Creating a Culture of Care in Nursing Education
Diane E. White*, Sharon Grason
Georgia Gwinnett College, Lawrenceville, Georgia, USA
*Corresponding author: Diane E. White, Dean School of Health Sciences, Georgia Gwinnett College, 1000 University Center Lane, Lawrenceville, Georgia 30043, USA. Tel: +1-6784075610; Email: Dwhite9@ggc.edu; Dwhite9@ggc.edu
Received Date: 29 September, 2019; Accepted Date: 21 October, 2019; Published Date: 25 October, 2019
Citation: White DE, Grason S (2019) Creating a Culture of Care in Nursing Education. Int J Nurs Health Care Res 10: 1122. DOI: 10.29011/2688-9501.101122
Background: Prelicensure nursing students come to nursing programs with the thought of caring for others but some leave not learning how to care for and about others but rather how to not care.
Aim: To create a prelicensure nursing program that transforms nursing education through a caring environment.
Method: An innovative prelicensure baccalaureate nursing program was intentionally developed using Boykin & Schoenhofer’ s  model of caring as a premise for the program.
Results: Evidence from students, faculty and national accreditors show that the program is a model for creating a culture of care in nursing education while maintaining high standards and meeting student outcomes.
Conclusion: Caring for and about others is best learned in nursing education and can be accomplished by creating a culture of care in the learning environment.
Caring; Education; Nursing
Caring has long been a core concept of nursing . While most pre-nursing students come into the education arena to ‘care for’ others, they may leave without the knowledge, skills or attitudes of how to ‘care for’ nor ‘care about’ but rather, how not to care . Nursing students have reported unprofessional behavior by faculty, poor communication techniques, fear, inequality, a sense of loss of control over one’s world, and a stressful clinical environment as some of their perceptions of incivility in nursing education contributing to their feelings of not being cared for by faculty.
Historically prelicensure nursing education has been orchestrated as a ‘rite of passage’. While the ceremonial events surrounding nursing education such as white coat ceremonies, blessings of the hands, and pinning ceremonies reflect the rite of passage from pre-nursing to nursing student and nursing student to professional nurse, the educational environment has been decorated with behaviors that may appear as ‘emotional hazing’ to undergraduate nursing students. Students sometimes feel attacked by faculty when questioning them and often hear such phrases like, “When I was in nursing school we didn’t question our superiors we just did it….” Additionally, students cite behaviors toward students that are condescending or demeaning . For example, faculty say things when asked a question by students, as if the student should know the answer or assume that the student didn’t do the work necessary to know the answer. These examples do not lead to a positive development of students as a professional nurse and students do not feel nurtured and cared for by faculty.
Beck  noted caring to be a multidimensional concept expressed through interactions among nursing faculty, between faculty and nursing students, among nursing students, and between nursing students and patients. These interactions influence a student’s caring experience and how he/she learn to care for others. Boykin and Schoenhofer  nursing as caring theory focuses on nurses as nurturing persons living caring and growing in caring. Working within this theory, nursing faculty have the opportunity to shape a student’s identity as a professional nurse. By fostering nurturing relationships with students, faculty can demonstrate living caring and contribute to a growing, caring environment which assist students in learning how to care for others. A newly developed BSN program in the Southeast used this theory as a framework for the development of a transformational prelicensure program which has proven student outcomes supporting the nursing as caring theory.
Boykin and Schoenhofer  emphasize the importance of the nurse’s relationship with self and the ability to recognize that caring has real meaning and value. Providing experiences for faculty and students to self-reflect on their meaning and value of caring is essential for growing in caring. There are multiple ways to have this self-reflection occur individually and among students and faculty. Intentional assignments across the curriculum can assist students in developing their own sense of caring and how to care for others. The BSN program developed using Boykin & Schoenhofer theory of nursing as caring has students reflect the first semester on what caring means to them and then each semester after students reflect on caring for self, others, and then ultimately write a philosophy of caring paper in the capstone course.
An example of collaborative reflection of caring between faculty and students is evident in the processes used for skill validations. Instead of traditional use of face to face evaluations where faculty members “Check Off” a list while watching the student’s every move, causing undo anxiety; this program uses technology to assist with skills validations. Students are videotaped completing each skill with the faculty member in the control room and not visible to the student. After the validation the faculty member and student review the film and grading rubric together reflecting on the student’s performance. This promotes value of the student’s opinion and contributes to a meaningful, caring professional nurse identity.
It is exposure to these types of behaviors in nursing school that transcend into the practice environment where some professional nurses tend to ‘eat their young’ and where ‘bullying’ and/or ‘horizontal workplace violence’ often occurs. Additionally, students learn how to have crucial conversations through intentional classroom and simulation activities that assist them in addressing unprofessional behaviors in the workplace. The education environment as a safe place for learning crucial skills, prepares students to have conversations that foster support of colleagues.
Incivility experienced in nursing school can lead to bullying behaviors which lead to physical and psychological oppression that cause professional nurses to leave their workplace, leading to more of a shortage of each for the nursing profession . Aul  found that the perceptions of occurrence of incivility among nursing students and faculty were similar and concurred that administrators needed to address the issue and offer education about incivility. Often these behaviors go unreported due to fear of retaliation, and lack of administrative support . Nurse leaders need to address the behaviors that lead to a negative work environment  and create strategies to prevent incivility .
Creating a culture of care in nursing education is one such strategy. Part of the culture is holding individuals accountable for their uncivil behaviors, while providing coaching and mentoring rather than punishment. An example of how this was done in this innovative BSN program was when incivility was occurring between faculty, the nurse leader brought them together for a 3-series of coaching sessions on conflict engagement. Faculty were given an article with questions to answer each week. The following week there was open dialogue about the questions and lessons learned. Participants were coached in a positive environment and were allowed to speak openly without retribution. The faculty learned about themselves and each other which better helped them care for each other and feel cared for in the workplace.
In effort to transform nursing education by providing a safe learning environment where civility is the norm and caring is the culture, the nurse leaders constructed the vision, mission, conceptual framework, policies and procedures, student outcomes, curriculum, and evaluation measures with intentionality to caring. The use of theory grounded in the nursing metaparadigm concepts of nursing, person, environment and health may appear antiquated when transforming education; however, the metaparadigm frames the body of knowledge specific to the nursing discipline and, in turn, generates professional identity, ownership and accountability .
The conceptual framework for the program is a concept-based, student-centered, invitational learning environment which embodies eight domains of nursing. These domains include: caring, professionalism, critical thinking, wellness and illness, leadership, culture and diversity, technology, and informatics and evidence-based practice. Central to the model is that through caring holistically for individuals, families, groups, and populations, students can visualize health through a global lens. Invitational theory encompasses care, intentionality, optimism, trust and respect as valuable elements and needed to create an invitational learning environment . Having an invitational learning environment fosters the outcome of care as interactions and communications occur among and with faculty and students. This offers a learning environment where students can be nurtured and grow while forming their identity as a professional nurse.
In order to foster an invitational learning environment, instructional spaces were designed to be functional, attractive, personal, and warm fostering a sense of invitation to the learner. Learning areas are circular in design where ‘pods’ of students work in groups to problem solve application lessons offered in the classroom. Faculty members do not stand in front of the students, but rather, stand or sit with the students as they learn. This allows the living caring experience to take place in the classroom. Additionally, pod learning facilitates behaviors needed in the professional environment such as collaboration and teamwork. Working in groups helps students learn how to care for colleagues through listening, empathy and respect. This in turn can foster healthy relationships.
The domains of invitational theory were considered in developing policies and procedures with intentional language that was inclusive, positive, and consistent. For example, instead of using the word ‘fail’ or ‘failure’ the words ‘not successful’ were used. Another example was the use of no bolded content in the student handbook. Traditionally, clinical skills are ‘pass or fail’ and often referred to as, ‘skills check off’ sessions. The program chose to label these sessions as ‘skill validations’. The word validation reflects affirmation rather than failure or some kind of ending. Another example where language was intentional was in calling test reviews, ‘exam reflections’. Exam reflections offer the student and faculty opportunities to reflect on their performance and contribution to the exam and the outcomes. Reflection is individual; however, opportunities exist for students and faculty to dialogue about the exam in a professional manner at a later time. These intentional behaviors centered on language contribute to a caring learning environment.
Not only does the language have to foster an invitational learning environment, but also the processes by which day to day operations occur within the program. Open dialogue among faculty and faculty with students is encouraged, where no fear of retribution is sensed. As mentioned previously, crucial conversations occur in and outside the classroom and are done so that learning occurs among each person. Daily practice of the nursing as caring theory can be challenging for communication among faculty and students; however, when faculty show concern, use active listening and keep an open mind, students feel cared for by faculty. If students are allowed to experience this type of dialogue in nursing school, they will be better equipped to use the same techniques when communicating with their patients, families and colleagues.
A collaborative approach versus a silo approach is used in the curriculum. The concept-based, integrated curriculum fosters, teamwork and collaboration. This approach contributes to a nurturing, caring environment. Faculty are able to teach across the curriculum and since the curriculum is integrated, faculty are responsible to colleagues for their courses. Each semester, courses are integrated in that students have interrelated assignments; thus, communication among faculty is of utmost importance. Professional communication demonstrated between faculty members facilitates nurturing relationships and caring for others. Having an integrated curriculum, collaboratively developed by all faculty help each faculty person and course have value in the curriculum. Additionally, this process fosters trust in the learning environment among faculty. Students benefit and feel cared for by faculty when collaboration occurs among faculty. Each semester the courses within the semester review the course calendars to not only align related concepts but also to review when student assignments and tests occur, as to not overburden students with multiple evaluation measures the same week.
If the theory of nursing as caring is to transform nursing education, then nurse education leaders must be the role model of caring behaviors and address issues that do not foster caring in the learning environment . When students have issues that need resolving, they are coached to go to the person (faculty, staff or peer) to resolve the issue. If resolution cannot occur there is a process in place to assist in finding resolution. Documentation if needed for any issue is completed with the parties involved and a collaborative plan put into place. Faculty are also instructed by administration to seek resolution with other faculty and staff prior to escalating it to the level of the Program Director. When resolution cannot occur, then coaching is done with the individuals using a team approach rather than a punishment approach. Faculty and staff, just as students, are expected to work toward resolution that promotes a positive work and learning environment.
A priority to caring is evident in the student learning outcomes and throughout the curriculum and evaluation measures. The first student learning outcome states that the student will: Describe how a personal philosophy of caring as a mode of being can affect health outcomes. This student learning outcome is further expanded upon in each nursing course as each course has the first course and/or clinical objective related to demonstration or explanation of caring behaviors. For example, explain how caring behaviors in various setting impact health among individuals and families and selected vulnerable populations…. Demonstrate caring and nurture a caring connection with clients… These course outcomes are measured in a variety of ways in the curriculum. Some courses use reflective writing assignments, case studies, role play activities to evaluate the course outcome. Student portfolios are used throughout the curriculum and allow various expressions and examples of caring to be included. The clinical evaluation tool measures the clinical outcome through observation of initiating and maintain caring behaviors with patients, families, staff, and peers.
Additionally, the curriculum was developed with courses that focus on caring behaviors of the professional nurse. The curriculum has three professional nursing courses and two leadership courses. This was done intentionally to have a focus on concepts that relate to a caring professional nurses, such as: advocacy, ethics, workplace violence/bullying, transcultural care, communication, emotional intelligence, integrity, and accountability. An example of one learning activity completed in a professional course is one that is to develop caring behaviors toward the impaired licensed professional. A recovering impaired nurse provides his/her written story of the journey of impairment and the impact on his/her family and most of all his/her patients. The students read it with the faculty member and then discuss their feelings towards this nurse and his/her behavior. Students tend to be outraged, angry, and judgmental toward the impaired nurse. The emotions are strong and can be felt in the room when suddenly, a nurse appears into the room that says, “Hi, I am…… the impaired nurse you just read about”. The silence is deadly and often the emotions turn from anger to compassion, empathy and such. This happens as student’s dialogue with the nurse and begin to understand better his/her story. This also shows the role of nurses who enable impaired nurses and the power of forgiveness.
This caring environment has been noted by experienced faculty to be “Like no other” and novice faculty “Don’t understand the horror stories” of “Eating their young” and “Bullying” by colleagues at other nursing programs. Often faculty send ‘gratitude’ emails to faculty and staff for things done and ‘congratulations’ to one another for success in and outside the classroom. Faculty write emails and notes to students, thanking them for caring behaviors shown to others; it seems to be a culture of gratitude that demonstrates caring in the workplace. Faculty reported to the on-site accreditation visitors  that, “…. This is a place that truly cares about us individually and collectively…. it is top down and is conveyed to our students just as it is conveyed to us….”
Caring is measured at the program level through objective data methods. Each semester students complete course and clinical evaluations for each of four courses taken that semester. Each evaluation has an item related to caring behaviors, such as: Demonstrates caring and nurtures a caring connection with clients. Furthermore, the exit survey along with post-graduation 6 and 12 month surveys include an item related to the measurement of care; because of my education at GGC I have a personal philosophy of caring. The Likert scale measures this item from 1-5 with 1 being “Not at all” and 5 being “Absolutely”. Aggregate data from the 2016 to present show an average of 4.9 on this items. One alumni noted in fall 2017, “…. The caring tradition that faculty displays and installs in the students will always stay with us as nurses.” . Another student noted, “...This program has taught us to care spiritually and holistically about people and for our classmates” .
Another outcome of utilizing a caring theory for the education framework is the benefit of students learning how to recognize caring behaviors of colleagues. One of the graduating class awards is the Caring Award. This award is voted on by the class and given to the student who they feel best demonstrates the Nursing as Caring theory as described by Boykin and Schoenhofer . Living caring in his/her life, this student focuses on nurturing and has dreams and aspirations of growing in caring with intentionality and authentic presence. This student demonstrates caring with patients and also classmates and is recognized for this at the pinning ceremony. Having students identify caring behaviors that are intentional and authentic fosters recognition in the workplace and appreciation of such behaviors.
Additionally, the December class of 2017, through the Nursing Student Government Association, started giving a Caring Award to the faculty member who they felt best demonstrated the caring theory in their teaching and has resulted in a profound impact and positive impact on their learning. Students who nominate a faculty person must write to each of the core premises of the caring theory and gives examples of how the faculty demonstrated those premises. The plaque with each faculty person’s name is located in the School of Health Science Deans suite. Although historically nurses have had tales of horror about their experiences in nursing school, it is the belief of these authors that nursing education can be transformed to foster an invitational, caring learning environment where students can learn how to care for and care about individuals, families, groups, and populations. Nurses will know how to care for one another and care about important healthcare issues, which translates into a healthy workplace where nurse retention and teamwork are paramount. Not only will nursing education benefit from this transformation but, most importantly, patients being cared for by nurses who know how to care will receive the most award.
Limitations may exist in implementing this model of care into nursing education. Prelicensure nursing programs with large faculty and/or student numbers may lack sufficient opportunities to engage with each other at the level necessary to participate in caring behaviors and crucial conversations. It is anticipated using this model in nursing education that faculty role model caring behaviors to students so that students in turn learn how to care for and about others. Additionally, having crucial conversations with students is vital in helping students learn how to do this with peers and colleagues. Crucial conversations foster accountability of caring behaviors and are a means of demonstrating care for others. Another limitation is that many nursing programs have a tenure system in place. The program where the model of care was implemented does not have a tenure system. Not having a tenure system fosters accountability for faculty behaviors and thus lends itself to faculty “Buy in” to the caring model.
Future research to examine the caring concept in nursing education in an attempt to define the concept and methods to measure for evaluation purposes is warranted. By doing this, nursing programs can identify ways to foster caring behaviors in the academic arena. Additionally, being able to define and measure this concept will allow for instrument construction that can be used to measure caring for and about others. Examining this while in nursing school and longitudinally post-graduation may give insight to what is needed prior to graduation to continue caring behaviors throughout their nursing career. Finally, it is imperative nurse leaders’ support and role model caring behaviors needed in creating a culture of care. Leaders who expect these behaviors from faculty and students will foster the culture needed to transform nursing education.
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