Faculty-Student Caring Interaction in Nursing Education: An Integrative Review.

Introduction: Faculty- student caring relationship in nursing education has been offered as enhancing students' learning experiences to care , desire to care for others and self-actu-alization. This review therefore was carried out to analyze faculty-student caring interactions in nursing education.
Methods: This concept analysis of caring in the nursing education was conducted based on Broom methodology of integrative review. The literature was consisted of two books from two known theorists, and 47 relevant articles. They retrieved from English data bases including MEDLINE, CINAHL, ERIC, SCOPUS, and SID, with based on the keywords of caring and "nursing education", during the period 2005-2014.
Results: Caring in nursing education refers to faculty-student interaction based on ethical and human values. The development of values and moral principles in education, flexibility in educational processes, application of objective patterns in learning, and dynamism in educational processes are identified as caring concept attributes in teaching-learning process. This requires environmental support, constant human relationship, and knowing. Internalization of values, achieving self-esteem, peace, and towards human evolution were the main achievements of the concept of caring in nursing education.
Conclusion: The details obtained from the dimensions of "caring" concept in this study could be utilized by nursing education researchers and designers in order to develop content and structure for educational programs.

Introduction

Studies in higher education show the significant of a learning atmosphere that is caring, confident, and welcoming, and favorable to academic growth for all students. In the pedagogic context caring "involves developing rapport and going out of one's way to provide learning experiences geared toward students' attributes".[1] In caring-based interactions, the actions and feelings of instructors and students are considered equally.[1,2]

Unfortunately, caring found within faculty- nursing student relationship is affected by the restrictions present in the universityenvironment. Behaviorism tradition at education, inflexibility in scheduling educational programs, and administrative process are some of the factors that limit the application of caring collegiate environment. According to Watson, the issue that prevents teacher-student interactions from being respectful, fruitful, and remedial is lack of caring at colleges, educational systems, and society.[3]

Noddings, an influential philosopher in education, introduced caring as a framework for learning processes. He considers caring as a mutual relationship between a care giver and receiver. From caring perspective, teaching-learning process is a mutual relationship between a teacher and student in which their participation is vital to make learning meaningful.[4]

Recently, Nursing education is moving toward caring paradigm based on humanistic frame where caring has a main impress to act in the teaching-learning process. To achieve this goal, nursing researchers and experts have made an effort to incorporate human caring paradigm into nursing educational program.[5,6] Human caring paradigm basically focuses on connection, having holistic view, respect people’s identities and choices, as well as commitment and respond to the needs of the society.[1-3] In the humanistic paradigm faculty and student are both seen as active attendant in the teaching/learning process and share ideas and feelings. Nursing faculty are trying to incorporate caring as a valued basis in philosophic principals and educational programs. However, studies that provide insights on how caring can be applied as an educational approach are very limited. Subsequently, the dimensions of “caring” concept are not clearly defined and analyzed in nursing teaching-learning processes.[1,7,8]

A review of the extant literature reveals that studies conducted specifically on caring analysis in education, are outdated. However, they all confirm that there is a lack of caring concept analysis in education. Cohen stated that the educational dimensions of caring is less processed and considered in comparison with the other dimensions such as ontology, epistemology, anthropology/ cultural, ethical, and legal aspects. Also, the meaning of caring in education is less precise.[3] By performing a criticizing analysis, Peterson and Craford mentioned that the variety and diversity of definitions proposed for the concept of caring creates difficulty in making its concept in education. They pointed out that the caring concept in education is very similar to its concept in practice in their study and caring in teacher-student relationship is assumed to be similar to patient care behavior.[9] Some recent studies have implicitly mentioned several dimensions of caring concept. For instance, Beck stated some metaphors of caring in nursing education without its precise definition.[10]

Despite the valuable results demonstrated by earlier studies in this regard, only some parts of caring knowledge have been processed in education. It indicates that they are insufficient to draw a comprehensive picture of caring concept in education.

To understand the concept and identify its dimensions, it is necessary to carry out a comprehensive review of the concept in the literature. As such, a concept analysis through integrative review of literature is applied in this study to elaborate the concept definition and its dimensions. Integrative review helps researchers integrate and classify new existing information relevant to the concept and leads to a comprehensive understanding of the concept.[11] Hence, this study aims to analyze the caring concept in nursing education, identify definitions, clarify various dimensions of the concept, and discuss the intended subject.

Materials and methods

This study applied an integrative review method to analyze the caring concept in education. Integrative review method, one of the concept development methods, is the most comprehensive review method in which perfect understanding of the subject is obtained through simultaneous integrative of experimental and non-experimental studies.[11,12] In this method, relevant literature to a specific subject is criticized and combined in a way to provide and conclude new viewpoints and frameworks about the intended subject.

Integrative review method includes five steps as follows:

1) Problem identification; 2) Literature search; 3) Data evaluation; 4) Data analysis including data reduction, data display, data comparison, conclusion drawing and verification; and 5) Findings presentation.[11,12]

To achieve the research objective and problem identification in nursing literature from caring concept in education, several questions were raised:

What definitions are presented from caring concept in nursing education?

What attributes from caring concept in nursing education are presented based on the mentioned definitions?

What are antecedents of caring in education?

What are the consequences of caring in education?

An integrative review method informed by Broom was used to identify published theoretical and empirical research in nursing to provide a more comprehensive understanding of caring in nursing education.

Inclusion criteria were: a) English language, b) Articles published between 2005 and 2014, and c) key words " caring" and " nursing education" in the title and abstract , using the databases of MEDLINE, CINAHL, ERIC, SCOPUS, and SID. The number of articles retrieved at this stage was 307. The five-member research team assessed the accuracy of the data and the qualitative scoring of the searched literature, using the initial coding sheet. Maximum score was 5 and a score of 3 and higher was considered as the inclusion criterion for the context or the article. Qualitative criteria used to evaluate the literature consisted of the concept of caring in education, theoretical and conceptual models of caring, measurement and evaluation of caring, theories of caring in education, application of the concept of caring in teaching - learning process. Each article obtained a score of 1, if it had the inclusion criteria and 0 if it did not. Among the retrieved literature, thesis (n=6), articles with only the abstract available (n=6) and conceptually-unrelated (n=256) were omitted .The final literature consisted of 37 articles that addressed caring in nursing education. Through the screening of the search and collection of resources, five related articles and two books were identified and selected. A total of 44 literature resources were considered for analysis in this study.

Results

Findings of this study are classified into three dimensions of antecedents, attributes and consequences and finally theoretical definition of intended concept is presented.

Antecedents

The antecedents of caring in nursing education were extracted in three categories that are following: supportive environment, making constant human relationship, knowing supportive environment, express opinions and questions freely,[2,13-17] Creating an atmosphere based on trust[18,19]are subcategories of a supportive educational environment.

"Learning is facilitated in an environment that is caring and respectful, and where students believe they are safe to express their questions, ideas, or emerging thoughts"(Lewis 2006, P. 32).

Making constant human relationship

Sustainable and mutual communication,[2,13,20] based on humanitarian principles, respect, and equality[8,13]has been emphasized in all interactions and processes of teaching and learning.

"In nursing education communication is an important tool for classroom teaching as well as for clinical supervision of the students"(Begum 2012, P. 335).

Knowing

Knowing means to understand, place importance on, and provide caring. Obtaining knowledge and identification of the situation are necessary to do any action, operation or caring. The findings of this study emphasize the necessity of teacher’s identification of students’ needs and abilities [1,21-23], his/her help to students to know him/herself better, and recognition to care in encountering with others. "The creation of a caring context within the classroom requires strategies to know students as persons with unique needs and aspirations"(MacNeil 2005, P. 49).

Attributes

Caring concept attributes are classified into four themes including: the development of values and fundamental ethics in education, Flexibility in educational programs, Dynamicity in educational guidelines, and Applying objective patterns in learning.

The development of values and fundamental ethics in education respect to dignity,[24] unique characteristics[2,25]diversity cultural of students,[24,26] and compassion[1,20,27,28] are the categories of this component .

"Caring in education involves how our humanism is ever present to that of the student. Humanistic caring involves relating to each other on a personal, equitable, and human level" (MacNeil, 2005, P. 49).

Flexibility in educational programs

This component refers to teachers’ floating patterns in teaching,[21] openness to different perspective and flexibility in unpredictable situations.[2,23,29,30]

"For nursing faculty, openness to multiple possibilities presents a particular challenge and an opportunity to suspend entrenched patterns of teaching nursing interdependence "(Boykin & Schoenhofer, 2013, P. 58).

Dynamicity in educational processes

The concept of dynamism in educational processes refers to: developing a research approach in education,[14,21,31] Sharing learning experiences in groups,[14,32] designing an educational program proportionate to needs, goals, and principals of learning[1,2,24,26,33,34], Reflection and Critical attitude to Educational Activities.[2, 21, 26, 32, 35-37]

"The creation of a caring context within the classroom requires strategies to know students as persons with unique needs and aspirations. This method avoids objectifying and empowers students to learn while maintaining standards" MacNeil, 2005, P. 49).

Applying objective pattern in learning

Objective patterns in learning refers to: programming and creating learning situations for students,[27,31,32] applying evidences and instances in educational processes,[2,31] helping students have meaningful learning experiences,[6,21,32] introducing objective patterns of caring behavior to students.[1,24,30,38-40]

"Since caring is taught primarily through role modeling (Mixer, 2011), faculty who experience culturally congruent caring are more likely to effectively role model such caring to students” (Mixer 2013,P. 1474).

Consequences

Based on integration of the results of caring concept in nursing education, four category are extracted as follows: internalization of caring value in students, students’ awareness and perfection development, students’ achievement of self-esteem and peace, and development of professional place of nursing teacher in the society

Internalization of caring value in students

Educators’ emphasis on the emotional goals of learning and developing the principles of values, such as attention and sensitivity to others, are the practical issues that help students in the internalization of the value of caring.[20,24,26,37]

"There is evidence from the current literature that the attitudes and values that student nurses develop and take with them into the clinical area are fostered and nurtured by the nurse educators to whom they are exposed throughout their education" (Haigh, 2007, P.10 ).

Students’ awareness and perfection development

Caring attitude in nursing education programs has valuable effects, such as creating a sense of growth and change[1] and self-awareness in students,[2] conjoining life experience with humanity,[19]character development in a nurturing relationship[21] and moving towards knowing, wisdom and the whole.[28]

"The experience of caring in an educational milieu is associated with students expressin feelings of growth and change" (MacNeil, 2005, P. 47).

Students’ achievement of self-esteem and peace reduced anxiety,[14,33] developing self-esteem,[2,32] and increased the sense of empowerment in students[1,20,32] are the outcomes of inducing caring concept in educational system.

“Caring as an essential emphasis in nursing education has been related to a reduction in student anxiety and improvement in basic skill and professional value acquisition” (Coyle-Rogers 2005, P. 160).

Finding related to the application of the concept caring in nursing education.

The literature review showed the diverse and numerous applications of the concept of caring in nursing education. Assessment of the studies showed that the concept of caring has been applied in the three areas of: the designing curriculum based on the concept of caring[16,19,22,31,41-48] instrument development,[17,18] and as a criterion to measure caring behavior[49,50] (Table 1).

Table 1

List of literatures related to application of concept

Title	Journal	Type of information	Authors	Year	Type of implication
How does the nurse educator measure ‘caring’?	International Journal of Nursing Education Scholarship	Descriptive	Caroline Porr, Rylan Egan	2013	Applying ‘caring’ in building instrument
Nursing students’ perceptions of instructor ‘caring’: an instrument based on watson’s theory of transpersonal ‘caring’	Journal of Nursing Education	Descriptive	Wade G H, Kasper N	2006
First- and third-year student nurses’ perceptions of ‘caring behaviors	Nursing Ethics	Descriptive	Mlinar S	2010	‏‘Caring’ as a criteriaIn measuring ‘caring’ behaviors
The impact of nurse education on the ‘caring’ behaviors of nursing students	Nurse Education Today	Descriptive	Murphy F	2009
Application and evaluation of a ‘caring’ code in clinical nursing education	Journal of Nursing Education	Clinical trial	Lee-Hsieh J, Kuo C L, H F Tseng	2005
Impact of a ‘caring’ behavior educational program based on human care theory on nursing students’ perception of the care	Iranian Journal of Medical Education	Quasi-experimental	Zareh Hoshyari Khah H, Moradbeygi K, Elhami S, Cheraghian B	2014	‏‘Caring’ concept asfoundation in nursing curriculum
The design and testing of a ‘caring’ teaching model based on the theoretical framework of ‘caring’ in the Chinese context: a mixed-method stud	Nurse Education Today	Mixed-method	Guo Y	2013
Integrating ‘caring’ theory with nursing practice and education: connecting with what matters	Journal of Nursing Administration	Qualitative study	Dyess S	2010
Compelling teaching with the four Cs: ‘caring’, comedy, creativity, and challenging	Journal of Nursing Education	Case study article	Story L	2010
Teaching excellence in nursing education: a ‘caring’ framework	Journal of Professional Nursing	Review article	Sawatzky JAV	2009
Cultivating ‘caring’ through ‘caring’ group and ropes course experiences	Nurse Educator	Semi experimental	Birx, E	2008
Nursing students’ perceptions of the importance of ‘caring’ behaviors	Journal of Advanced Nursing	Descriptive	Khademian ZF	2008
Action research on the development of a‘caring’ curriculum in Taiwan: part II	Journal of Nursing Education	Action research	Lee-Hsieh J	2007
The CCARE model of clinical supervision: bridging the theory- practice gap	Nurse education in practice	Review article	Baxter P	2007
Student understanding of culturally and ethically responsive care: implications for nursing curricula	Nursing Education Perspectives	Quasi experimental	Cagle C S	2006
Exploring the concept of ‘caring’ novel strategies for a diverse student group	Nurse educator	SemiExperimental	Stowe A.C	2006
Transforming pedagogy in nursing education: a ‘caring’ learning environment for adult students	Nursing education perspectives	Case study article	Bankert E	2005
‘Caring’ for self while learning to care for others: a challenge for nursing students	The Journal of nursing education	Quasi experimental	Stark M A	2005

Theoretical definition

The integration of all extracted results and themes, classification and integration of data in this study led to developing a conceptual map (Figure 1) and defining the caring concept in nursing education. The validity and reliability of the results were assessed through continual comparison of extracted data.

Figure 1

“Caring is defined as a teaching-learning approach that is formed based on constant teacher-student interactions and human and ethical values. Specifically, the nature of this educational strategy focuses on caring.

Based on their individual and professional abilities, teachers provide a supportive environment that allows them consciously engage in an interaction with students and recognize their unique properties. Teachers try to create a caring atmosphere through developing ethical values, flexibility, and dynamicity, as well as using objective learning patterns. The expected educational activities from student include: students’ active partnership in learning opportunities, contemplation of their operation, and sharing of the gained experiences through conversation with friends and teachers in a comfortable atmosphere. In such a caring environment, students receive the teacher as a caring and human pattern. The human, mutual, and constant interactions can result in self-esteem, peace, and self-confidence. The other result of such interaction is moving towards human perfection.

Discussion

According to study findings, in education, the caring concept is defined as an approach in teaching-learning processes that is based on mutual relationship between the teacher and students as well as ethical and human principals. In a caring based interaction, both teachers and students’ operation and feeling are equally considered‏.

The study discussion is presented based on four scientific questions including definition, antecedents, properties, and consequences of care concept. This study also considered challenge expression and thematic gaps, while comparing the results of this study with other research.

Defining caring concept

Evaluation of the relevant literature revealed that only one study.[1] defined caring concept explicitly, while some other studies[20,21,24,28] mentioned it implicitly. The mutual relationship between the teacher and students which is formed based on human values with a focus on students’ unique needs is the core of existing definitions. It is worth noting that the caring concept in education was processed earlier by Noddings (1984-1992). As a significant education philosopher, he believed caring concept is an alternative ethical approach in education that helps teachers make educational decisions based on ethical responsibility and students’’ unique talents.[51,52] Emphasis on ethics and attention to the student’s unique needs were the common aspects in Noddings perspective and the present study on the concept of caring in education. Kim applied Noddings’ belief, caring as a relation between the care giver and care receiver in order to supply needs, and introduced caring as a focused strategy on teacher-student relation leading to meaningful learning.[4] The mentioned definitions for caring concept are very similar the caring definition presented in this study. It is evident that while caring concept drew the attention of a number of scholars in general, little effort was made to precisely define it in nursing educaurther more, evaluating the related literature in this study focuses on teacher-student interaction that is rarely considered at interactional levels. Brown stated that caring in nursing education is a multi-dimensional concept. This concept could be manifested through teacher-teacher, teacher-student, student-student, and student-patient interactions.[26]

Conceptual model of the concept of caring in education as an interaction between faculties

(This figure presents the conceptual components of caring in education as transpersonal interaction between faculty and student. This transpersonal interaction is contextual for growth and personal development: growing in caring)

However, this study focused on the concept of caring based on teacher-student interaction without emphasizing the other educational interactions. There are few studies that pointed out the necessity of mutual and respectful interaction of teachers with each other, or nursing students’ attention to the public, and community and physical environment.

Processing of caring concept is expected to be more in educational and social environment regarding the broad concept of caring in general meaning (according to Noddings) and the importance of caring as a valued concept in the education platform.

Caring concept attributes in nursing education

Friendship and real affection of teacher to students as well as flexibility in teaching-learning processes are notable and treatable among properties extracted from the evaluated literature. From the writer’s point of view, these two properties are useful in creating a free learning atmosphere. However, they can be threatening factors for teacher-student relation borders and learning goals realization if they are treated unintelligently. Thus, teachers’ plan of merging kindness and authority and attending educational laws and certainty of learning goals realization can help predict challenges. These challenges include appearance of extremist behavior during interactions, tarnishing the dignity of the teacher and student, mental damage and failing to gain educational goals.[53]

Antecedents of caring concept in nursing education

It is evident from evaluating the literature that culture and religion are important factors to create contextual conditions or to be antecedents of caring behavior appearance in educational environment.[20]As such, the possible various dimensions of this subject were less examined, similar to property dimension which ignored the cultural differences of learners.

‏ Additionally, Mixer in his ethnographic study, introduced and identified the necessity of organized educational programs based on cultural frameworks, the compatibility of teachers’ operation with college goals and prophecy, the support provided by college leaders to teachers, and the presence of mentors and caring patterns from co-workers. These are the underlying factors that create a caring environment based on cultural caring in colleges.[50]

The consequences of caring concept in nursing education

Although the current study introduced caring as an educational approach that can lead to students’ self-esteem and perfection or internalization of caring value, achievement to all results and professional and educational merits cannot be expected from this approach. According to Noddings caring relations do not contain all of the things that should be achieved in education. It can just provide a basis for training learners. Listening to, working together, and living with learners can pave the way of their growth and perfection.

‏ Furthermore, caring relation is an appropriate framework for guiding and creating ethical education.[54,55]

‏ The reviewed literature in this study is limited to the previous decade. Although there are a number of other studies and literature in this area, this study could not consider them due to time and cost constrains as well as inaccessibility of them in Iran.

Conclusion

This study applied an integrative review method to analyze the caring concept. The results indicate that caring in nursing education is identified as an approach in educational processes. The establishment of educational interactions based on moral and human principals is emphasized in this perspective.

‏ Yet, a few definitions are proposed for caring concept in nursing education and there is limited effort in transferring and using these findings in nursing area of Iran. Moreover, limited number of studies mentioned the contextual conditions such as cultural and religious factors for presence of caring behavior in the educational environment. Another important point is that interaction was widely conceptualized at the teacher-student level, while teacher-teacher and student-student interactions, or students’ caring attitude towards public were rarely considered. Besides, vague points arise to mind as the following questions:

- Is this teacher-student mutual interaction based approach able to guarantee the required needs of nursing students?

- Does it have any contradiction with educational principals?

- Is caring, as an educational approach, able to respond to professional needs of nursing?

‏ Identification and clarification of more details of caring concept in nursing education can improve teaching-learning processes and help teachers train students with caring attitude. Furthermore, the insights provided from this study about the caring concept can help authorities in nursing education and researchers to design and develop suitable content and structure for educational programs. Creating an appropriate framework for nursing educational programs provides a context in which students can develop their individual, social, and professional life.

Acknowledgments

This paper was adopted from the author’s postgraduate thesis, which was accepted by Mashhad University of Medical Sciences, Mashhad, Iran (Code: 922857). The authors appreciate the assistance and support provided by the Associate for Research at Mashhad University of Medical Sciences, Mashhad, Iran.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study‏.