Introduction

Caring is the essence of nursing practice and it is based on building an authentic relationship between nurses, patients and patients’ families [1]. Watson’s human caring theory better explains this concept [2–6]. According to Watson, human caring can be defined as the intensity of person-to-person relationship aiming at helping patients to maintain human dignity by achieving a wholeness of mind, body, and soul [5]. Her theory emphasizes the humanity of nursing because it promotes health better than simple medical cures [3]. Non-caring models are more task-oriented than psychological and social aspects; these models can lead to patient dissatisfaction as a main threat to quality care [7]. Watson’s theory was used in different fields of nursing [8,9]. This suggests that it is necessary to address and assess nurses’ caring experience to improve their awareness, as well as their caring outcomes [10].

Caring measures have already been developed and grounded by several studies in the Italian culture (see [11–15]). However, these validated instruments specifically refer to perceived caring behaviour [14,15] and to perceptions related to the dimensions of caring [11,13] in nurses and patients. Although these studies represent an important basis for caring research, any specific instruments providing for the measurement of self-reported caring competence cannot be found in the Italian nursing context. As caring efficacy can both improve patient satisfaction [16] and workers wellbeing [17], measuring nurses’ caring efficacy would allow for the development of strategies that could to reduce any weaknesses, thus helping nurses to better meet the actual needs of hospital patients, as well as to improve their care strategies.

As a result, by following on Watson’s theory, this study aimed at culturally adapting and validating Caring Efficacy Scale in Italy by testing psychometric properties of Coates’s original scale [18].

Literature review

On the basis of on Watson’s theory and Bandura’s self-efficacy theory [19], Coates [18] developed the Caring Efficacy Scale (CES). CES was developed as a tool for the measurement of nurses’ caring experience, including nurses’ abilities, attitudes and cognitions in establishing a caring relationship. The scale assesses the nurses’ perceived self-efficacy in conveying caring orientation and in reinforcing a therapeutic relationship with patients. In Italian context, several tools measuring human caring are available, such as Care-Italy questionnaire [13] and Caring Behavior Inventory (CBIta). These tools analyse caring by considering different factors: patients’ surveillance, professional relationships with patients, satisfying patients’ and family members’ practical and psychological needs, team consultation, and nurses’ emotions. However, nurses’ caring competencies are not included in these measurements. By taking this factor into account, Coates’ CES appears to be the most appropriated tool. The original scale included 46 items measuring caring attitudes, skills and behaviours by using a six-point Likert scale. The current version totally includes 30 items and is balanced both for positive and negative items. The sense of efficacy in establishing caring relationships with patients is considered as the main factor of the scale. The original scale had a good internal consistency (Cronbach’s Alpha value of .857). Successively, the scale was validated in Chile by Carmen Poblete-Troncoso et al. [20]. The authors found a three-factor structure: the first factor reflected the caring self-efficacy dimension and accounted for the most part of variance. The other two factors did not represent distinct dimensions, but they just captured the inverted items of the tool thus ratifying a one-factor structure of the scale. More recently, in their Australian validation Reid and his colleagues [21] revealed a two-factor structure that correspond to the positively and negatively worded items of the original scale. The two sub-dimensions were called Confidence to Care—namely confidence and ability to relate and care for patients—and Doubts and Concerns—a person’s uncertainty about his/her ability to relate and care for patients. In addition to Australia and Chile countries, CES has been used in United States [22] and its reliability has been therefore sufficiently demonstrated. Some studies have highlighted positive relationships with clinical competence [18]. Hence, the ability to develop and maintain caring relationships with patients is a crucial aspect in the current nursing practice [23].

Testing convergent and discriminant validity

The Caring Efficacy Scale was developed on self-efficacy theory [19,24], which refers to beliefs in one’s own capabilities to organize resources and execute courses of action to meet situational demands. In nursing, this sense of control can influence an individual’s ability to build up caring relationships with patients [18]. A recent study in the field has found that self-efficacy is positively correlated to the individual sense of coherence [25]. Sense of coherence (SOC) is an important source of self-efficacy and protection for human health [26]. SOC includes three components: comprehensibility, manageability, and meaningfulness [27]. Comprehensibility represents the cognitive component and can be defined as the extent to which individuals have confidence that life events are understandable and make sense to them. Manageability is the behavioural component, and represents the extent to which individuals have available resources to face situational demands. Meaningfulness is the motivational component and refers to the extent to which individuals are worthy of taking actions on demands, which make sense in their lives from an emotional perspective. However, Antonovsky [26] highlights the indivisibility of the construct. Literature indicated that SOC is a global orientation that conveys a feeling of trust about an individual’s ability to use cognitive, emotional, and instrumental strategies to cope with daily difficulties [28]. Individuals with high levels of sense of coherence better cope with difficult situations and environments [29,30]. Studies in nursing context showed that nurses’ sense of coherence had a positive correlation with professional functioning [31,32]. These findings denote that SOC can be considered as an individual’s self-efficacy measure. By following these premises, it is likely that sense of coherence will be associated with caring efficacy in nurses.

Study aim

The aim of the study was to culturally adapt, and validate the Caring Efficacy Scale by testing psychometric properties in a sample of Italian nurses.

Methods

Results

Testing for factor structure and convergent and discriminant validity

In line with Reid et al. [21], parallel test indicated the presence of two factors whose eigenvalues were significantly greater than 1 (p < .05). Item analysis was performed to assess items that provided the best representation of the two dimensions of the Caring Efficacy Scale. We retained items loading on their own reference construct with a factor loading equal or higher than .40. After content analysis, seven items were kept for Confidence to Care sub-dimension. Ten items were kept for the sub-dimension called Doubts and Concerns about nurses’ ability to develop caring relationships with patients. Items 8, 17, 21, 24, and 27 from Doubts and Concerns and items 2, 9, 14, 18, 19, 22, 25, and 28 from Confidence to Care were deleted because their factor loadings were lower than .40, or because they loaded at the same time on different factors. All the final 17 items loaded on their respective factors with factor loading ranging from .40 to .77. The two factors accounted for 35% of the variance. Inter-factor correlation indicated moderate correlations (r = -0.19) between the two factors. Communalities ranged from .23 to .58. The two-factor structure reflected the two mean dimensions of the Caring Efficacy Scale with a shortened measure (see Table 1 for all the items and the factor loadings).

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Table 1. EFA results: Items and factor loadings for the two-factor structure of Care Efficacy Scale.

https://doi.org/10.1371/journal.pone.0217106.t001

Then, the two dimensions of the shorted version of 17 items were subjected to CFA. The fit of this model was good (Table 2). The two-factor structure of 17 items was compared with two alternative models. The first included (i) a two-factor model with all the 30 items (i.e., 15 items for Doubts and Concerns and 15 items for Confidence to Care dimensions) from the original scale. The second included (ii) a one-factor structure in which all the 17 items from the shorted version loaded into a common factor. The results showed that both the model (i) and model (ii) fitted data significantly worse than the two-factor model with 17 items: Δχ2 (Δdf = 285) = 595.3, p < .001; Δχ2(Δdf = 1) = 219.9, p < .001, respectively (see Table 2 for fit indices).

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Table 2. Fit statistics of the hypothesized and the alternative models for the Mediterranean countries.

https://doi.org/10.1371/journal.pone.0217106.t002

Thus, the two-factor structure with 17 items was supported. Cronbach’s Alpha value was 0.84 for Confidence to Care, and 0.75, for Doubts and Concerns. The overall Cronbach’s Alpha for the scale was 0.75. These values are in line with those obtained by Reid et al. [21] and suggest a good reliability for the whole 17-item scale and their sub-dimensions. The mean value reported by nurses was 2.51 (SD = 1.03) for Doubts and Concerns, and 5.05 (SD = .70) for Confidence to Care.

Correlation analysis for convergent and discriminant validity showed that nurses’ SOC was positively correlated with Confidence to Care of the caring efficacy scale (r = .163, p < .05) and there was no evidence for a significant correlation with Doubts and Concerns (r = -.115, p >. 05).

Discussion

This study aimed at performing cultural adaptation and validation of the Caring Efficacy Scale in a sample of Italian nurses, on the basis of Watson’s Human Caring Theory [2]. The analysis of psychometric properties of the scale appears to be important because good caring relationships can improve patient satisfaction [16] and workers wellbeing [17]. In addition, no instrument measuring nurses’ perceived self-efficacy to convey a caring orientation and develop caring relationships with patients has been developed in the Italian language so far. In line with Reid et al. [21], results show a two-factor structure representing nurses’ Confidence to Care and Doubts and Concerns about their ability to develop caring relationships with patients. Nevertheless, cultural aspects could have influenced the intelligibility of some items. After a content analysis, seven items out of fifteen were kept for the Confidence to Care sub-dimension, and 10 out of fifteen items were kept for Doubts and Concerns. The deleted items (i.e., 8, 17, 21, 24, and 27) for Doubts and Concerns referred to different relationship problems with patients due to personal prejudices, conflicts, and to different culture of patients. Item 8 was too long and difficult to interpret, while items 17 and 27 were too general: they lacked of specific circumstances/problems. Item 21 was ambiguous because it implied that in front of a conflict, nurses did something to solve it. Finally, item 24 referred to relationship problems with patients of a different culture. It is likely that the recruited nurses did not experience similar problems because the percentage rate of foreign patients in the study hospital is less than 3%. As for Confidence to Care sub-dimension, the items 2, 9, 22, and 25 were deleted because they provided a description of nurses’ experience of caring that could not be representative of all the working situations. In effect, in some hospital units, nurses have a limited time to interact with patients because of a brief hospitalization. Items 18 and 19 were also removed because of redundancy. Finally, items 14 and 28 referred to communication aspects with patients, but they were too vague and were deleted from analysis. As expected, nurses declared to have low doubts and concerns about caring orientation and relationship with patients, and reported a high average value for Confidence to Care. These findings indicate that the two subscales are in line with the theoretical conceptualization of the construct, while supporting the results of Reid et al. [21].

The shortened version of 17 items provides for a better representation of the Caring Efficacy Scale in the Italian nursing context. In addition, the advantage of a reduced version allows for the study of the whole construct without making a questionnaire that is too long [46], thus reducing the time needed to complete it, as well as reducing potential non-response rates for participants.

Overall, the 17 items of the Caring Efficacy Scale constitute a robust measure of caring orientation displaying a Cronbach’s Alpha value exceeding the .70 [47] both for the two sub-dimensions and the whole scale. On the basis of these results, there are two distinct factors that best capture caring orientation in Italian nurses, as also shown by the Australian results [21].

As expected, the Caring Efficacy scale appeared to be correlated with a self-efficacy measure such as SOC. Specifically, SOC and Confidence to Care sub-dimension were positively correlated. This would mean that a nurse’s ability to use cognitive, emotional, and instrumental strategies to cope with professional difficulties [28] increases the likelihood conveying caring orientation and reinforcing a therapeutic relationship with patients [18]. This result is consistent with previous studies in nursing showing that nurses’ SOC has a positive correlation with professional functioning [31,32]. Finally, these findings support the theoretical and empirical assumptions [25,29,30] that suggest that SOC is an important coping source for nurses who have to face difficult situations with patients. SOC and Doubts and Concerns subscale were not significantly correlated. Even though an inverse correlation was expected, overall the results support the convergent and discriminant validity for the instrument.

Conclusion

The caring efficacy scale can be used to identify the main aspects that may affect the caring orientation of nurses and use this information to address education and training. Therefore, this tool can become a valuable resource for nurse managers that can efficiently measure the self-efficacy of the nurse on the basis of the human caring theory, thus identifying any weaknesses in providing care in order to improve patient’s health. In addition, this instrument can also be useful for future nurses [22] during clinical learning to improve the critical aspects of the therapeutic approach to the patient. According to Reid et al. [21], the scale can examine the effects of counselling programs and professional development to improve self-efficacy in nurses in health institutions.

Supporting information

Acknowledgments

We would like to thank all the nurses who took part in in this study.