Meanings assigned to the concept of caring

Background: Caring is a key concept in nursing and is considered to be the essence of nursing. For nurses, caring is the defining characteristic of their practice. Objectives: To identify the meanings assigned to caring by nurses and nursing students. Methodology: This is an exploratory, descriptive and quantitative study. We used the Scale of Assessment of Significance of Caring (Escala de Avaliação do Significado de Cuidar), composed of 44 items distributed by 5 dimensions (Caring as a Human Trait, Moral Imperative, Affect, Interpersonal Relationship, and Therapeutic Intervention). The scale was applied to a non-probability convenience sample of 251 subjects: 122 first-year students and 48 fourth-year students attending the Nursing Degree, and 81 nurses. Results: The Therapeutic Intervention and Interpersonal Relationship dimensions obtained the highest mean scores, while the Human Trait and Affect dimensions obtained the lowest scores. The gender mean difference was not statistically significant for any dimension and total scale. Conclusion: Therapeutic Intervention and Interpersonal Relationship are the main meanings assigned to caring. The Caring as Moral Imperative, Affect and Human Trait dimensions obtained the lowest scores.


Introduction
Since caring is inherent to the human condition, and caring for and being cared for is part of what it means to be human, it is important to clarify the specific meanings attached to this concept within the nursing field and what distinguishes it from meanings assigned by others besides nurses.Caring is a key concept in nursing and influences nursing theory, research, practice and education.Many nursing theories have developed around this concept.The act of caring is taught, as well as the provision of quality care toward an assertive and evidence-based practice, which must be the result of research processes.Care is described as the "essence of nursing and the central, dominant and unifying feature of nursing" (Leininger, 1988, p. 152).
Caring can be considered from a personal, psychological or cultural perspective (Morse, Bottorff, Neander, & Solberg, 1991;Meleis, 2012), and, from a "disciplinary perspective, care is the object of nursing knowledge, and a basic criterion to distinguish it from other disciplines in the health field" (Medina, 1999, p. 35).
Based on these considerations about the concept of caring, it becomes relevant to identify the different meanings assigned to it by professionals and students.It is important to understand all aspects involving this concept and how it is perceived by this population.The meanings assigned and appropriated by nurses and nursing students regarding the concept of caring are analyzed within the context of nursing epistemological research.These meanings are obtained through the assessment of different dimensions, included in a scale of meanings assigned to caring.

Background
Caring has been considered as a key concept in the nursing field, and nurses consider it to be a defining characteristic of their professional practice.The knowledge about the meanings assigned and appropriated by nurses and nursing students regarding the concept of caring is of the utmost importance to develop the nursing discipline.According to Leininger (1978), care is the essence of nursing, distinguishing between several types of care: generic caring, professional caring, and professional nursing care.Professional nursing care is defined as "those cognitively learned humanistic and scientific modes of helping or enabling an individual, family or community to receive personalized services through specific culturally defined or ascribed modes of caring processes, techniques and patterns to improve or maintain a favorably health condition for life or death" (Leininger, 1978, p. 9).Generic care is inherent to the human condition, as we all care for and need to be cared for, and professional caring is a purposive and intentional action toward things and/or people, which is organized and practiced in a professional manner, not limited to nursing.In this sense, "care, within the nursing context, is the professionalization and scientification of the instinctive and culturally mediated predisposition of human beings as a species for the protection of its members" (Medina, 1999, p. 42).Based on Heidegger (2005), who divides caresorge -into besorgen, translated as occupation, and fürsorgen, when care becomes a solicitude or concern (Rocha, 2011), it becomes clear that "another dimension is the extension of caring, going beyond the act itself (care provision) to the attitude (concern, solicitude, readiness, compassion -caring)" (Queirós, 2015).Caring is what "allows integrating care actions into the act of caring … , what drives a professional human being to engage in a rational relationship with another human being who experiences what must be experienced" (Hesbeen, 2013, p. 15).It is what nurses do when they apply their theoretical knowledge, together with practical knowledge, to develop and put into practice a relational competence of the situation (Hesbeen, 2013).According to Meleis (2012), nursing is "a human science, with a practice orientation, caring tradition, and a health orientation", clearly emphasizing and priorizing the concept of caring.For this author, caring is one of the four important characteristics that define the nursing perspective: nursing as a human science, practice orientation, caring, and health orientation.Furthermore, "caring, … has the same origin as the human being, … the action of caring reveals something very specific of the individual's humanity -its intimate constitution" (Roselló, 2009, p. 118).In the same line, "care only exists when one who is of prime importance to me exists and, so, I dedicate myself to that person" (Boff, 1999, p. 2).Additionally, Boff also considers that caring finds its greatest expression when it is considered as integral care, of the person and the environment.
According to Pellegrino, there are four senses in which caring can be understood: caring as compassion; doing for others; invite to transfer responsibility; and take care .For this author, "integral care -in the four senses here expressed -is a moral obligation of health professionals" (Pellegrino, 1985, p. 13).In turn, Morse et al. (1991) define caring according to five ontological conceptualizations: caring as a Human Trait; caring as a Moral Imperative or Ideal; caring as an Affect; caring as an Interpersonal Interaction; and caring as a Therapeutic Intervention.Based on this classification, Meleis (2012) explains that care as a human trait should be considered from a personal, psychological, or cultural perspective, while care as a moral imperative assumes the protection of the dignity of others as the fundamental essence of nursing.Caring as affect is manifested through emotional feelings, empathy and dedication.The nurse-patient relationship is the essence of caring, which is seen as a therapeutic intervention.
In the above-mentioned study, Morse et al. (1991) describe the different characteristics of caring.Caring as a human trait requires perceiving care as essential for the human being, as universal, necessary for survival, a basic way of being, constant and longlasting.As a moral imperative, it encompasses the nurse's qualities and the maintenance of the patient's dignity, guides decision-making, provides codes of conduct, and includes the constant concern with the patient.As an affect, caring involves emotions, feelings of compassion or empathy.As an interpersonal interaction, caring implies an exchange characterized by respect and trust, mutual engagement, a close relationship, and mutual growth.As a therapeutic intervention, caring covers the actions that meet the patients' needs, which change according to situational demands and the nurses' knowledge and skills.According to Hernández Vergel, Zequeira Betancourt, and Miranda Guerra, a humanist vision of caring is essential to understand the human being since "only through care can we understand the human being" (2010, p. 31).Therefore, caring for someone implies a genuine interest, devotion and concern, without losing sight of the fact that "caring should be understood as a facilitation process through which the nurse creates favorable conditions to allow the person to make his/her own choices to solve his/ her health problems" (Bison, Almeida, Santos, & Furegato, 2013, p. 91), or even that "caring is being-with-the-other: caring is presence: caring is self-care, to take care of oneself " (Sebold et al., 2016, p. 245).Therefore, from an open and extended perspective, it is possible to maintain the designation of the nurse as care provider, since "the care provider's activity is not limited to a set of tasks; it refers to all possible and impossible actions throughout his/her day" (Campia, 2013, p. 104).Caring is also integral care, to the extent that it encompasses, in all its dimensions, caring for the other, caring for oneself, and caring for nature.These three aspects are closely related, since context is inherent to the human condition, the condition of a person's existence throughout his/her life.

Research questions
The purpose of this study was to answer the following general research question: Do the meanings assigned to care differ according to educational, professional, and sociodemographic variables, and are they different among nursing students and nurses?

Methodology
This is a exploratory descriptive study of quantitative nature.The study was conducted with nursing students and nurses, using a non-probability convenience sample of 251 subjects: 122 first-year students and 48 fourth-year students attending the Nursing Degree of a public school in the Center region of Portugal, in the academic year of 2014/15, and 81 nurses.Since we used a convenience sampling method, the inclusion criterion for both nurses and students was their acceptance to participate in this study.Data were collected using the 44-item version of the Scale of Assessment of Significance of Caring (Escala de Avaliação do Significado de Cuidar -EASC; Bison et al., 2013), which is based on 5 ontological dimensions: 1) Caring as a Human Trait; 2) Caring as a Moral Imperative or Ideal; 3) Caring as an Affect; 4) Caring as an Interpersonal Relationship; and 5) Caring as a Therapeutic Intervention (Morse et al., 1991).This is a 5-point Likert-type scale ranging from strongly disagree, disagree, do not know, agree, to strongly agree.With regard to the psychometric properties of the scale, namely its reliability, Correia and Costa (2012) obtained a Cronbach's alpha of .82 for internal consistency.In the study of Bison et al. (2013), the dimension values ranged between .62 and .71,with a value of .74 for the total scale.After confirming the internal consistency of the scale with the sample in this study, we obtained a Cronbach's alpha of 0.86 for the total scale, having obtained reasonable values (.68, .66,and .64)for three of the five dimensions and lower values (.48 and .46)for the remaining two dimensions.We asked the author of the scale for authorization to use it in this study, submitted the project for appreciation by the Ethics Committee (EC) of the Health Sciences Research Unit: Nursing (UICISA: E) of the Nursing School of Coimbra (ESEnfC), and requested authorization from the ESEnfC direction board.After obtaining the necessary permissions, we started the field work by collecting data using the EASC between May and July 2015.We collected students' data in the classroom, after ensuring a favorable environment to focus and reflect on the scale and choose the most appropriate answer.We explained the study objectives, and informed them that their participation was voluntary and anonymous.Nurses completed the questionnaire either in the classroom, in the case of nurses attending Postgraduate and Master's degrees, or in the services where they worked.In both circumstances, we explained the purpose of the study, and informed nurses that their participation was anonymous and voluntary.The completed questionnaires were then collected by the research team.All respondents (nurses and students) signed an informed consent form.After data collection, we inserted the data in the Statistical Package for the Social Sciences (SPSS) software, version 19, to perform the statistical analysis.

Results
With regard to the participants' sociodemographic characteristics, we found that 85.43% (211) of them were women, and 14.57% (36) were men.The sample consisted of three subsamples: 122 first-year nursing students (48.60%),48 fourth-year nursing students (19.12%), and 81 nurses (32.28%).As shown in Table 1, the percentage of women was higher in the student subsamples (first-year: 88.33%; second-year: 87.23%) than in the nurse subsample (80%).The total sample had a mean age of 25.83 years, with a mean age of 19.17 years in the subsample of first-year students, 23.87 years in the subsample of fourth-year students, and 36.89 years in the subsample of nurses.In relation to marital status, a total of 188 participants were single (76.43%), 54 were married (21.96%), three were divorced (1.21%), and one was widowed (0.40%).As expected, there was a higher percentage of single respondents among students, and of married respondents among nurses (Table 1).Nurses reported a mean length of professional experience of 14.08 years.Regarding the number of years in the profession, we took into account Benner's classification (2001), with 5 levels of acquisition of nursing expertise.In this study, we merged the competent and proficient levels, based on a criterion of statistical feasibility.We assigned the novice level to students, and divided nurses into three groups (advanced beginner: ≥ 0 to ≤ 2 years; competent/ proficient: ≥ 3 to ≤ 9 years; and expert: ≥ 10 years).Based on this adjusted classification, the sample included 47 expert nurses, 30 competent/proficient nurses, one advanced beginner nurse, and 169 novices (students without any professional experience).First-year students had the highest scores for the total scale and all dimensions, except for the Interpersonal Relationship dimension (Table 4).In this dimension, fourth-year students had the highest score; however, the mean differences were not statistically significant.The total scale and the remaining dimensions (Therapeutic Intervention, Moral Imperative, Affect, and Human Trait) showed statistically significant differences, calculated using the Kruskal-Wallis test: p<.001; p=.019; p=.002; p=.042; p=.001, respectively.When combining both subsamples of students and comparing them to the subsample of nurses, we found that students had a higher score in the Therapeutic Intervention dimension, followed by the Interpersonal Relationship, Moral Imperative, Affect and Human Trait dimensions.
Nurses had lower mean scores in all dimensions.
According to the Mann-Whitney U test, statistically significant differences were found for all dimensions and the total scale: p=.005;p=.039;p=.001;p=.013;p<.001;p<.001,respectively (Table 5).We divided the years in the profession into four groups (1-9 years; 10-19 years, 20-29 years; 30 and more years), and found higher mean scores in the group of respondents with 30 and more years in the profession.However, Moral Imperative was the only dimension with statistically significant differences (p = .040),calculated using the Kruskal-Wallis test.In this dimension, the highest mean scores were found in the group with more years in the profession (30 and more years; Table 7).3 to 9 years of experience as competent/proficient, and participants with 10 or more years of experience as experts (Table 8).
We found statistically significant differences between the three groups in the Therapeutic Intervention (p=.033),Moral Imperative (p=.004),Affect (p=.013), and Human Trait (p=.001) dimensions, as well as in the total scale (p<.001).Novices usually scored higher and experts usually scored lower.No statistically significant differences were found in the Interpersonal Relationship dimension.
We also analyzed the meanings assigned based on the participants' length of professional experience, which had been classified according to Benner's expertise levels (2001): novice, advanced beginner, competent, proficient, and expert.For the purposes of our study, we decided to merge the competent and proficient levels.Furthermore, in order to analyze the mean differences, we excluded the advanced beginner level (≥ 0 to ≤ 2 years of experience) because there was only one participant in this group.We considered students as novices, participants with

Discussion
The small number of participants, distributed across three subsamples of different sizes, is the main limitation of this study.More participants and more balance in the samples, particularly between the number of students and the number of professionals, would allow for a more consistent analysis of the psychometric properties of the data collection instrument, its dimensions and factor structure.Furthermore, the comparisons between students and professionals would gain added relevance.Younger participants of this study obtained generally higher mean scores than older participants, which may be explained by the fact that they have completed their training more recently.This is based on the assumption that, in addition to technical and instrumental aspects, contemporary nursing education values aspects associated with what nursing scholars have considered to be a defining characteristic of caring.In other words, caring goes beyond its technical dimension, not being limited to the instrumental dimension of care provision.It encompasses the attitudinal dimension of Availability, Solicitude, the desire to be cared for.Caring is associated with a situational relational competence, a combination between theoretical and practical knowledge, which allows placing a professional human being in contact with a human being requiring care (Hesbeen, 2013).
On the other hand, it should be noted that we found no statically significant gender differences, both for the total scale and dimensions, in the meanings assigned to caring.This gender homogeneity in the assigned meanings should be further analyzed in future studies since it intersects with gender stereotypes, particularly those in which men, in this case nurses, are believed to have more technical skills and women are believed to be more affectionate and loving.There seems to be no consensus on the association between the meanings of caring and gender and age, despite some studies indicating "that women reported perceiving care differently from men" (Hernández Vergel et al., 2010, p. 36).
It should be noted that most participants scored higher in the instrumental dimensions -Caring as Therapeutic Intervention and Interpersonal Relationship -than in the Caring as an Affect and Human Trait dimensions.In other words, the dimensions involving action, intervention, and relationship prevail over attitudes, such as affect and human trait.These results are consistent with the study conducted by Correia and Costa (2012), which reports similar results for final-year students.
In this line of thought, older nurses scored higher in the dimension related to the meaning of caring as a moral imperative.This dimension occupied an intermediate position between action-related and attitudinal-related dimensions, building the ethical bridge between actions and attitudes.We should also note that overall mean scores, both in the total sample and subsamples, ranked from high to low, in which the Therapeutic Intervention dimension obtained a higher score, and the Human Trait dimension a lower one.These results are opposed to the notion that "care sensitivity is extended in the sense that caring does not necessarily mean to perform procedures but also that … care can be provided with subjective attitudes" (Sebold et al., 2016 p. 245).Ultimately, training processes must result in "an overall where caring derives from the harmonized appreciation of its different dimensions" (Correia & Costa, 2012, p. 75).In studying the different perspectives inherent to caring, it is important to consider the context, in the extent that "skills must be associated with clinical reasoning and the context in which students are integrated" (Rodrigues et al., 2016, p. 389), and the meanings assigned to caring, "defined as: act, action, disposition (being cautious), behavior (taking care)" (Honoré, 2013, p. 126).
In view of the above, we believe that the participants in this study draw closer to Leininger's (1978) distinction between generic caring, professional caring, and professional nursing care since, in fact, caring as a Human Trait (the dimension where professionals scored lower) corresponds to the description of generic care, while the dimension with the highest scores -Therapeutic Interventionreflects professional nursing care.

Conclusion
The identification of caring as Therapeutic Intervention and Interpersonal Relationship can be seen in the high mean scores obtained in these dimensions of the assessment scale on the meanings assigned to caring.In other words, both nursing students and nurses identify caring more with a Therapeutic Intervention and an Interpersonal Relationship than with a Human trait and an Affect.The Therapeutic Intervention dimension obtained the highest scores in all comparisons.No gender differences were found in the mean scores for all the dimensions and the total scale.In all dimensions of the meaning of caring, students scored higher than the professionals.Single participants also scored higher than married participants in all dimensions and in the total scale, with the exception of the Affect dimension, in which no differences were found.
With regard to the years in the profession, nurses with more years in the profession scored higher, with statistical significance, in the Moral Imperative dimension.Using Benner's classification (2001), novice and competent/ proficient participants had higher mean scores than experts for all the dimensions and the total scale.The Therapeutic Intervention, Moral Imperative, Affect, Human Trait dimensions, as well as the total scale, showed statistically significant difference.
The meanings of Therapeutic Intervention and Interpersonal Relationship are particularly assigned to caring, with students, single and novice participants assigning these meanings more clearly.In general, the meanings of Caring as a Moral Imperative, Affect and Human Trait obtained lower scores.However, the meaning of Caring as a Moral Imperative obtained higher scores from nurses with more years in the profession.These data allows us to conclude that it is essential to promote teaching strategies and develop professional competences so that the attitudinal dimensions (Moral, Affect, Human Trait) can be as expressive as the instrumental dimensions (Therapeutic Intervention and Interpersonal Relationship) in terms of the meanings assigned to caring.As suggestions and implications for nursing practice, we emphasize the importance of introducing strategies aimed at valuing the caring components into the formal education and training system.These components are specific and defining characteristics of nursing care that go beyond instrumental care (care provision); they are associated with attitudes, availability, and the development of relational competences that may emerge as therapeutic competences.

Table 1
Sample distribution, sociodemographic data

Table 3
Meanings of caring by gender

Table 4
Meanings of caring assigned by first and fourth-year students and nurses

Table 5
Meanings of caring assigned by students and nursesWhen comparing the meanings assigned to caring according to the marital status (Table6), we found that single participants usually score higher in all dimensions and the total scale, with statistically significant differences between single and married participants, except in the Affect dimension (Mann-Whitney U test).The Therapeutic Intervention and Interpersonal Relationship dimensions had the highest mean scores, the Moral Imperative dimension had intermediate mean scores, and the Affect and Human Trait dimensions had the lowest mean scores.

Table 6
Meanings of caring by marital status

Table 7
Meanings of caring by years in the profession

Table 8
Meanings of caring by years in the profession, according to Benner's classification of expertise levels