Journal of Nursing Measurement The Pragmatic Utility of Watson Based-Caring Measures

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1 Journal of Nursing Measurement The Pragmatic Utility of Watson Based-Caring Measures --Manuscript Draft-- Manuscript Number: Full Title: Article Type: Keywords: Corresponding Author: JNM-D R1 The Pragmatic Utility of Watson Based-Caring Measures Original Study caring behaviour scale; psychometric properties of caring instruments; conceptualization of caring behaviour; dimensions of caring behaviour Huda Atiyeh, Ph.D. Princess Rahma Pediatric Hospital Irbid, JORDAN Corresponding Author Secondary Information: Corresponding Author's Institution: Princess Rahma Pediatric Hospital Corresponding Author's Secondary Institution: First Author: Huda Atiyeh, Ph.D. First Author Secondary Information: Order of Authors: Huda Atiyeh, Ph.D. Muayyad Ahmad, professor Eman Alslman, Ph.D. Manar Bani Hani, Ph.D. Order of Authors Secondary Information: Abstract: Purpose: This study aimed to clarify the caring concept with emphasis on the pragmatic utility of caring measures. Method: The Morse et al. (1996) criteria for concept maturity were used as a framework. A literature review of Watson's based caring concept was undertaken to evaluate the logical, epistemological, linguistical and pragmatic parameters. Results: The concept of caring as conceptualized by Watson and operationalized through different measures appeared mature. Despite differences, shorter scales of caring measures were effective to capture caring behavior. Conclusions: Caring concept was further clarified and more confidence in using caring measures for assessment, evaluation and modification of caring behavior become more feasible. Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation

2 Cover Letter 10 th January, 2016 Faculty of Nursing, University of Jordan Amman- Jordan Dear Editor I am writing to submit our manuscript entitled, The Pragmatic Utility of Watson Based- Caring Measures" for consideration for publication in the Journal of Nursing Measurement. This study aimed to clarify the concept of caring in the nursing discipline based on Watson s Theory of Caring using Morse et al. (1996a, 1996b) parameters for evaluation of concept maturity level with an emphasis on the pragmatic parameter to evaluate the utility of the caring instruments. Nursing educators and managers need brief instruments to measure caring behaviour among nursing students, nurses and patients to improve the quality of care. However, the validity of such instruments to measure caring as an existential human relational phenomenon may be questioned. Our finding showed the effectiveness of caring instruments to capture the phenomena of caring as conceptualized by Watson. Consequently, it may enhance confidence among readers of your journal in caring instruments as empirical indicators that can help them to assess and evaluate caring behaviour. This manuscript describes original work and is not under consideration by any other journal. All authors approved the manuscript and this submission. Ethical approval was not needed. Please address all correspondence concerning this manuscript to me at HDA @FGS.JU.EDU.JO; huda_atiyeh@yahoo.com Thank you for your consideration of this manuscript and considering it for review. We appreciate your time and look forward to your response. Kind regards Huda Atiyeh RN, MSN, PhD Student

3 Point by Point Response to Reviewer 1 Click here to download Point by Point Response to Reviewers Point by point to reviewer 1.docx Point by point to reviewer 1 Thank you very much for your valuable comments NO Point Matching between references and citations throughout the manuscript The title; remove s from Watson's-Based Caring Measures Abstract ; remove "approved to be" Correct behavior throughout the text Space before citations End sentences with expanded and start a new sentence p.3 line 1 Conceptual Framework Throughout the text The recommended statement inserted p.3 line Remove "and in which" and start the sentence : The measures were based..long-term facilities p.3 line 58 p.34 line 3,10 and 12 p.4 line need revision p.5 line 49 reference list 2007 p.6 line 34 and 39 delete Iranian or Iran p.7 line 29 sentence should begin with Watson not Watson's p.8 lines proper APA format p.8 lines 29 and 51 P.9 line 41 p.10 line 12 response 2 missing citation( Wolf,2006) and (Floyd&Wadaman,1995) added and one changed (Chrisman,2003) to (Watson,2008) Watson-based caring Measures removed Changed to behavior 3 spaces were inserted done Restated, clarified and parameter deleted we and our removed The search included fulltext articles.in the title or the abstract Removed and restated Revised and restructured Revised to read" after reviewing..factor analysis Corrected to 2008 Iran deleted and restated Watson's replaced with Watson Modified; The authors were mentioned only for the first time and then with et al. throughout the manuscript Semi-colon removed from line 29 and s added to hold in line 51 The sentence restructured ; overlapping replaced by unclear boundaries and restated I think it is better to start the discussion section by linking to the framework

4 p.11 lines 10 and 12 p.12 lines 34,49 and 51 Check for skilfully p.13 lines need revision p.13 lines 24 and 55 Restructured; 10 factors were reduced statistically to 4 by factor analysis as shown in Table 1 and 2 Restructured Replaced with skillfully throughout the text in 3 locations Revised to include "no instrument to measure caring behavior Delete "to better understand" and operationalized measures replaced with "developed measures"

5 Point by Point Response to Reviewer 2 Click here to download Point by Point Response to Reviewers Point by point to reviewer 2.docx Point by point to reviewer 2 Thank you very much for your valuable comments No. 1 2 Point For grammar and punctuation For the Implication section response Done throughout the text I did some modifications but keep with the points addressing the implications in nursing practice, education, management and research

6 Revised Manuscript INTRODUCTION In the midst of the growing use of technology in health care, it s important to consider how to retain our focus on caring as the essence of quality humanized care. Caring is often regarded as a significant concept in the art and science of nursing. Thus, caring requires personal, social, moral and spiritual engagement on the part of a nurse, as well as commitment to self and others (Gergis, 2015). In nursing there is a relatively large body of literature that addresses caring, and caring behavior is frequently embedded in discussions of the nurse and patient relationship (Charalambous, Chappell, Katajisto, & Suhonen, 2012; Della-Monica, 2008; Duffy, Brewer, & Weaver, 2014; Fogarty, 2012; Lin, 2001; Rafael, 2000; Suhonen, Gustafsson, Katajisto, Välimäki, & Leino-Kilpi, 2010). Over the past 25 years, Watson s (1979) humanistic stance has brought prominence to the concept of caring within the discipline of nursing and this concept has formed the basis for significant theory development and refinement. Watson s human caring theory provides clear guidelines for nurse-patient interactions (Tomey & Alligood, 2010). In addition, Watson considered the concept of caring and quality of care as global concerns in nursing as well in other disciplines (Menke, 2003). According to Watson, caring occurs every time a nurse comes into contact with a client and can be observed through the behavior of the nurse while providing care for the client (Udomluck, Tonmukayakul, Tiansawad, & Srisuphan, 2010). It is vital for nursing to move on from describing caring as a research goal to documenting its effects on patient outcomes. Attempting to measure caring involves documenting the caring work done by nurses, which is often not perceived either by themselves or by those outside the nursing profession. Cossette, Cote, Pepin, Ricard, and D'Aoust (2006) concluded with a note of caution that research into the caring measurement body of knowledge will reach theoretical saturation and will reduce more accessible description of nursing in clinical practice and if endlessly

7 expanded. This concept of caring in nursing might not survive. It might eventually incorporate almost every possible theoretical combination of words and expressions that would be impossible to comprehend in clinical practice. Consequently, it is useful to use the accumulative body of knowledge to refine the caring concept and it is more practical to advance the concept toward higher order of maturation by a common and universal method of operationalization that increases its pragmatic utility until the time it is no more effective, because the concept maturity level is not a static condition. This study aimed to seek for more clarification and refinement of the concept of caring based on Watson s Theory with more emphasis on the pragmatic utility of the caring instruments. CONCEPTUAL FRAMEWORK The four parameters of Morse et al. criteria for the evaluation of the concept maturity level ; pragmatic, epistemological, linguistic and logical were used for the evaluation of the caring concept maturity level (Morse, Hupcey, Mitcham, & Lenz, 1996a; Morse, Mitcham, Hupcey, & Tason, 1996b). PROCEDURES AND DATA SOURCE Selection of studies For the purpose of conceptual clarification of caring behavior and evaluation of the pragmatic utility of different measures in nursing, empirical studies explicitly focusing on the psychometric properties of caring behavior among nurses and patients were searched. Thus, the inclusion criteria focused on studies that examined the construct validity of the instruments developed to measure this concept. Two search strategies were used to systematically collect studies. First, the articles obtained from the CINAHL, Science Direct, SAGE and Medline databases. The search included full-text articles published in English in the nursing literature that included psychometric properties of self-reporting measures of a caring scale and / or inventory in either the title or the abstract. The measures were based on Watson s Theory of Caring and tested with nurses, nursing students engaged in training and

8 adult patients in medical and surgical wards and the elderly in long-term facilities. Articles not published in English were excluded, although caring behavior scales could have been administered in any language. Articles were also excluded if the caring measures were tested with a sample consisting of families, maternity clients, paediatric patients, educators, managers or organizations and if the measure is observational tool or if it is not based on Watson s conceptualization of caring. Second, the references lists of the obtained articles were searched for further relevant studies. Twenty articles which matched the inclusion criteria were retained. After reviewing them, analysis was conducted only on those which were based on Watson s Human Caring Theory, and in which the researchers investigated the factorial structure of the instruments by an exploratory or confirmatory factor analysis. Consequently, six articles were identified. The search strategy is shown in Figure 1. Data extraction The following information was extracted: 1) The title, author and year of publication of the study 2) Country in which the study was conducted 3) Description of the population and sample size 4) Description of the measure/tool (Name, Factors and Items) 5) Results of exploratory factor analysis and/or confirmatory factor analysis; number of factors extracted; percentages of explained variance and/or fit indices. Please insert Figure 1 here Findings The six included studies were examined by applying the four parameters described by Morse et al. (1996a, 1996b) to evaluate the level of concept maturity with an emphasis on the pragmatic parameter. First: The pragmatic parameter

9 This parameter investigates if the concept fits with the phenomena common to the discipline and if the concept has been appropriately operationalized. It is clear that caring concept is embedded in nursing and widely discussed as an integral component of nursing practice and sometimes as equivalent to nursing (Fogarty, 2012). Furthermore, Watson suggested that some of the instruments could serve as quality indicators of practice in evidence-based practice (Watson, 2008). In relation to operationalization, the factorial structure of the caring measures based on Watson s Caring Theory was examined through factor analysis (See Table 1 and Table 2). Factor analysis is one of the most common and valuable procedures used in the development, refinement and evaluation of clinical measures. Exploratory factor analysis is used either for identification of latent constructs or for data reduction and the confirmatory analysis is used for the validation of the dimensional structure of a specific measure using structural equation modeling (Floyd & Widaman, 1995). First, the results reported by Cossette et al. (2006) about the factor structure of the Caring Nurse Patient Interaction Scale were examined. The study aimed to refine the initial 70-item scale to a shorter one. The results showed that 23 items loaded on 4 factors explained 64.45% of the total variance. The first factor was the clinical care which explained 22.56% of the total variance followed by relational care. These results were obtained from the perspective of nursing students beginning their first, second or third year of a nursing program in Canada. Additional testing of the scale was conducted by Cossette et al. (2008) using a larger sample of nursing students to conduct a confirmatory factor analysis. The chi-squaredassociated P value was statistically significant. However, the other indices reached acceptable levels (See Table 2). Second, the Caring Behavior Inventory for Elders, developed and tested by Wolf et al. (2006) was examined. The psychometric properties were tested by using a convenience

10 sample of elders and their caregivers. The data revealed 28 items loaded on 5 factors explaining 61.9% of the total variance in which the first factor Attending to Individual Needs explained more than half of the total variance. In addition, a convenience sample of 362 hospitalized patients was used to test the Caring Behaviors Inventory, a 42-item instrument by Wu, Larrabee, and Putman (2006). An exploratory factor analysis revealed a reduction of the items to 24 items loaded on 4 factors explaining 97% of the 42 items of the original instrument and for the factor Assurance of Human Presence in the first order (See Table 1.) Furthermore, a confirmatory factor analysis was performed to assess the cross-cultural validation of the Greek version of the 24-item of the Caring Behaviors Inventory from the perspective of nurses working in general hospitals. The analysis showed that all items loaded significantly onto their respective factors (Papastavrou et al., 2011). For more details, see Table 2. Finally, Iranian study was examined in which a cross-cultural validation and psychometric testing of the Caring Dimension Inventory consisting of 25 items. Data collected from the perspective of nurses and nursing students revealed 23 items loaded on 4 factors explaining 55.07% of the total variance, and the psychosocial and technical factors having approximately the same variance and together explaining more than half of the total variance (Salimi, Azimpour, Mohammadzadeh, & Fesharaki, 2014). In this Persian version, only two factors were representing Watson s 10 carative factors and the other two factors; Inappropriate and Unnecessary Activities, were structured to enhance the validity of the instrument (See Table 1.). Please insert Table 1 and Table 2 here Second: Epistemological Parameter This parameter examines if the concept is clearly defined and well differentiated from other concepts. Within the scope of this paper, the caring concept was clearly defined by the

11 10 carative factors conceptualized by Watson s Caring Theory. These carative factors identify the ingredients of humanism in nursing care in therapeutic relationships as well as in clinical activities. The 10 carative factors include: (1) humanistic-altruistic value system; (2) faith-hope; (3) sensitivity to self and others; (4) helping-trusting, human care relationship; (5) expressing positive and negative feelings; (6) creative problem-solving caring processes; (7) transpersonal teaching-learning; (8) supportive, protective, and/or corrective mental, physical, societal and spiritual environment; (9) human needs assistance; and (10) existentialphenomenological-spiritual forces ( Porr & Egan, 2013). An important epistemological issue addressed was about the rationalization of having empirical objective measures about an existential human relational phenomenon as human caring in nursing practice (Menke, 2003). Watson reported that caring may never be reduced and truly measured and she expressed concern about the reductionism that is apparent in some of the caring instruments. Watson conceptualized caring as being on a continuum ranging from caring as ontology to caring as an empirical indicator. Implicitly, she acknowledged that caring is a phenomenon that can be studied within either the simultaneity or totality paradigm with different questions and methods. Moreover, she encouraged exploration of the use of multiple paradigms and possibly development of emergent paradigms that are congruent with her post-modern perspective (Menke, 2003). Within the frame of the six studies included in this paper, the dimensions of caring were slightly different from each other. For example, the Caring Behavior Inventory developed and tested by Wolf et al. (2006) was the only measure with 5 dimensions. It includes 2 factors that appeared similar to each other or at least overlapping regarding the epistemological and ontological aspects; Respecting Autonomy and Showing Respect. The other measures shown in Table 1 and 2 included 4 factors but with different titles / names. Third: Linguistic Parameter

12 This parameter examines if the concept is used consistently and appropriately within context. There was a great degree of consistency throughout the literature when using the conceptualization of caring based on Watson Theory of Caring. However, when the concept is operationalized in the caring measures with underlying factorial structure, there were some linguistic inconsistencies in naming the factors. For example, the scientific aspect of nursing practice was measured in each instrument by a single factor but with different semantic form. Cossette et al. (2006) named it clinical care, Wolf et al. (2006) as practicing knowledgeably and skillfully and Salimi et al. (2014) as technical care. In addition, Watson s carative factors Assistance with gratification of human needs, is reflected in different ways in caring instruments; Attending to the individual needs (Wolf et al., 2006) and Psychosocial needs by Salami et al. (2014). Another carative factor; Development of helping trusting, human caring relationship was named by Cossette (2006) as Humanistic Care and Wu et al. (2006) as Positive Connectedness. These differences may be related to different contexts in which caring measures were tested and sometimes it could be related to translation issues when the aim was for transcultural validation of a caring measure e.g. the Persian language version of Caring Dimension Inventory by Salimi et al. (2014). Fourth: Logical Parameter This parameter discusses if the concept holds its boundaries through theoretical integration with other concepts. The concept of caring is widely discussed in the literature and sometimes it is used interchangeably with the concept of nursing. Cipriano (2007) reported that knowledge represents the science of nursing, and caring represents the art of nursing ("The Essence of Nursing: Knowledge and Caring ", n.d). So it is clear that the boundaries of caring concept cannot be separated from nursing concept but there is a theoretical integration between both concepts and more specifically caring could be described as an essential dimension of nursing. This explanation could be supported by the seven

13 features of professional nursing that have been identified from definitions of nursing (ANA, 2010b, p. 9) cited in ("The Essence of Nursing: Knowledge and Caring ", n.d) 1. Provision of a caring relationship that facilitates health and healing. 2. Attention to the range of human experiences and responses to health and illness within the physical and social environments. 3. Integration of assessment data with knowledge gained from an appreciation of the patient or the group. 4. Application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking. 5. Advancement of professional nursing knowledge through scholarly inquiry. 6. Influence on social and public policy to promote social justice. 7. Assurance of safe, quality, and evidence-based practice. A comparison between these 7 features of nursing and Watson s 10 carative factors will yield unclear boundaries between the two concepts with respect to caring relationship that facilitates health and healing and human experiences within the physical and social environments. The features that exclusively distinguished caring based on Watson s 10 carative factors from the 7 features of nursing (ANA, 2010b, p. 9) cited in ("The Essence of Nursing: Knowledge and Caring ", n.d.) are ; humanistic altruistic values; and allowance for existential-phenomenological spiritual dimensions. On the other hand, exclusive features to nursing are the assurance of evidenced-based practice, advancement of professional nursing knowledge and contribution to policy issues. Because boundaries means what is and what is not related to caring concept, the included factors in the caring measures were not exclusive to conceptualization of caring, e.g. the Clinical/Technical Care are shared factors with nursing features. Consequently, the boundaries of the caring concept are not clear cut to differentiate caring from nursing.

14 DISCUSSION Based on Morse et al. (1996a, 1996b) criteria to determine the maturity level of a certain concept, the reviewed literature worked as an indicator for the type of concept analysis inquiry. The inquiry is in the area of concept clarification to the concept refinement along the continuum of concept maturity. Caring conceptualization and the corresponding operationalization based on Watson s Theory of Caring appeared well developed and near maturity. There is a large body of literature that includes definitions and rich descriptions of quantitative instruments, but still it is applied in different ways. The dimensions, boundaries and potential indicators of caring concept have been identified to a great extent. Some caring instruments are designed to be completed by patients only, by nurses only, by nursing students or by either patients or nurses. Although a cross-cultural validation was done in different cultures (Papastavrou et al., 2011; Salimi et al., 2014), it needs further validation across other cultures such as Arabic culture. So the validity of the operationalization across populations and contexts has not been completely determined. While there is an epistemological debate regarding the reduction of caring, the developed measures appeared valid to capture considerable aspects of caring as an existential human experience evidenced by the validity of the factorial structure. For the theoretical integration, some overlapped areas were identified between caring and the concept of nursing. However, there was an exclusive feature for both concepts in which it may help in formulating the boundaries of each concept and advance both toward a higher maturity level. Moreover, some linguistic inconsistencies were realized in the naming of the measurement tools and its factorial structure. By investigating the operationalization of Watson -Based Caring Measures, the factorial structure appeared congruent with the original conceptualization. Although it was reduced to a fewer number of factors, the overall measures had significant explained variance and fit

15 indices. A closer look of the factorial structure of the measures revealed inconsistencies in the number of items relevant to similar factors in different measures: Wolf et al. (2006) developed the Caring Behaviors Inventory for Elders with 28 items, but only 5 items were measuring the factor; Practicing Knowledgeably and Skillfully which explained 4.91 % of the total variance. However, Cossette (2006) structured 9 items to measure a similar factor Clinical Care after the refinement of the Caring Nurse Patient Interaction Scale to a shorter scale consisting of 23 items; the 9 items explained 22.56% of the total variance. A possible explanation for such inconsistency could be referred to the structural issues in which the tool developer maybe affected by preconceptions he/she holds toward the targeted population for which the measure is intended to be used. Another explanation could be referred to sampling issues when the psychometric properties are tested e.g. Cossette (2006) used a sample of nursing students to refine the Caring Nurse Patient Interaction Scale and this could clarify the high value of explained variance of Clinical Care factor compared with the variance of the factor of Practicing Knowledgeably and Skillfully developed by Wolf et al. (2006) and tested using a sample of elderly and the nurses taking care of them, because nursing students may give a higher value for the knowledge and skills over the other factors than practicing nurses. This explanation could be supported by the results of a longitudinal study conducted by Watson et al. (1999) in which they found that caring is built over time. Overall, none of the Watson-Based Caring Measures included 10 factors that reflect the 10 carative factors. However, the factor analysis showed that the used measures were representative of the theoretical construct. One possible interpretation of this result is that the whole number of items represents the concept and not only the number of factors. Another possible explanation could be referred to overlapping areas between the 10 carative factors. This explanation is strongly supported by the results shown in Table 1 and 2 in which the 10 carative factors were reduced statistically by factor analysis to 4 or 5 factors. In terms of the

16 total number of items in each measure, similar results were obtained by Cossette (2006) when he reduced the 70 items to 23 items and Wu et al. (2006) when they reduced the 42 items to 24 items. So these results showed the pragmatic utility of shorter scales of Watson s-based Caring Measures and these results were supported through the confirmatory factor analysis conducted by Cossette et al. (2008) and Papastavrou et al. (2010). For the linguistic parameter, areas of inconsistencies were realized in the titles or names of similar factors from a measure to another, this could be referred to translation issues. In addition, for the epistemological parameter, similar factors did not hold the same weight or number of items across different measures and this could be referred to the cultural or contextual issues in which certain factor/s may have higher value over another ones. Consequently, further transcultural validation is recommended to investigate sources of variation. In spite of the large body of knowledge about caring in the nursing discipline, clear boundaries are not determined yet. However, the caring concept lends itself to the aesthetic part of the nursing profession and this is evident in Watson s 10 carative factors in which no single factor is clearly expressing the empirical aspect of nursing profession. On the other hand, all Watson-based caring measures in this study included one factor presenting the empirical aspect of nursing profession e.g. Clinical Care, Technical Care and Practicing Knowledgeably and Skillfully. Accordingly, the conceptual boundaries of caring concept need more investigation to reach theoretical integration with other concepts. Implications for Nursing Caring is essential to accomplishing high-quality nursing practice standards and is the basis for competencies in all domains; cognitive, affective, and psychomotor (Porr & Egan, 2013). So knowing the anticipations and perceptions of patients about nursing care will improve quality of nursing care given to patients by nurses (Akansel, Watson, Aydin, &

17 Özdemir, 2013). Caring and other affective objectives receive little to no attention in healthcare education compared with the current emphasis on the acquisition of technical skills. A valid and reliable tool to measure caring behavior of nursing students could help improve and stimulate their caring behavior. However, no instrument to measure caring behavior is currently available that is designed from an educational perspective (Gergis, 2015). Additionally, nursing administrators need brief instruments to assess caring behavior of the staff and to plan improvements (Salimi et al., 2014). Accordingly, it is important to have an empirical indicator through a valid measure of caring in order to assess, evaluate and improve the caring behavior among nursing students and nurses and to measure caring as perceived by patients as an indicator of quality of care and patient satisfaction. Conclusion The concept of caring as conceptualized by Watson and operationalized through different measures appeared more toward maturity along the continuum of concept maturity. The pragmatic parameter highlighted the dimensions of caring measures. Factor analysis of the eligible instruments revealed congruency between Watson s conceptualization of caring and the developed measures and consequently enhancing confidence in using Watson-Based Caring Measures as empirical indicators for caring behavior among nursing student, nurses and patients. However, special attention should be given to the context in which the measure is to be used especially when the aim is to test the transcultural validation of an already existing instrument or when it is to be used with different participants. Overall, this paper added to the pragmatic utility of the caring concept. Yet, the theoretical meaning of caring and its significance and operationalization should continue to be discussed within the nursing profession to advance the concept more toward maturity.

18 References Akansel, N., Watson, R., Aydin, N., & Özdemir, A. (2013). Mokken scaling of the Caring Dimensions Inventory (CDI-25). Journal of Clinical Nursing, 22(13/14), doi: /j x Charalambous, A., Chappell, N. L., Katajisto, J., & Suhonen, R. (2012). The Conceptualization and Measurement of Individualized Care. Geriatric Nursing, 33(1), doi: /j.gerlnurse Cossette, S., Cote, J. K., Pepin, J., Ricard, N., & D'Aoust, L.-X. (2006). A dimensional structure of nurse-patient interactions from a caring perspective: Refinement of the Caring Nurse-Patient Interaction Scale (CNPI-Short Scale). Journal of Advanced Nursing, 55(2), Cossette, S., Pepin, J., Côté, J. K., & de Courval, F. P. (2008). The multidimensionality of caring: a confirmatory factor analysis of the Caring Nurse-Patient Interaction Short Scale. Journal of Advanced Nursing, 61(6), doi: /j x Della-Monica, N. R. (2008). Development and psychometric evaluation of the Nurse Caring Patient Scale. (Ph.D.), Boston College. Retrieved from ehost-live Available from EBSCOhost rzh database. Duffy, J. R., Brewer, B. B., & Weaver, M. T. (2014). Revision and Psychometric Properties of the Caring Assessment Tool. Clinical Nursing Research, 23(1), doi: / Floyd, F.,& Widaman, K.(1995). Factor Analysis in the Development and Refinement of Clinical Assessment Instruments. Psychological Assessment, 7(3),

19 Fogarty, S. (2012). Nursing, Caring, and Complexity Science - For Human-Environment Well-being. Nursing Philosophy, 13(4), doi: /j X x Gergis, M. (2015). Want to Graduate Clinicians Who Care? A Caring Behavior Scale for Healthcare Students (S740). Journal of Pain and Symptom Management, 49(2), 428. doi: Lin, P.-F. (2001). Development and psychometric evaluation of the Caring Behaviors Scale of baccalaureate nursing student in Taiwan. ( Ph.D.), Boston College, Ann Arbor. Retrieved from ProQuest Dissertations & Theses Global database. Menke, E. M. (2003). Caring Science and the Development of Measurement Approaches. Nursing Science Quarterly, 16(4), doi: / Morse, J. M., Hupcey, J. E., Mitcham, C., & Lenz, E. R. (1996a). Concept analysis in nursing research: a critical appraisal. Scholarly Inquiry for Nursing Practice, 10(3), Morse, J. M., Mitcham, C., Hupcey, J. E., & Tason, M. C. (1996b). Criteria for concept evaluation. Journal of Advanced Nursing, 24(2), doi: /j x Papastavrou, E., Karlou, C., Tsangari, H., Efstathiou, G., Sousa, V. D., Merkouris, A., & Patiraki, E. (2011). Cross-cultural validation and psychometric properties of the Greek version of the Caring Behaviors Inventory: a methodological study. Journal of Evaluation in Clinical Practice, 17(3), doi: /j x Porr, C., & Egan, R. (2013). How does the Nurse Educator Measure Caring? International Journal of Nursing Education Scholarship, 10(1), 1-9. doi: /ijnes

20 Rafael, A. R. F. (2000). Watson's philosophy, science, and theory of human caring as a conceptual framework for guiding community health nursing practice. Advances in Nursing Science, 23(2), Salimi, S., Azimpour, A., Mohammadzadeh, S., & Fesharaki, M. (2014). Psychometric properties of Persian version of the Caring Dimension Inventory (PCDI-25). Iranian Journal Of Nursing And Midwifery Research, 19(2), Suhonen, R., Gustafsson, M., Katajisto, J., Välimäki, M., & Leino-Kilpi, H. (2010). Individualized care scale - nurse version: a Finnish validation study. Journal of Evaluation in Clinical Practice, 16(1), doi: /j x Tomey, A. M., & Alligood, M. R. (2010). Nursing theorists and their work (7th ed ed.). Maryland Heights, Mo. : Mosby/Elsevier: St. Louis, Mo.; London: Elsevier Mosby. Udomluck, S., Tonmukayakul, O., Tiansawad, S., & Srisuphan, W. (2010). Development of Thai nurses' caring behavior scale. Pacific Rim International Journal of Nursing Research, 14(1), Watson, R., Deary, I. J., & Lea, A. (1999). A longitudinal study into the perceptions of caring among student nurses using multivariate analysis of the Caring Dimensions Inventory. Journal of Advanced Nursing, 30(5), doi: /j x Watson, J. (2008). Assessing and measuring caring in nursing and health science. New York: Springer Pub. Wolf, Z., Zuzelo, P., Goldberg, E., Crothers, R., & Jacobson, N. (2006). The Caring Behaviors Inventory for Elders: development and psychometric characteristics. International Journal For Human Caring, 10(1), p.

21 Wu, Y., Larrabee, J., & Putman, H. (2006). Caring Behaviors Inventory: a reduction of the 42-item instrument. Nursing Research, 55(1), p.

22 Figure CINAHL 17 Science Direct 3 SAGE 13 Medline with full text articles after duplication removed 10 articles screened for content and reference list 10 additional eligible articles 20 articles of psychometric properties of caring measures 10 articles based on Watson Theory screened for including FA 10 articles excluded; not based on Watson s Theory 3 measures based on conceptualization derived from qualitative studies 1 based on the metaphor of instrumental friendship identified by Rawnsley (1982). 2 measures based on Swanson Theory of Caring (1991) 3 measures based on Suhonen et al. (2000, 2002, 2005) 1measure based on Larson (1987) 4 articles didn t use FA 6 articles retained that used FA; 4 PCA and 2 CFA Figure 1 Search strategy map

23 Table 1 Table 1 A Summary of Factorial Structure of Watson s-based Caring Measures (Principal Component Analysis; PCA) Study Country Population Sample size Name of the measure No. of factors Name of factors No. of items Explained variance Psychometric properties of Iran Nurses 143 Caring Dimension Psychosocial % Persian version of the Inventory Technical % Caring Dimension Inventory Nursing students 145 (PCDI-25) 4 Inappropriate % (Salami et al.,2014) Unnecessary activities % Total The Caring Behaviours USA Elders in Long- 215 Caring Behaviours Attending to Individual Needs % Inventory for Elders: Term Care Inventory for 5 Showing Respect % Development and Facilities 138 Elders Practicing Knowledgeably and % Psychometric Characteristics (Wolf et al.,2006) Nurses (CBI-E-28) Skilfully Respecting Autonomy % Supporting Religious/Spiritual % Needs Total % A dimensional structure of nurse patient interactions from a caring perspective: refinement of the Caring Nurse Patient Interaction Scale (CNPI-Short Scale) (Cossette,2005) Canada Nursing student 377 Caring Nurse Patient Interaction Scale (CNPI-70) 4 Clinical Care %, Relational Care % Humanistic care % Comforting Care % Total % Caring Behaviours USA Adult hospitalized Caring Behaviours Assurance of human presence 8 NA Inventory: a reduction of the patients 362 Inventory-42 items 42-item instrument (Wu et Professional Knowledge and al.,2006) 4 Skills 5 NA Respectful dimension 6 NA Positive Connectedness 5 NA Total 24 97% of original tool

24 Table 2 Table 2 A Summary of factorial structure of Watson s-based Caring Measures (Confirmatory Factor Analysis ;CFA) Study Country Population Cross-cultural validation and psychometric properties of the Greek version of the Caring Behaviours Inventory: a methodological study (Papastavrou et al.,2010) Sample size Greece Nurses 245 Name of the measure Greek version of the Caring Behaviours Inventory-24 items No. of factors 4 Name of factors/dimension Assurance of human presence Professional knowledge and skills No. of items Factor loading to to 0.85 Respectful dimension to 0.78 Positive connectedness to 0.76 Total 24 Fit Indices X 2 (239) = , P < a CFI = 0.91 c RMSEA = The multidimensionality of caring: a confirmatory factor analysis of the Caring Nurse Patient Interaction Short Scale (Cossette et al.,2008) Canada Nursing students (20% were already Registered Nurses) 531 Greek version of the Caring Behaviours Inventory-24 items 4 Clinical care to Relational care to 0.82 Humanistic care to Comforting care to X 2 (224) = , P < a CFI =0.98 b GFI=0.88, c RMSEA=0.070 Total 23 a Comparative Fit Index b Goodness of Fit Index c Root Mean-Square Error of Approximation

25 Title Page with Author Information and Acknowledgments Title Page Journal of Nursing Measurement Title of Article: The Pragmatic Utility of Watson Based- Caring Measures Authors Information - Huda Mohammad Atiyeh (Principal and corresponding author; study conception/design; data collection, analysis and drafting of manuscript). RN, MSN, PhD student Faculty of Nursing, the University of Jordan, Amman, Jordan HDA @FGS.JU.EDU - Muayyad M. Ahmad (Coauthor; critical revisions for important intellectual content; supervision and statistical expertise) PhD, RN, Professor, Faculty of Nursing, The University of Jordan. mma4jo@yahoo.com; mma4@ju.edu.jo -Eman Tariq Alslman (Coauthor; study conception/design and data collection) RN, MSN, PhD student Faculty of Nursing, the University of Jordan, Amman, Jordan Address: eman.yassen@hotmail.com -Manar Ali Bani Hani (Coauthor; study conception/design and data collection) RN, MSN, PhD student Faculty of Nursing, the University of Jordan, Amman, Jordan Address: manaryousef2013@gmail.com Acknowledgments The authors would thank Prof. Susan Larocco for her review for English language and assistance in manuscript preparation. Source of funding This paper was partially funded by the University of Jordan Ethical approval was not needed Ethical approval