Perceptions of nurse managers and staff nurses regarding Technological Competency as Caring in Nursing theory in general hospitals in Japan

Study Design

This is a cross-sectional study with a web-based questionnaire survey using the TCCNI-R.

Settings and Samples

The study settings were 11 general hospitals in Chugoku-Shikoku district, Japan. These hospitals have 200 or more in-patient beds. The sample of the study was selected based on the following inclusion criteria: a) currently employed as nurse managers and staff nurses; b) practicing in a private or public healthcare system or both; c) qualified and registered to practice nursing; d) agreed to participate in the survey; e) nurse managers included the director of nursing, vice director of nursing, head nurse, and chief nurse; and f) nursing staff was registered nurses (RNs) only. Excluded from the study were professionals who were ineligible to participate in the survey, such as nursing students who decided to quit the study at any stage and for any reason.

For sample size estimation, the researcher performed a statistical power analysis. The effect size in this study is considered large using Cohen (1988) ’s criteria. With an α = 0.05 and power = 0.80, the projected sample size needed with effect sizes (G*Power 3.1.9.7) (Faul et al., 2007) reflected values for the t-test (N = 128), for the one-way analysis of variance (N = 200) and for correlation coefficient (N = 82). Therefore, the sample size was adequate for the main objective of this study. The data were collected using a stratified sampling method in which 20% was allocated to each group who were within the age range of 20 to 60 years old.

Instrument

The TCCNI-R was used to evaluate the participants’ perception of TCCN. TCCNI-R utilizes a 5-point Likert scale measurement with values ranging from 1 as “Strongly Disagree” to 5 as “Strongly Agree.” Former TCCNI-R has 25 items. In this study, we used the 19 items version with the original numbers of items based on confirmatory factor analysis results of the study by Yokotani et al. (2021). This instrument is available in Japanese and English. The Japanese version was used in this study.

Exploratory factor analysis, confirmatory factor analysis, and Cronbach’s alpha coefficient established validity and reliability. The root means square error of approximation (RMSEA) showed less than or equal to about 0.08, indicating the result as having a reasonable approximation error. The covariance structure analysis with a causal model revealed that the structural theory of TCCN had similar causal relationships to the model that has been hypothesized (Yokotani et al., 2021). The authors had obtained permission from its creator to use TCCNI-R in this study.

Data Collection

The 11 general hospitals in Chugoku-Shikoku Island, Japan, introduced a category of general care wards for advanced care, with a higher staffing standard, a patient-to-nurse ratio of 7:1. The “7:1” nursing placement standard is an accurate placement, with one nurse assigned to every seven patients on average over 24 hours. In addition, it is obligatory to display information on the number of nursing staff working during the day, evening, and night in each ward (Morioka et al., 2017; Japanese Nursing Association, n.d.). Those hospitals were contacted to obtain permission from their respective management administrators for their nurse managers and staff to participate in the survey. Survey Monkey© platform was used for this survey. The survey was conducted from October to December 2019. The researcher provided a letter of invitation to participate and disseminated information about the study together with the Survey Monkey URL to the Nurse Managers who agreed to distribute the document containing the URL for participants to access the survey instrument. After permission was obtained, a briefing document containing the URL of the questionnaire was distributed to nurse managers in each hospital. The document package included information for nurses’ cooperation in this survey. The nurse managers at each hospital distributed the survey briefing documents to their respective staff.

Data Analysis

This study tested the following hypotheses: a) Nurses with years of nursing experience show a high perception of TCCN, b) Nurses with experience of receiving education on caring in the nursing show a high perception of TCCN, and c) Nurse managers show a high perception of TCCN.

From the Survey Monkey© data, only 421 responses could be used for the study. Excluded were questionnaire responses that had missing data. Statistical analysis was conducted using IBM SPSS Version 21 (IBM Institute, Chicago, USA) and R (version 3.6.2, R Foundation for Statistical Computing, Vienna, Austria).

The mean and standard deviation with a 95% confidence interval (95% CI) was calculated. The ceiling and floor effects for each question item were confirmed with the basic statistics. Descriptive statistics were used to describe the gender, age, the experience of receiving education on caring in nursing (respondents judged whether they experienced receiving education on caring in nursing based on their subjectivity), employment position, length of experience as an RN, and educational background.

The mean for each factor of the TCCNI-R was calculated: Welch’s t-test was used to determine differences by the experience of receiving education on caring in nursing, and employment position (nurse manager or staff nurse); Welch’s analysis of variance (ANOVA) with posthoc tests of Games-Howell was used to determine the differences by the length of experience as an RN. To identify significant differences between specific groups, a pairwise comparisons post hoc test was performed. Games-Howell’s multiple comparison method is appropriate when using Welch’s ANOVA. The level of statistical significance was set at p<0.001. Statistical analyses were conducted using IBM SPSS Version 24 (IBM Institute) and R (version 3.6.2, R Foundation for Statistical Computing). The level of statistical significance was set at p < .001.

Ethical Consideration

Ethical approval was obtained from the Ethics Review Committee of Tokushima University Hospital (Approval Number 2914-3). When participants accessed the URL, information was made available about this study. This information included the details of the research and a request for their agreement or permission to participate and collect personal data. Participation was voluntary, and no penalty would be imposed if they decided to quit the study at any time. Personal information was kept confidential. All respondents’ data were secured in the researcher’s computer that was also accessible only through a password known only by the main researcher.

Nursing experience in years

When considering the length of experience as an RN, nurses with years of experience within the range of 20 to less than 30 years showed the highest TCCNI-R scores among the two groups. This indicated that nurses with a length of experience within 20 to less than 30 years were aware of the necessity of knowing patients as important to nursing. In explaining how years of experience can influence nurses’ thinking about caring in nursing, no related literature was found. However, some associated studies were found that examined the relationship between the periods of clinical experience and expressions of caring behavior (Aupia et al., 2018). Kato et al. (2017) revealed that nurses with ten or more years of clinical experience obtained a significantly higher score regarding the practice of nursing based on the theory of TCCN than nurses who had fewer years of clinical experience.

Jiang et al. (2015) found that nurses with a high-ranking job title had higher competency and feasibility. These results suggested that greater life experiences, years of work experience, and better competencies in practice enhance the promotion of more caring behavior among nurses. Lechleitner (2019) also found that nurses will be able to show more consideration for other people when they become older and gain new experiences.

In addition, a previous study (Takase, 2013) has reported that the relationships between the levels of nursing competence and the length of clinical experience were illustrated by a rapid increase in competence levels at the early stage of the nursing career. Therefore, length of experience as registered nurses in this study was classified into five groups of (a: 1- less than 5, b: 5- less than 10, c: 10- less than 20, d: 20- less than 30, e: more than 30), based on this idea, perception differences in TCCN theory were analyzed. As seen in these studies, support for the influence of years of experience in clinical practice is reflected well in the context of the TCCNI-R.

Experience of receiving education on TCCN theory

Caring in nursing is grounded on the fundamental concept that persons are caring and that nursing is a discipline and a profession (Boykin et al., 2001). In the nurse managers` group, the experience of receiving education on caring in nursing was 24%, and 24.3% in staff nurses in this study. Nurses who had received education on caring in nursing showed significant differences for Factor 2 (Technological Competency as Caring).

Three other factors, other than Factor 2, showed no significant difference, namely in Factor 1 (Nursing Expression as Caring), Factor 3 (Technology and Caring), and Factor 4 (Technological Knowing). However, the average scores of these three factors were about four points, indicating high scores. These scores reflect the respondents’ observance of professional ethics and occupational discipline, supported by items of the TCCNI-R, and as a result, their awareness of caring in nursing was considered high for TCCN.

Alternatively, Factor 2 (Technological Competency as Caring) is a factor that shows the basic concept of caring, that is, to know the patient more fully as a person intentionally and to respect the patient as a person in providing caring in nursing. The practice of caring in nursing requires an understanding of the other person. To that end, it is important to truly know the persons as participants in their care rather than as objects of care.

Nurses themselves may be able to share their own personal experiences. Similarly, in gaining clinical experience involving various patient situations and including their own life experience, it becomes easier to share humanistic caring practices with patients and their families. Learning nursing from situations of caring can enhance better appreciation of a person’s lived experience.

The finding that the caring-educated group scored significantly higher in Factor 2 meant that nurses educated on caring in nursing were highly aware of the theory of “Nursing as Caring” by Boykin et al. (2001) and of “TCCN” theory by Locsin (2005).

Furthermore, the group of nurses who were educated on technological competency as an expression of caring in nursing had significantly higher scores about the TCCN compared with the group of nurses who had not received the educational intervention. Knowledge about caring has been valued most by nurses and nursing students regarding caring in their practice (Aupia et al., 2018). Still, in another study, it was found that nursing students had the lowest scores in caring behavior when compared to practicing nurses. These findings highlighted the importance of education on the concept of caring, particularly for nursing students, before they start engaging in their clinical nursing practice (Aupia et al., 2018).

A study of in-service education programs based on TCCN theory found that such programs resulted in promoting patient understanding, and quality care management with the focus on patient-centered care, hoping to improve quality patient care services. There is a need for education on the practice of theory to enable better understanding and eventual practice of human caring in nursing. Vujanic et al. (2020) declared that it is necessary to stress the significance of caring theories during initial nursing education as well as during their further education. This educational activity supports the view that nurses need lifelong education and training in order to uphold the essential nursing values and ensure that caring remains vital in their nursing practice. It is desirable to have an in-service education system that allows nurses to grow through reflection as well as through actual nursing practice.

Differences in their positions in nursing practice

Participants’ employment positions were nurse manager (22.8%) and staff nurse (77.2%). It was found that nurse managers were more aware of the TCCN than were the staff nurses. Nurse managers were more aware of providing care using technology, as revealed in Factor 3 (Technology and Caring). Nurse managers also recognized the need-to-know patient needs through technology and provided care to the ever-changing patient’s condition as revealed in Factor 4 (Technological Knowing). Nurse managers use technology as an expression of caring from a compassionate perspective using multiple methods toward knowing persons, reflecting the use of nursing technology in order to know persons as caring. This finding shows that nurse managers were aware of the importance of using technology (Nakano et al., 2019) in order to know persons as caring. This study also showed that nurse managers were more aware of using technologies of care, as evidenced by their higher evaluation points when compared to the staff nurses.

About half of the nurse managers surveyed had participated in an in-service educational activity on TCCN. This experience was reflected in the nurse managers’ responses to the TCCNI-R. The nurse managers recognized that they could grow in their caring by learning about nursing, caring, and technology. It can be expected that these findings reflected the positive outcome of on-site education and human resource development as a staff management project for nurse managers. It is essential to underscore that nurse managers are responsible for improving the quality of nursing care throughout their assigned departments. Therefore, it is necessary that they show the direction of nursing for their staff and work together toward the same goal. In this situation, if it is only the nurse manager who will have an idea about caring in nursing, the goal of the department cannot be achieved. The staff that practice it must be engaged fully within the aims of the department. It has been documented that when nurse managers exemplify caring in nursing, the focus will lead to the development of the staff’s caring competencies. Education focused on caring should be positioned as consolidating the basis of nursing as a practice of technological competency as an expression of caring with required ideals inculcated in the educational process.

Limitations

This study had several limitations. The results of the study are considered to be limited due to differences in perceptions regarding caring education, which may include “course, training, or formal education” among the target population, and the fact that the target facilities were limited to acute care hospitals and data were not collected in various nursing areas, such as chronic care. In addition, the length of experience as a nurse manager was not asked during the survey.