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Fostering Caring Attributes to Improve Patient Care in Nursing Through Small Group Work: Perspectives of Students and Educators

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28 October 2024

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29 October 2024

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Abstract
Nursing, a profession known for its compassion and dedication to providing exceptional patient care, relies heavily on the cultivation of caring attributes to uphold the highest standards of practice. Despite the common use of small group work in nursing education, there is a gap in understanding how these caring attributes are developed through this approach. This qualitative study sought to explore the emergence of caring attributes in small group settings as perceived by nursing students and educators. Thirteen nursing students and ten educators participated in semi-structured group interviews at a professional educational institution. The study identified four key sets of caring attributes nurtured through small group work: interpersonal communication with respect, compassion, and empathy; competence and confidence; and accountability to commitment. These findings underscore the essential role of caring in nursing, emphasizing how collaborative group work can facilitate the development of crucial attributes through interpersonal interactions. The cultivation of respectful communication skills among students is highlighted as pivotal for enhancing interactions with healthcare professionals, patients, and families, ultimately improving the quality of care provided. By providing opportunities for interactive learning and ongoing practice, students can effectively embody these caring attributes, fostering their nursing professionalism throughout their careers.
Keywords: 
Subject: 
Public Health and Healthcare  -   Nursing

1. Introduction

Caring, a fundamental aspect of humanity [1], has long been recognized as a cornerstone of nursing practice, with Florence Nightingale's pioneering work emphasizing the importance of compassion and empathy in healthcare [2]. Over the last four decades, the concept of caring has undergone extensive exploration within the nursing profession, revealing its nuanced and multifaceted nature. Far from being a simplistic notion, 'caring' encompasses a rich tapestry of attributes that lie at the heart of nursing practice, serving as a guiding principle in promoting the well-being and recovery of patients [3,4]. Notably, Roach [1] delineated caring attributes that are integral to nursing professionalism, has sparked a growing recognition of their essential role in shaping patient care standards in clinical settings. Previous studies have underscored the significant impact of these attributes on enhancing the quality of care delivered to patients, highlighting the need for their cultivation and reinforcement among nursing professionals. [5,6].
In the realm of contemporary nursing education, small group work has emerged as a prevalent instructional method aimed at fostering knowledge acquisition, skill development, and preparing students for collaborative practice in diverse healthcare environments [7,8,9,10]. Despite its widespread adoption, there exists a gap in understanding how caring attributes are nurtured and developed through engagement in small group activities. This study thus endeavors to delve into the evolution of caring attributes among nursing students within the context of small group interactions, seeking to illuminate the transformative process through which these qualities are honed and embodied.
By drawing insights from the perspectives of both undergraduate nursing students and educators, this research aims to shed light on the intricate interplay between small group dynamics and the cultivation of caring attributes. Through a deeper exploration of the experiences, challenges, and growth opportunities encountered in small group settings, this study seeks to contribute valuable knowledge to the ongoing discourse on the integration of caring principles in nursing education. Ultimately, the findings of this study hold the potential to inform and enrich pedagogical practices, fostering the development of compassionate, skilled, and empathetic nursing professionals equipped to deliver high-quality care in diverse healthcare settings.

1.1. Literature Review

Caring in nursing embodies a profound humanistic and human-centered approach that encompasses a diverse array of caring processes, phenomena, and experiences [11]. It serves as a cornerstone of professional training, intertwining with essential elements such as professional knowledge, clinical expertise, moral values, and actions that define and uphold nursing professionalism [1,11]. Drawing from the insights of Watson's seminal work, caring is not merely a task to be completed but rather a fundamental way of being that establishes nurturing relationships between nurses and patients, fostering environments that facilitate healing and holistic well-being [11,12].
The significance of caring in nursing practice transcends mere assistance and support; it extends to the core of fostering meaningful relationships that play a crucial role in enhancing patient well-being and aiding in their recovery from illness and disability. This emphasis on caring not only positively impacts healthcare services but also underscores nursing as a nurturing profession that places compassionate care at the forefront of its core values [12,13,14]. In an era marked by rapid technological advancements in healthcare, nurses are tasked with balancing technological proficiency with the provision of compassionate care, recognizing that the capacity for caring significantly contributes to patients' coping mechanisms, overall well-being, and the personal and professional fulfilment of nurses themselves [3,4].
As the healthcare landscape continues to evolve, the imperative to cultivate and enhance the caring abilities of nursing students during their education becomes increasingly crucial. The guidance provided to nursing students as they navigate their journey towards becoming caring professionals plays a pivotal role in shaping the quality of patient care delivered in contemporary healthcare settings.
In the realm of nursing education, the innovative approach of small group work emerges as a promising teaching methodology that transcends traditional teacher-centered instruction. By adopting a student-centered model that emphasizes active learning and collaborative skill-building, small group work offers a conducive environment for nursing students to develop essential competencies [7,8,9,10]. Despite its recognized benefits, there exists a gap in understanding how small group work contributes to the development of caring attributes among nursing students. This study seeks to illuminate this process by investigating how nursing students cultivate caring attributes through active participation in small group activities. By shedding light on this transformative process, educators can provide tailored support to students, thereby enhancing their capacity for compassionate care and strengthening nursing professionalism within the student cohort

2. Materials and Methods

2.1. Design

A qualitative research design was employed, utilizing semi-structured group interviews as the primary data collection method. The Consolidated Criteria for Reporting Qualitative Research (COREQ-32) guided the study process.

2.2. Sample

The study participants included undergraduate nursing students from various cohorts and nurse educators from a professional educational institution who had experience in learning or teaching within small group settings. The selection of participants was purposive in nature to ensure relevance to the study objectives.

2.3. Data Collection

Semi-structured face-to-face group interviews were conducted by the principal investigator (PI) in a conducive environment within the study institute. Prior to the interviews, participants were briefed on the study objectives and provided with informed consent forms. Students and educators were interviewed separately in sessions consisting of three to four individuals to encourage open and uninhibited expression of viewpoints. Open-ended questions were posed to elicit participants' perspectives on the caring attributes essential for nursing professionals. For students, the question was framed as, “While you were working in a group, tell me the caring attributes to be developed for your nursing profession.” Educators were asked, “While your students were working in a group, tell me the caring attributes to be developed for their nursing profession.” The interview guides for students and educators are attached in Appendix 1.
Each interview had a duration of around 45 to 60 minutes and was recorded digitally. Data saturation was reached, and member checks were conducted to verify the accuracy of their experiences at the conclusion of each interview.

2.4. Ethical Considerations

Ethics approval (2015-00-55 R150401) was obtained from the research ethics committee of the educational institute before commencing the study. Participants were required to sign written consent forms prior to their involvement in the study, ensuring confidentiality and anonymity of all information shared.

2.5. Data Analysis

After each interview, the research assistant (RA) transcribed the audio-recorded interviews verbatim, and the Principal Investigator (PI) initially reviewed the content to confirm accuracy. Data analysis was conducted using the Colaizzi method [15]. Both the PI and RA independently reviewed and analyzed the transcripts to pinpoint significant statements related to caring attributes. A meticulous line-by-line approach was employed to create codes, which were then categorized thematically. Triangulation was utilized to cross-reference and validate data, enhancing the reliability of the findings. To mitigate biases and ensure fidelity to the participants' perspectives, bracketing and member checking techniques were applied.

3. Results

In this study, 13 nursing students (Year 2 to Year 5) and 10 nurse educators with 2 to more than 30 years’ teaching experience participated. The participants were divided into four groups of students and three groups of educators, each group consisting of three to four participants. The study identified caring attributes based on the perspectives of the participants, including interpersonal communication with respect, compassion and empathy, competence and confidence, and accountability to commitment.

3.1. Interpersonal Communication with Respect

Interpersonal communication plays a vital role in fostering healthy group dynamics [9,10,16,17]. Respect is highlighted as a crucial element in creating a positive work culture, as it enhances mutual trust, understanding, and productivity [18]. Effective interpersonal communication with respect was found to enable students to form closer relationships and cultivate a peaceful learning environment [18,19,20]. All participants emphasized the significance of respectful interpersonal communication in facilitating idea sharing and relationship-building within the group. They acknowledged that communication skills are essential for clinical practice and require continuous learning and practice.
Student #4 shared, “Working in a group facilitates our communication among our teammates. I can communicate with my teammates to share our viewpoints and to share our feelings. I found that my communication skills have improved each time through sharing and listening to others with respect and understanding.”
Student #11 highlighted, “We not only learn knowledge and practical skills but also how to communicate with others. In our study, we need to do group works in many courses. Through working with others, I understand how to communicate with others in an appropriate way…. It is the practice of communication with respect. If no respect, the communication is failure.”
Student #6 expressed, “Small group work allows me to know new friends and communicate with them. Learning in a group helps me talk with patients and their families in clinical practice.”
All educators emphasized the importance of developing students' communication skills through small group work, as effective communication is essential for providing quality patient care. They stressed the need for students to learn how to communicate effectively with team members from diverse backgrounds, interests, and personalities.
Educator #6 stated, “Students must understand and accept others from different backgrounds and personalities. Good relationships and communication are key to success in their work. Respect is crucial for establishing and maintaining effective communication and interpersonal relationships. Some students are able to communicate with others very well. They listen to their groupmates, and they share their viewpoints. I believe that communication with patience, acceptance, and respect is very important for an effective communication.”
Educator #1 noted, “Most students learn communication skills while working with their teammates. Communication is vital for their future clinical practice. Mutual respect and understanding are essential components of effective communication. Communication gaps or misunderstandings can hinder group work, highlighting the importance of mutual respect in fostering effective communication.”

3.2. Compassion and Empathy

Compassion is a fundamental humanistic trait that involves showing consideration for others through empathy, sympathy, respect, and dignity [21,22]. A compassionate individual actively engages in understanding and alleviating another person's suffering, demonstrating a willingness to learn about their experiences in order to offer assistance and support consistently [23,24,25]. Empathy, on the other hand, is the ability to recognize and comprehend an individual's distress, playing a vital role in fostering therapeutic relationships [21,26]. An empathetic connection involves a genuine desire to comprehend a person's needs and emotions [27]. Both compassion and empathy are essential elements for building trust and establishing meaningful connections with others [21,22,23]. Many students emphasized the importance of understanding their groupmates' needs, abilities, and interests before delegating tasks. They preferred forming groups with friends as they were familiar with each other, making it easier to identify and address each other's needs.
Student #4 expressed, “We need to work together. First, to understand the needs of your teammates. Then, we can distribute our work more easily. …To me, I prefer forming a group…better with friends; we know one another. It is easier for me to ask their needs and their feelings… If anyone needs help in the team, we all should help. It is good to show our compassion by understanding the needs of others and provide timely assistance while working together.”
Nurse educators acknowledged that students learned to demonstrate compassion and empathy by recognizing and addressing the needs of others through group work, enabling them to offer support and assistance effectively. They highlighted that small group work served as a training ground for real-life clinical scenarios, allowing students to practice collaborating with individuals from diverse backgrounds. The teaching-learning approach in the classroom has the potential to enhance patient care and foster interdisciplinary collaboration in clinical practice. To support student learning, educators often encourage students to form groups with classmates they are already familiar with. Educators anticipate that students will grasp their teammates' needs effectively and engage in collaborative relationships from the outset while working in a group.
Educator #8 stated, “The purpose of small group work goes beyond project completion. Students are encouraged to collaborate, share talents, and support each other. Interaction in small groups helps students understand the needs of others and show compassion and empathy to those in need.”
Educator #2 added, “Students are trained to be caring and compassionate nurses. Small group work helps them develop these attributes by fostering a culture of care and willingness to help others.”

3.3. Competence and Confidence

Competence is defined as the ability to perform tasks and fulfil duties at an excellent standard, requiring continuous study and practice [28,29,30]. Confidence, on the other hand, is closely linked to competence and is developed based on an individual's proficiency with relevant knowledge and skills [31,32]. While competence showcases one's potential and capabilities, confidence serves as the driving force behind competence [27].
Students reported that they benefited from self-study and group discussions during collaborative work, enabling them to enhance their competence and confidence. Both students and educators acknowledged that small group work played a significant role in expanding knowledge and fostering collaborative relationships essential in the nursing field.
Student #12 shared, “I love group work as it enhances my learning efficiency. Working with friends and managing tasks within my control boosts my confidence in myself and others, leading to stronger relationships. Increased learning results in enhanced competence, which in turn builds my confidence to share knowledge with others.”
Student #4 expressed: “Group work allows for efficient learning as tasks are divided among team members, and collaboration leads to a comprehensive outcome. Learning from peers enhances my competence, crucial for patient care in clinical practice. Competence breeds confidence, especially in delivering patient care.”
Educator #3 noted: “Small group work facilitates student learning through peer interaction, enhancing their competence and confidence. Competence is vital for students to enrich their value and confidence, preparing them for clinical practice.”
Educator #5 emphasized: “Learning is a process. Competence is key to becoming qualified nurses who provide exceptional patient care. Caring, a fundamental aspect of nursing, is enriched by competence, which boosts confidence and the ability to care for those in need.”

3.4. Accountability to Commitment

Accountability is the sense of fulfilment in a task, indicating an individual's willingness to bear responsibility and take action [33,34]. Commitment, on the other hand, involves devoting oneself to executing best practices and delivering care of superior quality [35,36,37]. Accountability and commitment are interconnected, with accountable individuals taking responsibility for tasks and committing to achieving productive outcomes [33,38]. During group work, students experience a heightened sense of shared accountability, leading to increased individual commitment and improved group interactions [39,40]. Students unanimously agreed that they were responsible for their assigned tasks and recognized the importance of personal commitment to learning for better outcomes.
Student #5 expressed: “Learning is a personal asset. Putting effort and commitment into learning is essential for personal growth. Each group member should focus on their tasks to contribute to a successful outcome. The more responsibility I have, the more dedicated I become.”
Student #7 shared: “In group projects, we distribute tasks among team members. Each of us takes ownership of our assigned parts, ensuring that we contribute effectively to the project. Responsibility involves self-investment, and the team benefits when every member fulfils their role diligently.”
The educators observed that students needed to actively engage in their learning and collaborate with their peers in group settings. Students were accountable for their individual and group learning processes to achieve desired outcomes, fostering a sense of commitment.
Educator #11 emphasized, “Small group work is designed to teach students the importance of collaboration, responsibility, and communication. Students must respect and cooperate with one another to enhance their personal and professional growth. Taking accountability and showing commitment in group work is crucial for students to proactively engage in learning and take ownership of their educational journey.”
In summary, students effectively cultivate four core caring attributes through small group work: interpersonal communication marked by respect, compassion, and empathy; competence and confidence; and accountability to commitments. These caring attributes are essential in nursing to enhance professional values and image. Furthermore, they play a crucial role in promoting interdisciplinary collaboration, ultimately improving patient outcomes.

4. Discussion

Nursing encompasses essential caring attributes that are fundamental to nursing professionalism. These attributes are crucial elements for providing cost-effective and appropriate patient care [3]. Caring is viewed as an interpersonal process that integrates professional knowledge, skills, and sensitivity to address the bio-psycho-social needs of individuals and deliver suitable treatment and care [41]. The study emphasizes the significance of small group work in enabling students to identify learning needs, establish interpersonal relationships, share experiences, collaborate, and provide support, ultimately fostering the development of caring attributes.
Based on the perspectives of students and educators, four sets of interconnected caring attributes have been identified. Interpersonal communication with respect emerges as a crucial factor that links and activates other caring attributes. Watson's caring model underscores the importance of forming connections with others to cultivate caring moments and develop relationships [42]. Respectful communication is essential for nurturing students' collaborative skills, building trust, and fostering authentic caring relationships [18,42,43]. Effective communication within groups enhances productivity, quality outcomes, and conflict resolution, thereby contributing to a harmonious learning environment and the establishment of therapeutic relationships [17,18,19].
Through effective interpersonal communication, which involves exchanging learning experiences, providing feedback, and engaging in discussions within a group setting, students can enhance both individualized and group learning experiences [16,17,18,19,20]. Watson's caring model underscores the importance of establishing connections with others to create caring moments and cultivate transpersonal relationships [42]. Effective interpersonal communication fosters consideration and collaboration within the team, leading to improved teamwork dynamics [17,18,19]. This, in turn, paves the way for the development of other essential caring attributes [44,45,46]. Collaborative teamwork, aimed at reaching mutually beneficial agreements, can be honed through effective interpersonal communication, transcending individual differences in personalities, capabilities, and cultural backgrounds [18,19]. Compassion plays a pivotal role in enhancing team collaboration and fostering harmonious work environments [21,22,23]. In successful teams, communication thrives with close interactions rooted in compassionate and empathetic care among team members [47,48]. Students emphasized the importance of mutual consideration and understanding in team collaborations, highlighting the significance of forming relationships based on these values [10,18]. The study reveals that students, through group work, exhibit a heightened awareness of their peers' needs, indicating the development of compassion and empathy within the team. Deep awareness and empathy are fundamental components of providing compassionate care [45,46,47], serving as catalysts for enhancing interpersonal communication and fostering collaborative relationships within the team.
Competence encompasses the acquisition and application of evidence-based knowledge and skills in therapeutic interventions for current patient care [41,42]. Given the high expectations in healthcare services, nursing students must possess adequate competence to ensure safe patient care [10,17,41]. Nurses are expected to utilize updated knowledge and skills to deliver competent and quality healthcare services [29].
In the study, students enhanced competence through interactions with others, engaging actively in self-study, reflections, group discussions, feedback, sharing, and clarifications to facilitate effective learning and improvement opportunities [30,31]. Students engage in self-directed learning and group learning from sharing and discussions to seek more learning opportunities for improvement and excellence [8,9,10]. It is apparent that competence is reinforced over time through the engagement of lifelong learning and day-to-day practice [39,40]. In that sense, competence is essential in students’ lifelong learning for ensuring competent practice in the long term. Importantly, competence and confidence are interrelated and exist simultaneously [29]. Where competence reflects an individual’s potential and capabilities, confidence acts as the motivation to drive competence [49,50].
Confidence is developed in relation to the individual’s ability and competence with relevant knowledge and skills [1]. A confident person will make changes using knowledge and skills for better outcomes and address difficulties with a sense of commitment. Based on the participants’ experience, they admitted competence enhancement following an increase in confidence in performance and practice.
In the present study, accountability is a key focus and is cultivated among students while working in groups. Accountability entails individual responsibility and commitment and reflects conscience [49,50,51]. Conscience is the innate sense of right and wrong, guiding individuals' moral, ethical, and legal values in their actions and decisions [52]. It motivates individuals to exert effort and engage in responsible tasks, making moral judgments based on their cultural and religious background, education, life experiences, and knowledge and skills in relevant situations [51]. Through interactions with peers, students develop a heightened conscience and a stronger sense of moral responsibility [37,38]. They actively participate in group tasks, identifying and refining their values and fostering moral accountability [38,52]. In this context, conscience serves as a motivating factor for individual accountability, where accountability implies personal commitment.
Commitment involves a willingness to make sacrifices and dedicate oneself to achieving optimal practices and progress [39,40]. It is tied to an individual's attitude and efforts to deliver high-quality or exceptional care [44,51]. Therefore, commitment encompasses a significant level of individual responsibility, willingness, and loyalty to strive for continuous improvement and the delivery of therapeutic care [44,52,53]. By engaging with peers, students can cultivate a sense of commitment through self-directed learning and active participation in group discussions and activities. Notably, students demonstrated a willingness to commit to collaborative efforts with their peers, influenced by their relationships within the group, personal interests, capabilities, and the complexity of the tasks at hand [10]. Fostering collaborative team dynamics involves mutual respect, harmonious teamwork, individual and collective commitment, and collaborative partnerships [17,54].
In essence, cultivating caring attributes is an ongoing journey of personal and professional development aimed at enhancing the fulfilment of both learning and practical experiences [51,54,55]. The study findings indicate that students honed their caring attributes through meaningful communication and interactions with peers. These caring attributes are interconnected, with interpersonal communication grounded in respect serving as the foundational attribute linking the others. Figure 1 illustrates the interplay among these caring attributes nurtured through collaborative group work. Small group work serves as an effective educational platform for nursing students to not only meet their learning objectives but also cultivate their caring attributes, enhancing the quality of care and fostering the development of nursing professionalism.

4.1. Limitations

The present study utilized a qualitative design with in-depth interviews to investigate the development of caring attributes through small group work from the viewpoints of nursing students and educators. However, the findings are based on the subjective experiences of the participants, limiting their generalizability to other professional groups or settings. Additionally, the institutional rules and regulations may have influenced these experiences. Given the diverse backgrounds and experiences of participants in small group work, including study duration, group dynamics, and learning expectations, perspectives may vary significantly. Therefore, conducting large-sample quantitative studies can provide further insights into the cultivation of caring attributes through different educational approaches, such as small group work.

4.2. Implications for Practice

Interpersonal communication with respect is fundamental in fostering a collaborative work environment and promoting professional caring practices, aligning with the emphasis on multidisciplinary teamwork in healthcare settings [18,43]. Effective and respectful communication not only enhances patient-nurse and interdisciplinary relationships but also drives the development of other essential caring attributes, such as compassion, empathy, competence, confidence, accountability, and commitment, ultimately ensuring safe and optimal patient care [35,56]. Therefore, nurturing caring attributes is critical for shaping nursing values and enhancing patient outcomes in clinical practice.
To facilitate students' development of caring attributes, nurse educators should integrate interactive learning approaches, such as small group work, into the curriculum. Interactive learning methods not only enhance students' knowledge and practical skills but also foster personal and professional attributes through collaborative learning experiences, particularly beneficial for nursing practice [10,17]. Nurse educators should closely monitor students' progress in developing caring attributes, offering guidance and support during group work [10,55]. Given the positive impact of interactive learning on the development of caring attributes and nursing professionalism, integrating small group work and other interactive approaches into theoretical and clinical nursing courses is recommended.
This study serves to raise awareness among nurse educators regarding the importance of fostering caring attributes through interactive teaching-learning methods. Programme developers should consider incorporating diverse interactive teaching-learning strategies, such as small group work, into nursing curricula to enhance caring attributes and promote the development of nursing professionalism

5. Conclusion

Caring is considered the core of nursing practice, encapsulating the humanity of the nurse and extending to encompass the humanity of others. It aims to uphold the mutual and trusting human-to-human relationship between nurses and patients, improving patient care in nursing. The cultivation of caring attributes is crucial for nurses to embody professional values and enhance nursing professionalism. Emphasizing caring in nursing practice is essential for ensuring patient safety, facilitating patient recovery, and upholding the standards of healthcare services. This study underscores the importance of students developing caring attributes through interactions in classroom settings, highlighting the significance of adequate teaching resources, such as qualified teaching staff, to facilitate effective group interactions. Both educators and students recognize and appreciate the benefits of small group work in development of caring attributes. The identified caring attributes, which include interpersonal communication with respect, compassion, empathy, competence, confidence, accountability, and commitment, are essential in nursing professional development and in optimizing patient care.

Author Contributions

Conceptualization, methodology, validation, formal analysis, investigation, resources, data curation, writing—original draft preparation, review, and editing, visualization, supervision, project administration, funding acquisition. The author has read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of Tung Wah College (protocol code REC2019044 on 9 September 2019).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the subjects to publish this paper.

Data Availability Statement

The data presented in this study are available on request from the corresponding author. The data are not publicly available due to keep the confidentiality.

Conflicts of Interest

The authors declare no conflict of interest.

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