this study, and the size of sample was also smaller than the researcher’s original plan. The questionnaire, which was designed by the research team, may not contain all essential components in caring training contents and may still miss some items.
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