Examining of Caring In Traditional and Non-traditional Nursing Students

Objectives: The purpose of this study examined traditional and non-traditional nursing students to determine if there are significant differences in caring. Methods: A descriptive comparative design was conducted using a convenience sampling using nursing students in an associate degree nursing program in northeastern Ohio, USA. A demographic survey and the Caring Efficacy Scale (CES) were given to the students to complete. Data was analyzed to determine the measures of central tendency including frequencies, means, and standard deviation (SD). Independent t-tests were used for the mean responses and stand deviations utilized to measure the dispersion of the data. The total number of students participating was 249. Results: Traditional students were identified as 29.7% of the total while the non-traditional students were 70.3% of the group. The total scores for the CES of the traditional students were 157.24 with a SD of 13.31 and non-traditional students’ total scores were 158.63 with a SD of 14.49. Results indicated that there were no significant differences identified between the two groups, including those students who had previous healthcare experience. Conclusions: Despite the findings, nurse educators must analyze the types of student who are entering nursing programs while assessing for those with caring as a part of their personality and interest for joining nursing. Without caring, patient outcomes may be affected. The results of this study indicated that caring, as the key to the nursing profession, is a needed attribute for those entering and pursuing care for individuals they are assigned to nurse. Examining of Caring In Traditional and Non-traditional Nursing Students Publication History: Received: May 21, 2015 Accepted: October 14, 2015 Published: October 16, 2015


Introduction
Choosing a nursing career is a very important decision which individuals begin to contemplate early in their lifetime.Many qualities may be considered important, but the most vital quality is hat of caring as nursing has long been recognized as a caring profession [1][2][3].Nurses have consistently been concerned with the human dimensions of healthcare and have been recognized as dealing holistically with patients [4].It is therefore essential that potential students recognize the importance of caring [1,2,5,6].While multiple nursing leaders, theorists and researchers have identified caring as a critical component of the discipline, the nursing student's ability to exhibit caring qualities has seldom been investigated [7].Specifically, there have been no studies examining the different types of students, traditional and non-traditional.There is a need to examine this topic.
Traditional students often enter into nursing because they have always wanted to be a nurse; they are attracted by the opportunity to "take care" of people [8].Although they may have considered other career options, these options generally fall into one of a helping profession [9].On the other hand, non-traditional students, including second degree students, may have selected a non-nursing career because initially they did not feel driven to a discipline designed to "take care" of others 10.For any number of reasons, these nontraditional students leave their initial career and enter nursing [11].Because their approach to becoming a nurse is different from that of the more traditional nursing students, it is valuable to ask whether these individuals have the same desire to "take care" of others [12][13][14].Non-traditional students may have already focused on another profession, family life or military service.Caring in these individuals may be viewed as being exceptional and what was always their focus in life or it may be viewed as a means to be trained for a valued profession with emphasis on future job security and financial income.

Review of the Literature
Jean Watson [15] included in her transpersonal theory the importance of specifically dissecting the term caring and not taking the concept at its superficial meaning.Inclusion of the need to be caring in the profession is a complex process since it includes the area of human behavior.As a person investigates their own personal caring, one initially should reflect what caring means to them and how caring is expressed by them and upon others.When planning to enter into a caring profession, the review of how one can be caring towards another through growing, learning and viewing the actual potential for their personal caring will proliferate.Inclusion of the caring person's own personal growth, inclusion of their own ethical values and ideas leading to personal autonomy is important.Beingable to be valued for their uniqueness must be assessed [16][17][18].
The presence of aspects of the spirit, mind and body, the caring nature of an individual becomes a connection with the person providing the care and the person receiving the care.The aspects of being a human are shared from birth to death with the caring and healing practices that are performed throughout this time period.Clark [19] suggested that a nurse using positive caring attitudes will portray a positive aspect yielding positive outcomes, while the nurse using negative aspects may not and may jeopardize patient outcomes in a negative manner.

Traditional and Non-Traditional Nursing Students
Traditional nursing students tend to have an interest in the nursing profession early in life, usually in middle school, and hence comewith little or no knowledge in their abilities to deal with people, especially those who are ill [20][21] Qualities that Watson [22] identified in the ten carative factors such as sensitivity, values, trust, ethics, empathy, tolerance, altruism, respect for human dignity, and caring for individuals are often not experienced by the traditional students and needs to be included as an extensive part of their educational process [23].Perhaps the few experiences the traditional students have with caring relationships may affect the perceptions that are initially apparent when entering a nursing program [24].Specific literature focusing on the backgrounds of students indicates that many of those entering nursing today are primarily non-traditional students [11,12,14,25].Non-traditional students, who come from the diverse population, tend to decide to enter the profession of nursing while in their high school years and beyond 20.These students may have cared for others prior to entering a nursing program, but not in the manner that a nurse provides care [13,25,26].Being motivated, they tend to strive to succeed, but are without the skills, values, and attitudes that need possessed for caring relationships [12,23,26,27].Supporting student learners, especially if they are non-traditional students through caring and a caring environment is important.Attention to the development of partnerships, assuring respect and trust, incorporating collaboration, allowing for selfdirection and innovative creativity is needed [5,28].
Second degree students (SDS) are an additional and a separate set of students who enter into the educational ranks.Although these individuals are considered non-traditional students, they have already entered a profession for one reason or another; they have a background in another field prior to entering into nursing.In comparison to the non-traditional students, SDS are viewed similarly [12].Their experiential learning is a positive for them along with maturity in life.One specific area addressed by Kenny, Kidd, Nankervis and Connell [29] focused upon SDS and difficulties that they perceived when entering into nursing.They responded by citing such concerns as failure, lack of confidence and realities of nursing not meeting their expectations [30].Page [31] suggested that those students coming from other divergent fields tend to have more motivation and drive to enter nursing than their younger counterparts.The question, though that is posed is whether caring and caring qualities are included in the SDS students.
In summary, the nursing profession has long been recognized as a caring profession [2,3,[32][33][34][35][36]. Rhodes [37] found that incoming nursing students identified the essential quality for the nurse is caring.Consequently, nurse educators must recognize the importance of caring in student nurses [2,5,6].By doing so, the ability to nurture and grow these behaviors will result and be carried out throughout their nursing education and as they begin in the profession [38,39] whether they are in the group of traditional or non-traditional learners.

Research Question
Is there a significant difference in the caring efficacy scores between traditional and non-traditional associate degree (AD) nursing students?"

Operational definitions
Nontraditional Nursing Student: The year of high school graduation will be greater than five years.Traditional Nursing Student: The year of high school graduation will be less than five years.

Research design
A descriptive comparative study design was implemented.

Samples and settings
The total number of students participating was 249 from the four satellite sites, representing 83% of the total second semester, first year nursing student population participated in this study using a convenience samples of nursing students in an associate degree nursing program in northeastern Ohio, USA.Participants were placed into categories (traditional vs. nontraditional students) based upon the demographic information.The year of high school graduation was placed in the traditional category if less than five years, while those with a year of graduation greater than five years were placed in the non-traditional category.These groups were needed to separate the responses from the two groups while evaluating the CES.
The sample size was determined by power analysis imputing default settings for an independent t test for differences between the two groups.By using convenience sampling, the means of all responses were used to examine independent t tests.

Instruments
Two surveys were utilized to collect data.A demographic survey was used to define participants as traditional or non-traditional nursing students, and to fully describe the sample.This instrument was developed by the researcher and was based on variables to not only differentiate between traditional and non-traditional nursing students but to also identify specifics about the participants.The student demographics additionally collected information regarding the participants' age, gender, ethnic and cultural background along with other information to describe the participants.Use of questions that were asked included information about when the decision to enter a nursing program was decided, previous healthcare experience, reasons college was not begun right out of high school and if a college degree has been obtained and in what field.The survey maintained anonymity of the respondent's responses.
The second survey, the Caring Efficacy Scale (CES), was used to assess how a person views caring in the nursing profession.Developed by Dr. Carolie Coates [40], this scale assessed the participants' ability to use and express a caring orientation.The focus by Coates [40] explored development of a caring relationship when a person provides caring during interactions with patients.The CES Self-Report B, used for this study, is based on 30 declarative statements with a sixpoint Likert scale including both positive and negative items ranging from strongly disagree (-3) to strongly agree (+3).When the study participants completed the CES, they were asked to think of their work in clinical settings and/or similar experiences and complete the 30 item Likert scale, using on six choices, -3 (strongly disagree) to +3 (strongly agree), based on their work with clients or patients.Twenty-three items are positively worded and seven are negatively worded.After recoding the negatively worded items, the score for each individual would be an average of their responses on the 30 items.A high score on the scale would equate to more caring efficacy which emphasizes the caring relationship.Coates [40] reported that the mean score for the responses was 3.97, the standard deviation was 0.55 and Cronbach's alpha was favorable at 0.92 [40].

High school graduation year
The year of high school graduation ranged from 1973 to 2012.Students graduated from high school in 2008 or after was 74 or 29.7 % (traditional) while those who graduated in 2007 or before was 175 or 70.3 % (non-traditional).Overall, the most significant group was the non-traditional nursing students for this study.

Previous healthcare experience
Those respondents having previous healthcare experience was 142 or 57% while those not having any previous healthcare experience were 107 or 43 %.This indicates that there were 14% more who had been involved in some form of healthcare experiences.Statistical analysis did not indicate any significant differences of an interaction or main effect as there was not enough variability in the scores between the traditional and non-traditional nursing students with previous healthcare experiences (Table 3).

Data collection process
After permission was obtained, the researcher began the data collection process at four respective university satellite sites.Prior to beginning the data collection process, an informed consent was given to the students to read, sign, and return.The potential number of participants for this study was determined to be at least 300 second semester, first year nursing students and in actuality, was 249.A large number of subjects were needed to insure an adequate number of both traditional and non-traditional students.The power analysis breakdown indicated that a total of 134 nursing students totally were needed for this study.

Ethical clearance
This study was approved by the Institutional Review Board at the university being utilized for data collection.In order to assure anonymity of the participants, no names of the students or other identifying information was requested on the CES survey instrument or demographic survey data form.Stipulations that no identification referring to any specific campus will be published or shared with others, including those who participated in the research study, except for the researcher's dissertation committee members.Numbering of the forms was done to compare the CES with the demographic data.All completed forms are considered confidential.

Data analysis
Data was entered and analyzed using the Statistical Package for the Social Sciences (SPSS) 41 version 21.The demographic data was analyzed to determine the measures of central tendency including frequencies, means, and standard deviations for the items surveyed.Independent t-tests were used for the means of all responses.Standard deviations were utilized to measure the dispersion of the data.For analysis of the CES, total scores and standard deviations were identified for both the traditional and non-traditional students.The level of significance was set at 0.05 %.

Results
A total of the results of this study began with a total of 249 respondents from the four satellite sites, representing 83% of the total second semester, first year nursing student population participated in this study.Ages ranged from 19 years to 57 years old (n = 249) with a mean of 29.82 years.Gender was represented with 85.1 % (n = 212) female and 14.9 % (n = 37) male.The ethnic background of the participants were 89.6 % (n = 223) Caucasian, 4.8 % (n = 12) Black, and 5.6 % (n = 14) other people of color.Graduation years ranged from 1973 to 2012 with those graduating after 2008 29.7 % (n = 74; traditional group) while those graduating before 2008 was 70.3 % (n = 175; non-traditional group).Those indicating a college degree in another field was 28.1% (n = 70) with 71.9% (n = 179) not having a college degree.The decision made to enter nursing school while in grade school was 7.6% (n = 19); while in middle school 6.0 & (n = 15); while in high school 20.5% (n = 51) and after completion of high school 65.9 % (n = 164).Inquiry into the time frame where the decision to go into the nursing and those having previous healthcare experience was 57 % (n = 142) of the respondents (Table 1).
The total scores for the CES for traditional students (n = 74) was 157.24 with a SD of 13.310 while the non-traditional students (n = 175) was 158.63 with a SD of 14.49.The significance was noted to be 0.59 with the -test for equality of means was 0.71 having a degree of freedom being 247.The 2 tailed t-tests identified a p value of 0.48 (Table 2).The responses of both the traditional and non-traditional nursing students may have reflected the timing of the data collection.The data was collected as the AD nursing students were in their second semester of the nursing program.Perhaps it would have been more appropriate to collect the data prior to beginning interactions with patients and learning about caring and caring aspects.Concern about the timing of data collection may have altered or enhanced the student's caring or perceptions of caring.The researcher wonders if caring is what drives an individual to enter into nursing as it is a caring profession.If caring is not what directs one to nursing, nursing educators need to research what are the driving forces.As traditional and non-traditional nursing students are individuals and are seen as being different, no significance differences in caring were identified in this research.Perhaps caring is really not different in the two groups or perhaps caring is not the appropriate variable that was identified to be studied [27,51].
Although the traditional nursing student's CES scores did not differ from the non-traditional students' , the larger number of nontraditional students who participated provided for an unpredicted finding.Perhaps a focus needs to be related specifically to the nontraditional student and their caring.Non-traditional students may be a group where nursing needs to focus research as they seem to be viewed as a successful group of individuals.Their success may be that of previous positive experiences, maturity, life experiences, and methods of being resourceful in life, hence learning is done through the carrying over of skills and knowledge from one setting to another.
There are many changes being encountered in society today.Those who are currently entering into the workforce, especially the nursing profession, bring different thoughts and perceptions, including that of caring [27,55].Nurse educators must be prepared to deal with diverse individuals, the traditional and non-traditional in many ways with identifying and promoting caring in their interactions with those they care [55].The needs of these individuals are different than that of the previous generations 61.Differences have been identified in traditional and non-traditional students in the review of the research literature related to age, gender, motivation, interest, learning styles, and resilience in traditional and non-traditional students [14,13] but not that of caring until this study.Some prospective nursing students are considered traditional students who are just coming out of high school.They are the current generation who are technological savvy, motivated, highly adaptable, multi-taskers, impatient, and have high expectations in all they do [61,12].Those who are the non-traditional students or the Baby Boomers tend to be service oriented, driven, hardworking, and needing stability in their current careers [61].Raines [62] suggests that non-traditional students have a desire to enter the workforce and make a difference.Research on caring by Khademian & Vizeshfar34 identified that the student respondents did not perceive caring differently in relation to age or gender.Since traditional and nontraditional students are different as students and with their learning abilities, so their perceptions of caring may additionally be perceived asbeing different [12].Hence, as previously stated, the study did not produce significant findings for differences in caring.
Nurse educators must continue to look at the students that are being admitted to nursing programs [63].Non-traditional nursing students were the predominate group of students as depicted by the year of high school graduation in this study.Research specifically targeted toward the non-traditional nursing student is needed.Seeking additional information about these individuals may assist in providing further

Limitations of the Study
A key limitation was the diversity of the convenience sample, using only one university with AD nursing students and not including BSN nursing students.Providing a variety of respondents of different ages, genders, and other ethnic cultures and backgrounds were viewed as a constraint.
Another limitation related to the timing of the data collection.Completing the data prior to entering a nursing program may have been a more insightful time choice [42].These students would not have already been in a nursing program and not cared for any patients as an educational requirement.Watson, Garfinkel, Gallop, Steven and Steiner [43] offered that when researching empathy, there are differences depending on such areas as age, length of time being a nurse and educational levels.In actuality, the younger, new nurse with a higher level of education had higher empathic scores [44,45].There was a relationship to the clinical experiences that they had had along with working with a larger number of patients, having some practice autonomy, and positive patient outcomes that they had been able to observe 46.Findings may be perceived that nursing students are seen initially as being caring and empathic, but then as student's continue on in their education endeavors, caring becomes a lesser aspect of how they aspire to enhance caring in the actions they perform [47].
For those nursing students not having the previous healthcare experiences their responses may have most likely affected their answers to the CES questions [47].For the 57% of students who responded that they had previous healthcare experience outside of the nursing program, caring may have been learned by these individuals through life experiences prompting caring.These individuals may have had preconceived insights learned when data collection took place [48,49].Wardet al. [44] found that the relationship towards caring may be perceived differently when looking at the two groups of individuals, traditional and non-traditional nursing students.Use of this specific tool to measure caring may be seen as a limitation.Use of more than one tool or revising of the study to be a qualitative or even mixed method study may have allowed for more detailed information offered by the participants.

Discussion
One of the reasons that caring is needed in the profession is that especially traditional nursing students must be able to understand the expectations of the profession are and to be able to initiate and exemplify overall caring [50].The researcher, along with other fellow nurse educators have expressed personal concerns that these present groups of students may not be able to fully develop as caring individuals.Their perceptions are that those entering into nursing programs are different from previous decades.They may not have the same personal communication and touch that indicates caring.Their concerns often relate to monetary compensation as opposed to feelings of satisfaction.The increased use of technology may inhibit their abilities to personalize interactions with patients and families.Their backgrounds and views of the profession do not always reflect that of a caring nature.in-depth understanding especially of the non-traditional student which can assist with understanding of their caring focusing on entering students and then in looking at the areas of recruitment, retention, and finally degree completion.
To be effective, the process will need to begin prior to admission to nursing programs and then faculty must learn who their students are, what their needs are, and how to assist them in order to be successful [27,42,39].Current literature is limited especially with information for the non-traditional student as identified by Raines [62].Understanding how caring abilities develop in a generic nursing student is important.They most likely have not focused on caring to this point and will be instructed and learn about caring as they progress in a nursing program.Non-traditional students, however, enter nursing with various backgrounds which may have enhanced or damaged their caring perceptions [27].Concern about what these backgrounds are and how their similarities and differences may have affected their perceptions of caring needs researched [62].
Although caring has been identified as an area in which how to care can be learned [52,53], caring may not be a part of the makeup of that individual.The student may be challenged to learn and develop caring.In the process, frustration can develop along with difficulties in the classroom and clinical setting.Their success in the nursing program may lead to unobtainable development of caring relationships when working with their patients [23,39,[54][55][56][57][58][59][60].
With the overall perceptions of the nursing profession, nurse researchers must show support and enhance confidence for the needs of the profession, including students admitted to and then completing nursing programs [57,58].In addition, the potentially caring students must be able to trust faculty, communicate effectively with them, and build a therapeutic relationship [64].What is of concern is that nursing students, whether traditional or non-traditional, may not be able to form and develop caring relationships [13,55].Since caring relationships are central to nursing practice, it is important to determine characteristics nursing students will need to possess in order to provide caring [59,60].
Further research is needed to differentiate and identify the characteristics of the traditional and non-traditional groups and their relationship to caring.As a nurse educator, this researcher perceives, through personal experiences, that there aredifferences in caring in the generations that are currently interested in the nursing profession and even those who are now practicing in the profession.Future examination into both the traditional and non-traditional groups is specifically needed [62].
This study examined traditional and non-traditional nursing students to determine if there are significant differences in caring.Results indicated that there were no significant differences identified between the two groups.Despite the findings, nurse educators must analyze the type of students who are entering nursing programs while assessing for those with caring as a part of their personality and interest for joining nursing.Without caring, patient outcomes may be affected.The results of this study indicated that caring, as the key to the nursing profession, is a needed attribute for those entering and pursuing care for individuals they are assigned to nurse.