Measuring the Caritas Processes: CaringFactor SurveyPamela P. DiNapoli, PhD, RN, CNLUniversity of New Hampshire

Marian Turkel, PhD, RN, NEA-BCAlbert Einstein Healthcare Network

John Nelson, BSN, MS, PhD(c), RNHealth Care Environment, Inc.

Jean Watson, PhD, RN, AHN-BC, FAANUniversity of Colorado College of NursingWatson Caring Sdence Institute

AbstractThe purpose of this quantitative study was to develop a lO·item survey to measure thecaritas processes. By using exploratory factor analysis to examine the underlying struc-ture of the 20-item Caring Factor Survey it was discovered that taken together the carl-tas processes are a measure of the single concept of caring that can be reliably measuredby a lO-item scale. The results of the factor analysis and item reduction, resulting in alO-item Caring Factor Survey are presented. The to.item Caring Factor Survey can be

used by registered nurses in the practice setting to measure caring when practice isguided by Watson's (1979) theory of human caring.

Key Words: Caring science, caritas pro-cess, caring, Caring Factor Survey

concept of caring as defined by Watson'stheory of human caring (Nelson, 2006;Persky, Nelson, Watson, & Bent, 2008).Caring is a concept and the 10 caritas pro-cesses are discussed as constructs that aremeasured by this contemporary instrument,the CFS. The purpose of this study was toexplore the underlying structure of the sur-vey to investigate if it could be transformedto a valid IO-item measurement tool thatmeasured the essential caritas processesused by nurses as a proxy for measuring theconcept of caring.

IntroductionTheoretical frameworks of human caring

have been developed and serve as the basisfor practice, education, and research in nurs-ing. Caring within the context of nursingpractice involves being. knowing, and doingall at once. In 2009. Bailey identified anddiscussed 10 individual theories groundedin the context of nurse caring or caring the-ory. The commonality of the theories wasthe emphasis on the caring-healing relation-ship between the nurse and the patient.Caring as a sacred act is honored and valuedby each of the theorists. As caring sciencecontinues to evolve and emerge in the prac-tice setting, the dialogue surrounding caring

has moved from research and academics topractice. The difficult task for practitionersis to fmd a way to demonstrate how caringpractices and professional models of caregrounded in the tenets of caring theory

make a difference in nursing, patient, or or-ganizational outcomes.

The original Caring Factor Survey (CFS)

was a 20-item scale designed to measure the

1 Love is capitalized to convey universal Love. not just ordinary love.

BackgroundCaring Science

The concept of paradigm as defined by

Kuhn (1970, 1977) serves as a basis for un-derstanding nursing knowledge (Parker,

2001). According to Kuhn (1977), paradigmis a framework or world view consisting ofassumptions held by members of the disci-pline considered to be essential in the devel-opment of the discipline. Traditionally, themetaparadigm'of nursing included the con-cepts of nursing, person, health, and envi-

ronment (Fawcett, 2000). For many nursingscholars, caring is considered as one of the

central features within the meta-paradigm ofnursing knowledge and practices. Caringscience seeks to unify and connect as an"evolving philosophical-ethical-epistemic

field of study that is grounded in the disci-

pline of nursing and informed by relatedfields" (Watson & Smith, 2002, p. 456).

The definition of caring as the essence ofnursing practice has evolved over time(Boykin & Schoenhofer, 1993; Leininger,1981; Ray 1989; Swanson, 1991) sinceWatson's (1979) conception in Nursing thePhilosophy and Science of Caring. Thisbook developed the concepts of transper-sonal caring relationship between the nurseand the patient, and the caring occasion,phenomenal field. and caring moment ad-vancing the notion that caring should beconsidered a meta paradigm concept withinthe discipline of nursing and not simplysomething that nurses do. In this seminal

work. Watson (1979) identified 10 carativefactors as being the essential aspects of car-ing in nursing and the core of professionalnursing. Nursing practice guided by the car-ative factors and grounded in a humanisticvalue system is the differentiation between

professional nursing practice and nursing

practice focused solely on the mechanics ortasks.

Caritas ProcessesWatson's original work continued to

evolve and grow; the carative factors be-came redefined as the caritas processes

(Watson, 2008) reflecting a deeper connec-tion among nursing praxis, caring science.and the universal concept of Love.! In

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Measuring the carltas Processes

Latin, caritas refers to caring as somethingprecious and fragile and that must be sus-tained. Caritas brings caring and Love-

universal and infinite Love=-lnto a

philosophy and ethic of caring science.Caritas in nursing makes explicit that caring

is related to love of humanity and to love ofcompassionate service to others and to hu-manity (Watson, 2008). Caritas nursingpractice involves the integration of

transpersonal caring and love within the

context of the nurse-patient relationship andinteractions resulting in a caring-healing re-

lationship (Watson, 2005, 2008). Transper-sonal, in this context, conveys the caringmoment and human-to-human connection

as greater than two people together; it

makes explicit that that human connectionin the moment has the capacity to transcendthe moment and go beyond the ego and

Table ITen Caritas Processes

physical focus and open to the spirit to spiritconnection. Therefore the caring nurse

seeks to "see" who is the heart-that spirit-filled person behind the patient, behind the

diagnosis, behind the treatment and proce-

dures, behind the behavior one may not likeor approve. Thus, the nurse and health prac-titioner practicing within a transpersonal

caritaslcaring science philosophy and the-ory seeks knowledge and skills that potenti-ate heart-to-heart, authentic human

-to-human connections, in the moment;opening options to be authentically presentto work from the other's frame of referenceand inner subjective life world, not just theouter behavior alone.

Measuring CaritasThe theoretical foundation of human car-

ing serves as a framework to transform

practitioners and nursing systems alike.

According to Watson (2006), carative fac-

tors are elements that exist within the inter-action between the nurse and the patient,

that are the tangible manifestationand em-

bodiment of human caring. Watson's (2006)theory asserted that if these 10 caritas pro-cesses, the facets of caring, are demon-strated by the caregiver, healing ispotentiated. The 10 facets of caring are la-beled in Table 1and each item is measuredby two statements. This assertion, when val-idated by a psychometrically sound, user-friendly caring assessment instrument,

theory through research, and appropriatemeasurements, comes alive in practice orpraxis. Praxis is informed practice; practice

that is empirically validated and informedby one's philosophical-ethical-theoreticalorientation, but grounded in concrete ac-

Caritas process Statement one Statement two

Practice loving kindness

Decision making

Instill faith and hope

Teaching and learning

Spiritual beliefs andpractices

Holistic care

Helping and trustingrelationship

Healing environment

Promote expression offeelings

Miracles

Everyday Iam here Isee that the care isprovided with loving kindness

Ibelieve the healthcare team Iam currentlyworking with solves unexpected problemsreally well IThe care prq~iders honored my own faith,helped instill hope, and respected my beliefsystem as pJ!rt of my careWhen my cJ~egivers teach me somethingnew, they te~ch me in a way. that Icanunderstand IIMy caregivf.S were very respectful of myindividual s iritual beliefs and practices

Iknow my Jealthcare team will help meet myphysical nedds as well as my emotional andspiritual ne,fisMy caregivers have established ahelpingf~~ng relationship with me duringmy time he'jfThis facilit)jjand its care providers havecreated an 9hvironment that helps me to healphysically ahd spirituallyMy care p~~viders encourage me to speakhonestly a~ut my feelings, no matter whatmy feelings are

I feel like if! told my care providers I believein miracles, they would support me in mybelief

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Overall the care Ihave received from the staffat the facility has been provided with lovingkindnessAs a team, my caregivers are good at creativeproblem solving to meet my individual needsand requestsWhile in this facility my caregivers helpedsupport my hope and faith during their careformeMy caregivers are responsive to how I learnand whether Iam ready to learn whenteaching me something newMy caregivers encouraged me to practice myown individual spiritual beliefs as part of myself-caring and healingMy caregivers have responded to me as awhole person, helping to take care of all myneeds and concernsEverybody on my healthcare team valuesrelationships that are helpful and trusting

My healthcare team has created a healing.environment that recognizes the connectionbetween my body, mind, and spiritI feel I can talk openly and honestly aboutwhat I'm thinking, because those who arecaring for me embrace my feelings, no matterwhat my feelings are

My caregivers are accepting and supportive ofmy beliefs regarding a higher power, whichallows for possibility of me and my family toheal

Measuring the Caritas Processes

tions and behaviors that can be empiricallyassessed and measured.

The Caring Factor SurveyRecently a group of scholars and practi-

tioners collaborated to explore CFS as ameasure of Watson's (2006) contemporarytheoretical concepts of caritas, which ac-knowledge connections between caring andLove and self-caring practices within ex-plicit references of spirituality. The originalCaring Factor Survey© (Nelson, 2006), a20-item instrument derived from Watson's(2006) theory, was designed to assess pa-tients' perceptions of care received fromnurses who practice from a loving kindnessconsciousness (Nelson, 2006; Persky et aI.,2008).

The scholarly discussion group wasguided by an interest in exploring if theoriginal 20-item scale could be reduced to a100itemscale and if the underlying structuremeasured a single concept. The groupsought to create a measurement tool thatwas as short as possible, which, from a the-oretical perspective, needed to remain trueto the tenets of the Watson's (2006) theory.Traditionally, long survey instruments usedin research may be more likely to bias theresults by exhausting the patient during aperiod of health recovery/restoration.Finally, from a pragmatic standpoint, a briefpsychometrically sound instrument is morecost effective in terms of time of adminis-tration and analysis of results.

MethodExploratory and Principal Component

Factor analyses were used to explore theunderlying structure of the original instru-ment through various combinations ofitems. The research question guiding thegroup was, Could a valid tool of only 10items be developed to measure caritas? Theconcern was that omitting anyone of thefactors as proposed by Watson (2006)would create model misspecification as theconcept measurement would have been in-complete as originally proposed in the cari-

tas processes. The original 20-item CFS hadtwo items for each of the 10 carative factors(processes). It was desired, in this currentanalysis, to evaluate if at least one of thetwo paired items would survive factor anal-ysis. This item-reduction method is com-monly utilized in new instrumentationdevelopment (Cronbach & Meehl, 1955). ACronbach's alpha of .70 was accepted asminimum for this new 20-item scale. Polit(1996) asserted that an alpha less than.70should be considered risky. The items oneach version were evaluated to determinewhether deleting them would result in an in-crease in the alpha value in developing thefinal tool.

ResultsTwo approaches to examining the data

were employed. The first used exploratoryfactor analysis, which was a pragmatic ap-proach of creating two 100item scales testedon a total of 89 patients and families. Datawere explored for misspecification errors.The first item in each paired caring factor,specified as "Model A." Then each of thesecond items in each of the paired caringfactors was specified as "Model B." Thegroup concluded that reducing the scale toI0 items would not invalidate either scale orits ability to measure the caritas processes.This was followed by the creation of"Model c." The item with the strongestloading from either A or B was specified in"Model c." Follow up survey using ModelC (N = 79) demonstrated the group had cre-ated a reliable tool (alpha = .95). Modelsspecified using this approach appears inTable 2.

The second approach used principal com-ponent factor analysis using secondary datacollected from a database created fromthree different studies (N =450). Inspectionof the data began with an ANOVA to see ifthere was a difference between data thatwas collected in the United States and datathat collected in the Philippines; there wasno difference and the factors were in similarrank order. In addition, the factor loadingsbetween each country were also similar, so

the entire sample of 450 from all three facil-ities was included in the factor analysis. Thefinal model was specified using the load-ings that were strong and consistent acrossall three facilities.

The revised lO-item CFS had one itemfor each of the 10 carative factors. ACronbach's alpha of .70 was accepted asminimum for this new 100itemscale. Themodel labeled as "0" is presented in Table3. The model had an alpha of .96 and wasselected as the final version of the 10-itemCFS.

The outcome of the scholarly work groupwas the emergence of a lO-item CFS.Factor analysis revealed at least one of thetwo paired items for each carative factorloaded into the final single lO-item solution.The final factor loadings for one of each ofthe 10 paired items for the caritas processranged from .833 to .891 (Nelson et al., per-sonal communication, August 8, 2008). Thereliability of the final 100itemCFS, usingCronbach's alpha for the study of 450nurses in three facilities, was .89. The factorthat accounted for 66% of the variance wasfactor one, the practice of loving kindness.Table 4 reviews the final lO-item CFS.

DiscussionWatson (2006) viewed the practice of

loving kindness as what is most importantto patients and families. The factor analysisprovides the empirical evidence to supportthis philosophical belief. Nurses need tobegin the dialogue of, How do I demon-strate loving kindness ro self, others, andthe world? If this is practiced from a heart-centered consciousness, caring and healingrelationships will evolve and patient out-comes will improve.

According to Parker (2006), "Creativenursing practice is the direct result of ongo-ing theory-based thinking, decision making,and action of nurses." The challenge tonursing professionals is the measuring ofthe caring that occurs within the complexand evolving environment of health care.The ability to transform theory into practice

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Table 2Pragmatic Model Specification

CFS Caring factor Loading Model A Loading Model B Loading Model C# (N=79)

1. Kindness .828 .8092. _ Decision making .826 .8173. Kindness .8484. Decision making .8375. Hope .866 .8656. Learning .851 .8427. Hope .8788. Leaming .8669. Spiritual practices .83610. Environment .874 .874II. Spiritual practices .845 .83212. Environment .89913. Trusting .88414. Holistic care .894 .89115. Trusting .851 .84916. Holistic care .86417. Express feelings .806 .80718. Miracles .80119. Express feelings .86620. Miracles .846 .838Reliabilities of each model .96 (.955) .96 (960) .95 (.954)(Cronbach's alpha):Eigenvalue 7.175 7.400 7.102

through research is a critical bridge to mea-suring quality nursing care. Thoughtful in-vestigation of the empirical indicators ofcaring is an example of this transformation.The ability to measure the unique domainsof nursing, such as the caritas processes, isessential to the discipline of nursing.

What resulted from the work of thisgroup was validation that caritas can be reli-ably measured using a brief instrument.With emphasis on patient outcomes and thecontinued importance of quality nursingcare, consideration must be given to the pa-tient as recipient of caritas. The ability tomeasure the patient's perception of lovingcare by the care providers who surroundedthem during a very vulnerable time is anoutcome of the utmost importance to thediscipline of nursing. From an ethical per-spective, what resulted was the ability tomeasure caring through the caritas pro-

cesses that are used by nurses.

ConclusionThe ability to measure caring as a con-

cept through the caritas processes advancesthe argument of caring as a metaparadigmconcept. By examining the underlyingstructure of the CFS it was discovered thattaken together the caritas processes are ameasure of a single entity, which is caring;the unique caring that is central to the disci-pline of nursing. In basic nursing educationthe response to the question, "Why do youwant to be a nurse?" is commonly "BecauseI want to take care of people." Is taking careof the same as caring for? Answering thisquestion can now be supported by morethan a philosophical perspective alone. Thetaking care of is operational while caringfor is an expression of nursing. Delineatingthis subtle but important distinction at an

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empirical level is only possible through thecareful development of theory-based instru-ments. The revised 10-item CFS is pre-sented as a refined guide to assess andmeasure the theoretical assumptions of cari-tas.

Caring, being unique in nursing, does notassert that nurses are the only ones whocare. This is similar to the profession of ed-ucation where teachers examine the impactof teaching methods and theories. Teachersare not the only people who teach others,but it is central to their profession and whatmakes them unique. This is similar to thecaritas processes where within the interface

of nurse-patient. being the application of the10 caring behaviors, engages the patientwithin every aspect of being human. It is thedominant presence of the nurse withinhealthcare that positions the nursing profes-sion to assess the impact that the caritas

Measuring the caritas Processes

Table 3Principal Component Factor Analysis

Loading Model DCFS # Caring factor

L Kindness

2. Decision making3. Kindness4. Decision making5. Hope

6. Learning7. Hope8. Learning9. Spiritual practices10. Environment11. Spiritual practices12. Environmentl3. Trusting14. Holistic care

15. Trusting16. Holistic care17. Express feelings18. Miracles

19. Express feelings20. Miracles

Reliabilities of each model(Cronbach's alpha):Eigenvalue

.854

.854

.865

.848

.833

.891

.89

.871

.867

.843

.96 (.961)

7.175

Table 4Final Ten-Item Caring Factor Survey

processes have on healing. It is this predom-inance of the nurse-patient interaction that

propelled Roach (1987) to assert" ... caring

may be considered unique in nursing" (p.

47).

SummaryThe CFS validates the philosophical tenet

that caring, as measured by caritas pro-cesses, is unique in nursing. Contemporarynursing knowledge can now scientifically

incorporate caring as a metaparadigm con-cept. This work validates caritas as an inter-vention that heals in ways neither

pharmacotherapy or machines can and isuniquely practiced in the profession of nurs-ing. While Watson's (1979) original asser-tion that caring inspires healing may be

difficult to quantify. the use of caritas pro-cesses by nurses can be measured. Thus,this new empirically validated knowledgeof caringlcaritas, through the CFS, canserve as a measurement guide toward trans-

forming nursing and patient caring experi-

ences. The CFS offers new forms ofevidence that authenticate intentional, con-scious, caring-theory-guided professional

Item inCFS

Caritas factorStatement from CFS

1.

2.Every day I am here, I see that the care is provided with loving kindnessAs a team, my caregivers are good at creative problem solving to meet myindividual needs and requestsThe care providers honored my own faith, helped instill hope, and respected mybelief system as part of my careWhen my care givers teach me something new, they teach me in a way that Ican understandMy caregivers encouraged me to practice my own individual spiritual beliefs aspart of my self-caring and healingMy caregivers have responded to me as a whole person, helping to take care ofall my rieeds and concernsMy caregivers have established a helping and trusting relationship with meduring my time hereMy healthcare team has created a healing environment that recognizes theconnection between my body, mind, and spiritI feel like I can talk openly and honestly about what I'm thinking, because thosewho are caring for me embrace my feelings, no matter what my feelings areMy caregivers are accepting and supportive of my beliefs regarding a higherpower, which allows for the possibility of me and my family to heal

Practice loving kindnessDecision making

Instill faith and hope

Teaching and learning

Spiritual beliefs and practices

Holistic care

Helping and trusting relationship

Healing environment

Promote expression of feelings

Miracles

3.

4.

5.

6.

7.

8.

9.

10.

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Measuring the Caritas Processes

practices and research. inviting new levelsof hope and purpose to advancing the disci-

pline and profession of nursing and caringscience, as well as new levels of hope forhealing of patients and systems alike.

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Author Note

Pamela P. DiNapoli, Associate Professor of Nursing, University of New Hampshire, Durham. New Hampshire; John Nelson, President,Health Care Environment Inc .• St, Paul, Minnesota; Marian Turkel, Director Professional Nursing Practice, Albert Einstein Healthcare

Network, Philadelphia, Pennsylvania; and Jean Watson, University of Colorado College of Nursing and the Watson Caring Science Institute.Boulder, Colorado.

Correspondence concerning this article should be addressed to Pamela P. DiNapoli, Associate Professor of Nursing, University of NewHampshire, Durham, NH 03824 USA. Electronic mail may be sent via Internet to ppdn@unh.edu

•• International Journal for Human Caring