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565The Journal of Continuing Education in Nursing · Vol 41, No 12, 2010

Building an Organizational Culture of Caring: Caring Perceptions Enhanced With Education Margaret M. Glembocki, DNP, ACNP-BC, CSC, and Karen S. Dunn, PhD, RN

As technical advances are made in the way in which health care is delivered at the bedside, the profes- sional nurse can quickly lose focus on the caring rela- tionships that are fundamental and essential to creating a healing environment for self, colleagues, and patients. Watson (2006) supported this view of nursing by stat- ing:

Dominant institutional values and commitments are in- formed and guided by economics, technology, medical science, and administrative theory, instead of basic con- siderations of what it means to be human, to be vulner- able, to be ill, to be cured, to be cared for, to be healthy, and to be healed. (p. 87)

Numerous authors, including Goodin (2003), have

documented the grave future of the nursing profession because of the shortage of those entering and continuing to practice this profession.

Currently, nurses are challenged to perform more tasks with fewer resources, leading to decreased job satisfaction and higher turnover rates (Christmas, 2008). Implement- ing relationship-based care with the assistance of the Re- igniting the Spirit of Caring (RSC) program from Cre- ative Healthcare Management as an educational program is believed to increase caring behaviors and lead to in- creased nursing and patient satisfaction. Transforming an organization to a culture of caring requires an investment in people and time. As an organization moves toward cul- tural change, striving for an environment that supports professional nursing practice and promotes positive clini- cal outcomes within the boundaries of the health care cul- ture and bureaucracy can ultimately transform the prac- tice environment to one of care and healing (Wade et al., 2008). Thus, this pilot study was conducted to determine whether the RSC program would enhance perceptions of caring behaviors among nurses.

LitEraturE rEviEW Caring behaviors are a central focus of nursing. Nurse

caring has been defined as “an interactive and intersub- jective process that occurs during moments of shared

mine whether an educational intervention called Reigniting the Spirit of Caring (RSC) from Creative Healthcare Man- agement would enhance perceptions of caring behaviors among nurses. A pretest/posttest within-subjects research design was used to evaluate the educational intervention.

Methods: Investigators used the licensed RSC program as the educational intervention. This study included 36 regis- tered nurses employed in one Midwestern hospital.

Results: Statistical differences were found in the pretest and posttest measurement of nurses’ perceptions of caring behaviors.

Conclusion: The RSC program can be used as an effec- tive educational intervention to increase nurses’ perceptions of caring, and the Caring Assessment for the Caregiver tool can be used as an effective tool to measure nurses’ percep- tions of caring behaviors. J Contin Educ Nurs 2010;41(12):565-570.

abstract Background: This pilot study was undertaken to deter-

Dr. Glembocki is Acute Care Nurse Practitioner, Crittenton Hos- pital, Rochester, Michigan. Dr. Dunn is Associate Professor, Oakland University, Rochester, Michigan.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.

Address correspondence to Karen S. Dunn, PhD, RN, Associate Pro- fessor, Oakland University, 402 O’Dowd Hall, Rochester, MI 48309. E-mail: kdunn@oakland.edu.

Received: January 12, 2010; Accepted: April 26, 2010; Posted: July 6, 2010. doi:10.3928/00220124-20100701-05

vulnerability between nurse and patient” (Yeakel, Malja- nian, Bohannon, & Coulombe, 2003, p. 434). In a quali- tative study, Clukey, Hayes, Merrill, and Curtis (2009) explored 10 family members’ perceptions of nurses’ car- ing behaviors in a trauma unit. Caring behaviors reported by these family members included: (1) nurses who were knowledgeable; (2) nonverbal behaviors, such as tone of voice and use of words, eye contact, offering assurance, listening, and getting to know them as people; (3) being skillful in keeping patients and family members comfort- able; and (4) taking adequate time and not acting hurried or bothered. Eight hundred fifty-five families who had recently experienced a death of a loved one in the hospi- tal were surveyed about their experiences with inpatient end-of-life care. Nurses’ caring behaviors perceived by these participants were: (1) treating patients and families with dignity and compassion; (2) not appearing over- worked; (3) addressing patients’ and families’ needs and wishes; (4) being open and honest; (5) being attentive and present; and (6) offering food and drink to visitors. These caring behaviors were also found to be positively associated with patient and family satisfaction (London & Lundstedt, 2006).

Nurses have also reported what they perceive as car- ing behaviors. Green (2004) surveyed 348 nurse practi- tioners using a modified version of the Caring Behavior Inventory and found that most of these nurse practitio- ners reported caring behaviors as: (1) being respectful to others; (2) being present, connecting, and learning about patients and families; and (3) being professional, knowl- edgeable, and skillful. Caring behaviors can also improve job satisfaction among nurses. Carter et al. (2008) sur- veyed 31 nurses who worked in an organization that was implementing Watson’s (1988) practice model of caring. They found that caring for colleagues was identified as being the most essential factor in keeping staff energized and that it increased caring behaviors with patients.

Improved health outcomes have also been reported. A qualitative study using grounded theory methods was conducted by Finch (2008) to develop a substantive the- ory of nurse caring. Fourteen chronically ill hospitalized older adult patients were interviewed. These participants reported improvement in physical and emotional health. Patients had less skin breakdown and fewer panic at- tacks, and they were physically more comfortable, had more knowledge and understanding of their disease and treatments, were more calm and relaxed, and had an im- proved outlook on life.

Three potential approaches have been reported in the literature that may enhance health care providers’ rela- tional behaviors with patients. These three approaches are: (1) training sessions for care providers aimed at im-

proving interactional skills, (2) introduction of conti- nuity of care models, and (3) establishment of clinically supervised environments (McGilton et al., 2004). The literature, however, does not provide evidence of im- proving caring behaviors through educational seminars that assist nurses to reflect on self and caring behaviors. Developing a culture of shared knowledge and values may serve as a guide to heartfelt caring practices that are grounded in both theory and evidence (Watson, 2006). This gap in the literature warrants further explo- ration of educational seminars to improve nurse caring behaviors.

NursiNg sigNifiCaNCE Modern nursing is in need of change because of the

daily demands of the health care system. The high stan- dards of clinical competencies and tasks have taken nurses away from the bedside and limited their ability to estab- lish a therapeutic nurse-patient relationship (Koloroutis, 2004). This inability to connect with patients may be the reason for the extremely high turnover rate (27.1%) of nurses in the first year of employment (Christmas, 2008). High turnover rates in health care organizations are costly and can cause negative outcomes in patient safety and satisfaction. As Felgen (2004) stated:

Caring and healing cultures are those in which there is pal- pable, visible regard for the dignity of human beings and where relationships between the members of the health care team and the people they serve are built on mutual respect and a shared commitment to healing. (p. 28)

The RSC educational program may be a cost-effective and efficient way to make nurses aware of the effect of practicing caring behaviors and the importance of creat- ing a caring culture with patients, with coworkers, and within themselves, significantly improving the work en- vironment and decreasing the rate of attrition.

thEOrEtiCaL framEWOrk The relationship-based care (RBC) model by Kolor-

outis (2004) was used as the framework for this study. This model “provides both philosophical foundation and practical infrastructure to achieve organization-wide transformation in the way care and services are provid- ed to patients and their families” (Koloroutis, 2004, p. 13). RBC is a holistic model, with the patient and fam- ily as the central focus, surrounded by six dimensions: (1) leadership, (2) teamwork, (3) professional nursing, (4) care delivery, (5) resources, and (6) outcomes. These six dimensions, along with three key relationships (i.e., care provider’s relationship with patients and families, care provider’s relationship with self, and care provider’s

567The Journal of Continuing Education in Nursing · Vol 41, No 12, 2010

relationship with colleagues), provide the organizational structure for transformation.

According to Koloroutis (2004), the RBC model was developed using the caring theories of Watson (1988) and Swanson (1991). Watson’s Model of Human Car- ing (1988) focused on the interpersonal relationship be- tween patient and nurse. In this model, the patient is in control of the change, and healing occurs from within while the nurse is present and facilitates these transfor- mations. Swanson (1991) built on this theory by adding five caring processes and ways for nurses to put them into practice. These five processes are (1) knowing (un- derstanding the lived experiences of others); (2) being with (being emotionally present); (3) doing for (doing for others what they could do if it were possible); (4) enabling and informing (facilitating movement through life transitions and unfamiliar situations); and (5) main- taining belief (maintaining the belief that others have the capacity to work through transitions and unfamil- iar situations). Swanson (1991) further identified caring behaviors for each of these processes that can be used by nurses in clinical practice.

The RBC model may transform nursing practice to a higher level of autonomy and professionalism and increase nurse and patient satisfaction. In addition, the RBC model can be easily implemented into nursing practice. Caring behaviors start from within the caregiv- er when the sense of self feels balanced. Hence, the RSC educational program allows for self-reflection and may enhance perceptions of caring behaviors in nurses.

mEthOds A pretest/posttest within-subjects research design was

used to evaluate the educational intervention. Investi- gators used a licensed program, Reigniting the Spirit of Caring, from Creative Healthcare Management, as the educational intervention. It was hypothesized that nurses who had participated in the intervention would have an increase in scores on the Caring Assessment for the Care- giver (CAC) tool (Wu, Larrabee, & Putman, 2006) from pretest to posttest. If this hypothesis was found to be cor- rect, then RSC will have enhanced perceptions of caring behaviors within a sample of nurses. This study included 36 registered nurses employed in one Midwestern hospi- tal. Registered nurses who had completed the 3-day edu- cational seminar were included. Those who missed one or more sessions were excluded.

Educational intervention The RSC program is a 3-day educational seminar that

focuses on three main relationships in nursing: (1) rela- tionship with self, (2) relationship with colleagues, and

(3) relationship with patients. The curriculum is based on adult learning theory and the principles needed for a learning organization. According to Senge, Kleiner, Roberts, Ross, and Smith (1994), five foundational core concepts are essential to build a learning organization: (1) personal mastery (personal and environmental capac- ities to achieve desired purposes and goals); (2) mental models (continuous evaluation and improvement of per- sonal views that govern actions and decisions); (3) shared vision (being committed to a group with shared visions and goals); (4) team learning (transforming communica- tion and collective thinking skills to develop knowledge); and (5) systems thinking (developing a common language and way of thinking to understand interrelationships that govern behavior and change). Implementing these core concepts can change the way people within orga- nizations think and interact and thus overcome barriers that are not easily identified. Content is built on research and theories on human caring. The RSC program is based on the belief that through reflection and learning, through intentional thought and action, through leader- ship and collegial support, and by enhancing awareness and refocusing on what matters most, people have the power to transform work environments into cultures in which personal responsibility prevails, healthy relation- ships thrive, appreciation is openly expressed, and caring and healing is the constant and core reason for existence (Koloroutis, 2004).

The RSC program uses a facilitative approach to learning and is taught by a team of two hospital-based employees who have been certified. The facilitators must complete a 5-day training course that is taught by the developer of the program, and after completion of the training, the facilitators are mentored with a person from Creative Healthcare Management with the first group of trainees. After all requirements are successfully met, the employees are certified as RSC facilitators by Creative Healthcare Management. Training and expectations are the same for all facilitators.

Protection of human subjects Institutional review board approval was obtained be-

fore the study by Oakland University and from the hos- pital’s research committee. Written consent from study participants was obtained before their participation in the RSC program.

instrumentation Participants were asked to complete a demographic

questionnaire that included participants’ gender, age, marital status, ethnic group, religious affiliation, level of nursing education, nursing specialty, and years of

experience as a nurse. In addition, the CAC tool (Kol- oroutis, 2008) was added to this questionnaire as a pre- test and posttest. The CAC is a 25-item evaluation tool that is divided into groups of five items that correlate with Swanson’s five caring processes: maintaining be- lief, knowing, being with, doing for, and enabling and informing. Each of the five processes has five items that include a statement on each side of a five-point Likert scale. For example, on one side, the statement “I tend to get my work done without concern about introduc- ing myself, stating my role, and describing what I am going to do” from the being with subscale would be scored as 1, whereas the statement “I initiate a relation- ship with the patient/family by extending a welcome and introducing myself (including my name, role, and how I will care for/serve them)” on the opposite side would be scored as 5. In other words, the lower num- bers represent a more task-focused perception of nurs- ing practice, whereas the higher numbers represent a more caring perception of nursing practice. It was ex- pected that participants would take approximately 20 minutes to complete the questionnaires. Reliability of the CAC was established in a previous study by Steele- Moses (2010). In a sample of 514 nurses, the researcher reported Cronbach’s alpha for the scale and subscales as 0.92 for the total scale, 0.80 for the maintaining belief subscale, 0.79 for the knowing subscale, 0.72 for the be- ing with subscale, 0.76 for the doing for subscale, and 0.83 for the enabling and informing subscale (Steele- Moses, 2010).

Procedures Participants were voluntarily recruited from a pool

of registered nurses who were scheduled to attend three sessions of the RSC program. The primary investigator met with potential participants and provided verbal and written information about this study. Written consent was obtained before the seminar session. On the day of the seminar, participants completed the demographic questionnaire and the CAC tool (Wu et al., 2006) as a pretest. Then the participants attended a 3-day, 8-hour- per-day seminar that presented the principles of RBC. The seminar focused on Swanson’s (1991) five caring processes and how these processes affect the relationship with self, the relationship with colleagues, and the re- lationship with patients. On completion of the seminar, the CAC tool was administered as a posttest.

data analysis Data were analyzed with SPSS Base 16.0 software, and

the level of significance for each test was preset at .05. Analyses for this study included descriptive statistics,

bivariate correlations, reliability analyses, and paired t- tests.

rEsuLts Characteristics of the sample

The sample consisted of 36 registered nurses who had attended the RSC seminar. The mean age was 46 years (SD = 8.72), with a range of 27 to 69 years. Most were female (88.9%), White (69.4%), and Catholic (47.2%), and practiced in women’s health (30.6%) and cardiac te- lemetry (27.8%). More than half of the sample was em- ployed full-time (58.3%). More than half of the sample had a bachelor’s degree or higher. The average number of years of nursing experience was approximately 21, and the average number of years practicing at the study hos- pital was approximately 11. Finally, the average number of years that nurses reported practicing on their current unit was approximately 7.5.

reigniting the spirit of Caring Program Paired sample t-tests were calculated to compare mean

pretest scores with mean posttest scores for the total scale and subscales. A significant increase in the mean scores of the total scale [t(35) = -3.108, p < .05] was reported from pretest (M = 107.39, SD = 10.56) to posttest (M = 114.36, SD = 14.85). Each subscale also had significant increases in mean scores, with the exception of the being with subscale [t(35) = .000, p > .05], which was not sig- nificant. The pretest mean score for this scale was 22.58 (SD = 2.37) and the posttest mean score was 22.58 (SD = 2.25). For the maintaining belief subscale, the pretest mean score was 20.86 (SD = 2.84) and the posttest mean score was 22.58 [SD = 2.84; t(35) = -4.353, p < .05]. In this subscale, nurses reported an increase in perceptions regarding their ability to convey empathy and compas- sion for patients (M = 4.17, SD = 0.85 to M = 4.58, SD = 0.73) and an awareness of maintaining an accepting and nonjudgmental attitude toward patients (M = 4.17, SD = 0.85 to M = 4.58, SD = 0.73).

The knowing subscale pretest mean score was 21.08 (SD = 2.64) and the posttest mean score was 22.67 [SD = 2.45; t(35) = -3.853, p < .05]. In this subscale, nurses reported an increase in perceptions related to their in- tention to spend time understanding the patient’s and family’s unique stories and circumstances (M = 3.94, SD = 0.86 to M = 4.47, SD = 0.70) and to prioritize medical and nursing care based on what the patients and families consider important (M = 4.11, SD = 0.71 to M = 4.53, SD = 0.56).

The doing for subscale pretest mean score was 21.36 (SD = 2.60) and the posttest mean score was 22.94 [SD = 2.27; t(35) = -3.578, p < .05]. In this subscale, nurses re-

569The Journal of Continuing Education in Nursing · Vol 41, No 12, 2010

ported an increase in perceptions associated with work- ing together as a team focused on patients and families (M = 4.03, SD = 1.06 to M = 4.50, SD = 0.70) and main- taining high levels of knowledge and skills (M = 4.17, SD = 0.74 to M = 4.50, SD = 0.61).

Finally, the enabling and informing subscale pretest mean score was 21.44 (SD = 2.98) and the posttest mean score was 22.28 [SD = 2.81; t(35) = -2.04, p < .05]. Nurses reported an increase in perceptions about risking their jobs to advocate for patients (M = 4.17, SD = 0.88 to M = 4.53, SD = 0.65) and involving patients and fami- lies in making informed decisions about their care (M = 4.36, SD = 0.87 to M = 4.61, SD = 0.73). Reliability of the CAC total scale was estimated by Cronbach’s alpha, with a being 0.90 for the pretest and 0.94 for the posttest. Cronbach’s alpha for the subscales ranged from 0.69 to 0.88 (Table).

Bivariate correlations were calculated for the relation- ships between age, years of experience as a nurse, gender, ethnicity, religious preference, total scale, and subscales. No significant correlations were found between these study variables.

disCussiON This study was conducted to determine whether the

RSC intervention was an effective educational program that could enhance the perceptions of caring behaviors of nurses within an organization. The mean age of the nurses was 46 years, which supports the findings that the average age of nurses is increasing (American Nurses As- sociation [ANA], 2009). The average length of practice as a nurse in this sample was 21 years, which supports the literature that indicates that fewer people are enter- ing the field of nursing (Buerhaus, Staiger, & Auerbach, 2003) and that a nursing shortage is predicted (ANA, 2009). Of the 36 nurses, 22 (61.1%) had a bachelor of science in nursing or higher, which is above the national

average of the educational level of nurses in the United States (ANA, 2009). Most of the participants practiced in a cardiac telemetry unit or in women’s health, which are very diverse practice areas.

The RSC program was found to be an effective edu- cational program that encouraged nurses to be more aware of their caring behaviors. Significant increases in nurses’ perception of caring behaviors were found be- tween pretest and posttest scores on the total CAC scale score and the subscale scores, with the exception of the being with subscale. The participants’ perceptions of caring behaviors that described the being with subscale did not significantly change from pretest to posttest. One reason for this finding could be that, on average, these nurses were already practicing these caring be- haviors (spending time with patients and families, using gentle touch, and listening). Conversely, another reason could be that the being with content within the RSC program is in need of revision to enhance these caring perceptions. As a whole, however, the RSC intervention did enhance caring behaviors. These caring behaviors included the nurses’ ability to (1) convey empathy and compassion, (2) be more accepting and nonjudgmen- tal, (3) spend more time with patients and families, (4) prioritize based on patient and family needs, (5) work as a team, (6) become experts through knowledge and skills, (7) be patient advocates, and (8) involve patients and family in care planning. Therefore, the RSC pro- gram can be used as an effective educational seminar to increase nurses’ perceptions of caring. In addition, the CAC can be used as an effective tool to measure nurses’ perception of caring behaviors. Thus, building an orga- nizational culture of caring through the enhancement of caring perceptions may also improve patient health care outcomes. Although these outcomes were not em- pirically tested in this study, Kinnaird and Dingman (2004) postulated that caring interactions with nursing

TAbLE

rELiaBiLity aNaLysEs, mEaN sCOrEs, aNd staNdard dEviatiONs Of thE CariNg assEssmENt fOr thE CarEgivEr tOtaL sCaLE aNd suBsCaLEs (N = 36)

Pretest Posttest

Caring assessment for the Caregiver a M SD a M SD

Total scale 0.90 107.39 10.56 0.94 114.36 14.85

Maintaining belief subscale 0.75 20.86 2.84 0.88 22.58 2.84

Knowing subscale 0.72 21.08 2.64 0.73 22.67 2.45

being with subscale 0.70 22.58 2.37 0.73 22.58 2.25

Doing for subscale 0.69 21.36 2.60 0.76 22.94 2.27

Enabling and informing subscale 0.77 21.44 2.98 0.85 22.28 2.81

staff may improve mortality rates, decrease length of stay, reduce the number of adverse incidents, decrease the number of complications, increase patient and fam- ily satisfaction with nursing care, and improve adher- ence to discharge planning.

A limitation of this study is the small sample size; therefore, the results cannot be generalized to the larg- er population of nurses. Also, it is unknown whether the increased perceptions translated into behavioral changes associated with how these nurses approached patients and families postintervention. Future research needs to be done to include more than one hospital and a larger number of participants as well as an examina- tion of behavioral changes in these participants.

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key points Culture of Caring Glembocki, M. M., Dunn, K. S. (2010). Building an Organizational Culture of Caring: Caring Perceptions Enhanced With Educa- tion. The Journal of Continuing Education in Nursing, 41(12), 565-570.

1 Caring behaviors are a central focus of nursing.

2 Reigniting the Spirit of Caring can enhance perceptions of caring behaviors in nurses through self-reflection. 3 The Caring Assessment for the Caregiver instrument is an effective tool to measure nurses’ perceptions of caring behav-

iors.

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