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Applying Watson's Nursing Theory to Assess Patient Perceptions of Being Cared for in a Multicultural Environment

Suliman, Wafika A.; Welmann, Elizabeth*; Omer, Tagwa**; Thomas, Laisamma***

doi: 10.1097/JNR.0b013e3181c122a3
Original Articles

Background: J. Watson's (2002) caring theory addresses caring relationships among humans and the deep experiences of life itself. M. Leininger (1988) noted that caring is a universal phenomenon, which is likely to be perceived differently by patients and nurses if they come from different cultural backgrounds. Little is known about the patients' perception of "being cared for" in the Kingdom of Saudi Arabia, where most nurses in the workforce come from cultural backgrounds different from their patients.

Purpose: This study was designed to explore Saudi patient perceptions of important caring behaviors and those most frequently attended to by staff nurses in a multicultural environment.

Methods: A questionnaire survey was used to explore discrepancies between the perceived importance of caring behaviors and how frequently those caring behaviors were attended to by staff nurses. A probability sample of 393 patients was drawn from three hospitals in three different regions of Saudi Arabia. The Caring Behaviors Assessment instrument of S. N. Cronin and B. Harrison (1988) was used in data collection.

Results: Patients rated overall caring behaviors as important (97.2%) and frequently experienced (73.7%). The discrepancy between the importance of and frequency of attendance to caring behaviors by nurses was statistically significant (t = −4.689, p = .001).

Conclusions and Implications for Practice: The caring behaviors based upon Jean Watson's theory were valued by Saudi patients irrespective of their cultural differences with the caregiver. However, the frequency of caring attended to by nurses in teaching/learning and helping/trust behavior subcategories were rated lower. Such is most likely the result of culture differences and language barriers existing between patients and nurses in Saudi Arabia. Results showed that the carative factors in Jean Watson's theory were also applicable to patients in Saudi Arabia and that nursing professionals should base their care on such theory to meet patient needs.

RN, PhD, Associate Professor & Dean, College of Nursing-Jeddah, King Saud bin Abdulaziz University for Health Sciences;

*RN, PhD, Associate Professor and Head, Nursing Department, College of Nursing-Jeddah, King Saud bin Abdulaziz University for Health Sciences;

**RN, PhD, Assistant Professor and Associate Dean for Administrative Affairs, College of Nursing-Jeddah, King Saud bin Abdulaziz University for Health Sciences;

***RN, MSN, Lecturer, Nursing Department, College of Nursing-Jeddah, King Saud bin Abdulaziz University for Health Sciences.

Received: May 27, 2009 Revised: August 6, 2009 Accepted: August 20, 2009

Address correspondence to: Wafika A. Suliman, P.O. Box 22490, Riyadh 11426, Kingdom of Saudi Arabia. Tel: +966-2675-6599; Fax: +966-2675-5370 ext. 29210; E-mail:

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A variety of factors impact caring as an act of providing care to patients in any healthcare setting. Cultural differences between the care receiver and the caregiver are one of these. Such is especially true in the Kingdom of Saudi Arabia, where there is a major difference between the culture of the patient and of the nurse, as healthcare facilities rely on a nursing workforce that draws nurses from many cultures around the world.

Leininger (2002) viewed humans as inseparable from their cultural environment. She noted that caring is a universal phenomenon and suggested that perceptions of caring may vary with one's cultural background, which contributes culturally learned behaviors, actions, techniques, process, and patterns (Leininger, 1988). Knott (2002) emphasized that healthcare must be culturally sensitive due to the many factors which may conflict between cultures (e.g., conversational style, eye contact, personal space, touch, dietary preferences, and religious customs). Many studies have shown that patient perceptions of caring may be incongruent with staff nurse perceptions, especially when the patient and nurses come from different ethnic or cultural backgrounds and hold different interpretations of concepts related to care and caring (Cortis, 2000).

Watson (2002) developed a theory on human caring relationships and the deep human experiences of life. This theory suggests that caring is a different way of being human, present, attentive, conscious, and intentional. In Watson's theory, nursing is centered around helping the patient achieve a higher degree of harmony within mind, body, and soul, and this harmony is achieved through caring transactions involving a transpersonal caring relationship.

Brilowski and Wendler (2005) tried to define the concept of caring, using data mined from a comprehensive search of CINHAL data spanning 1982 to 2002. They identified a list of relevant attributes, which included relationship (identified as foundation of nursing); action, as caring always includes action; attitude, as the nurse needs to have a positive attitude to be considered caring; acceptance, the consideration that a fellow human being is worthy of respect; and variability, as caring depends on circumstances, the environment, and people involved. Attempts have been made to study patient participation in their own care from the point of view of caregivers and patients. Frank, Asp, and Dahlberg (2008, 2009) used a phenomenographic method to study patients' participation in their own care in an emergency department. Their first study (2008) from the view of caregivers showed that patient participation was mainly at the conditional discretion of caregivers. However, their second study (2009) from the patients' view identified three conception categories, namely "being acknowledged," "struggling to become involved," and "having a clear space." Sahlsten, Larson, Sjostrom, and Plos (2009) identified three categories and 10 subcategories of nurse strategies with an aim to optimize patient participation in nursing care. These researchers concluded that patients need nurse support to guide them to attain meaningful experiences, discoveries, learning, and development.

The meaning of caring and caring behaviors was found to differ by patient category. Patients with cancer gave more importance to affective "caring actions" (Radwin, Farquhar, Knowles, & Virchick, 2005), intensive care unit patients felt technical competency and compassion to be of equal importance (Wilkin & Slevin, 2004), and patients in the emergency ward considered the technical aspect of caring as most important (Wiman & Wikblad, 2004). Medical-Surgical patients were identified as placing greater caring emphasis on physical caring competencies and the ability to deliver a general feeling of well-being (Henderson et al., 2007).

Caring orientation has been studied and found beneficial for both patients and nurses. Drach-Zahavy (2009) found that patient-centered care was detrimental to the physical health of nurses. However, such an orientation was found beneficial to patients and seemed to protect nurses from physical health deterioration. Other studies have identified important techniques for enhancing caring. For example, reauthoring of a patient-problem-saturated story is one of three techniques where nurses at all levels may act as collaborators to enhance positively patient self esteem (Aloi, 2009).

Brunton and Beaman (2000) identified the following caring behaviors among the top 10 important behaviors reported by nurse practitioners: appreciating the patient as a human being, showing respect for the patient, being sensitive to the patient, talking with the patient, treating patient information confidentially, treating the patient as an individual, and listening attentively to the patient. However, Manogin, Bechtel, and Rami (2000) reported that women in childbirth perceived the following behaviors to be most critical to proper care: "helping me with my care until I am able to do it for myself" and "giving me treatment and medication on time and checking my condition closely."

On the basis of previous research, it is particularly important to research patient perceptions of being cared for in hospitals in Saudi Arabia using Jean Watson's caring theory and carative factors. As such, these were adopted as guiding principles for this study. Results may be used to guide nurses in providing a high standard of nursing care to Saudi Arabians.

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Aims and Research Questions

This study aimed to explore Saudi patient perceptions of important caring behaviors and how frequently such were attended by staff nurses in a multicultural environment. Findings may enable nursing managers to strike a more appropriate balance between patient perceptions and expectations and nurses' caring behaviors. Specifically, this research sought to answer the following questions:

  1. What are the important caring behaviors as perceived by patients?
  2. How frequently are such caring behaviors attended to by staff nurses?
  3. Is there a discrepancy between patient perceptions of important caring behaviors and those attended to by staff nurses?
  4. Is there a correlation between patient gender and perceptions of important caring behaviors and those frequently attended to by staff nurses?
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A survey was designed to explore perceptions of important caring behaviors and those frequently attended to by staff nurses in a multicultural environment.

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Patients admitted to medical and surgical wards in three hospitals in Saudi Arabia in 2008 were invited to participate in this study. Each hospital was located in a different geographical region (Central, Western, and Eastern) operated by National Guard Health Affairs. These hospitals have passed accreditation under Joint Commission International standards at the excellent performance level.

The hospitals included in this study employ nurses from diverse national backgrounds, including nurses from South Africa, the Philippines, Malaysia, Pakistan, Mainland Europe, the United Kingdom, the United States, Jordan, Egypt, and Lebanon. Linguistic background diversity makes it necessary to mandate the use of English in these hospitals as the lingua franca, although nearly all patients are native Arabic speakers.

The sample was selected using a probability sampling design that combined cluster, systematic, and stratified sampling. Participants were selected from three clusters (one hospital in each region) in a systematic way (i.e., every other patient) that ensured both genders and wards (medical and surgical) were equally represented.

The sample was planned to include 396 patients, with 132 patients from each region and half from surgical and another half from medical wards. The sample also considered gender to ensure equal representation in the sample of men and women. To be eligible for the study, adult patients needed to be 20-50 years old, be admitted to the general medical or surgical wards for more than 2 days for the first time during data collection, and be fully conscious (i.e., surgical patients were eligible within 2 days of surgery). The final number of valid participants was 392, with a response rate of 98.9%.

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Data Collection

Data were collected by two research assistants in each of the three regions. One research assistant collected data from patients in surgical wards, and the other collected data from patients in medical wards. Research assistants were all trained in conducting systematic sampling in compliance with the inclusion and exclusion criteria under "participants." The questionnaire was distributed and administered by paper and pencil for patients who were assigned even numbers on the admissions list. Patients were offered assistance in filling out the questionnaire if they were unable to read and/or write.

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The Caring Behaviors Assessment (CBA) of Cronin and Harrison (1988) was adapted to assess nursing behaviors in relation to patient-reported caring experiences. The following seven CBA subscales were used: humanism/faith-hope/sensitivity, helping/trust, expression of positive/negative feelings, teaching/learning, supportive protective corrective environment, human needs assistance, and existential/phenomenological/spiritual forces.

The CBA is a 63-item self-reported questionnaire. Patients used a 5-point Likert-type scale ranging from 1 (little importance) to 5 (much importance) to indicate the importance of each survey item.

The questionnaire was based on Jean Watson's carative factors. Reliability was evaluated by examining the internal consistency of nursing behaviors against Cronbach's alpha. The alpha coefficient for the seven subscales demonstrated acceptable reliability (with a Cronbach's alpha ranging from .66 to .90). Face and content validity of the CBA was established in accordance with the suggestions of Cronin and Harrison (1988).

In this study, the CBA was adopted as mentioned earlier. However, a second 5-point Likert-type scale was added to assess frequency with which each caring behavior was attended to by the staff nurse. This additional scale ranged from 1 (least frequently attended) to 5 (most frequently attended). The instrument was translated into Arabic for study purposes, with content validity of the translated version established by a bilingual group of five experts. The reliability of the Arabic language version was evaluated after data collection. The Cronbach's alpha values for the importance and frequency of attendance scales were .958 and .983, respectively.

The instrument should take around 40 minutes to fill out, if the patient is able to read and write. Sixty minutes may be required if the patient requests the assistance of others (i.e., the study data collector).

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Ethical Considerations

Permission to conduct this study was granted by the institutional review board. Participation in the study was voluntary. Patients were given a written consent form and assured anonymity and confidentiality.

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Data Analysis

Descriptive analyses included frequencies, percentages, and mean scores for caring behavior items and subscales. Inferential statistics included the following: a Wilcoxon signed-rank test to compare the importance of caring behaviors with nurse attendance frequency and a Mann-Whitney U test to assess how participant gender may influence perceptions of relative caring behavior subscale importance and perceptions that said caring behaviors were attended to by nurses. The significance level was set at p < .05, with the cutoff point for the two scales set at 3.

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Patient Perceptions of Important Caring Behaviors

The percentage of participants responding to the overall CBA and the individual subscales was obtained (Table 1). The percentages in Columns 4 and 5 were combined together to enhance the presentation of results. A strong majority of participants (97.2%) rated overall caring behaviors as important. The most important caring behavior subscales included humanism/faith-hope/sensitivity (96.7%), supportive/protective/corrective environment (95.7%), and human needs assistance (95.4%).



On the basis of a single-item analysis, participant mean scores on caring behavior were calculated, with a range that fell between 2.89 and 4.80. As shown in Table 2, the range of mean scores of the top 10 caring behaviors was ranked in terms of importance and fell in a narrow range (4.74 to 4.80). The range of mean scores for the 10 caring behaviors ranked as least important was considerably wider (2.89 to 4.37).



Five of the top 10 important caring behaviors, ranked first, third, fifth, sixth, and seventh, corresponded with the supportive/protective/corrective environment subscale, including "gives me pain medication when I need it" (M = 4.8), "is gentle with me" (M = 4.79), "offers things to make me more comfortable" (M = 4.78), "leaves my room neat after working with me" (M = 4.78), and "is cheerful" (M = 4.77).

Four of the 10 least important behaviors, ranked seventh, eighth, ninth, and tenth, correspond with the helping/trust subscale. They included "introduce themselves to me" (M = 4.27), "asks me what I would like to be called" (M = 3.34), "visits me if I move to another hospital unit" (M = 3.2), and "talks with me about my life outside the hospital" (M = 2.89).

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Perceptions of How Often Nurses Attend to Caring Behaviors

The percentage of participants responding to the frequency of attendance for both the overall CBA and individual subscales was obtained (Table 1). By combining the percentages in Columns 4 and 5, more than 70% of the participants rated overall caring behaviors as more frequently experienced. Participant reports of subscales that occurred more frequently ranged from 56.4% to 78.5%. Frequency of caring corresponded to the nature of the behavior: For example, human needs assistance received the highest rating (78.5%), whereas behaviors reflected teaching/learning forces received the lowest rating (56.4%).

On the basis of a single-item analysis, participant reports of more frequent and less frequent caring behaviors were calculated. All caring behaviors received a mean score higher than 3.

As shown in Table 3, the highest mean scores for the 10 caring behaviors denoting more frequent attendance and the lowest mean scores for the 10 caring behaviors denoting less frequent attendance fell within a narrow range (4.15 to 4.43 and 3.25 to 3.62, respectively).



Four of the more frequently attended behaviors ranked second, sixth, eighth, and ninth corresponded with the supportive/protective/corrective environment subscale. Such included "gives me pain medication when I need it" (M = 4.34), "leaves my room neat after working with me" (M = 4.22), "is gentle with me" (M = 4.19), and "respects my modesty" (M = 4.19).

Five of the less frequently attended behaviors that ranked fourth, fifth, sixth, eighth, and ninth corresponded with the teaching/learning subscale included "encourages me to ask questions about my illness and treatment" (M = 3.55), "helps me plan ways to meet goals" (M = 3.55), "answers my questions clearly" (M = 3.54), "asks me questions to be sure I understand" (M = 3.37), and "asks me what I want to know about my health/illness" (M = 3.34).

Four items that ranked second, third, seventh, and tenth among the less frequently attended behaviors corresponded with the helping/trust subscale included: "asks me what I like to be called" (M = 3.59), "visits me if I move to another hospital unit" (M = 3.58), "talks to me about my life outside the hospital" (M = 3.51), and "introduce themselves to me" (M = 3.25).

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Discrepancy Between Patient Perceptions of Most Important Caring Behaviors and Those More Frequently Attended to by Staff Nurses

A Wilcoxon signed-rank test was used to examine the discrepancy between patient perceptions of the most important caring behavior subscales and those most frequently attended to by staff nurses. As shown in Table 1, results indicated significant differences with respect to the importance of overall caring behaviors (t = −4.689, p < .001) and all individual subscales (p < .001).

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Correlation Between Patient Gender and Perceptions of Caring Behaviors

A Mann-Whitney U test was used to assess the significant differences in caring behaviors in relation to patient gender. As shown in Table 4, results indicated a significant difference in overall caring behaviors in terms of importance (p < .001) in favor of women and in terms of all caring behaviors subscales (with the exception of existential/phenomenological/spiritual forces) in favor of women (p < .05). Furthermore, findings indicated that female patients rated five caring behavior subscales as statistically more frequently attended to by nurses than did male patients (p < .05).



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This study provided evidence that Saudi patients recognized overall caring behaviors and each individual subscales as important. The humanism/faith-hope/sensitivity, supportive/protective/corrective environment, and human needs assistance subscales were rated as the most important of all caring behaviors.

The humanism/faith-hope/sensitivity subscale deals mostly with higher order patient needs. Patients who feel stressed and frightened need to have their self-esteem boosted. Thus, nurses must instill hope in patients when making their presence felt. Nurses must also be sensitive to patient feelings and praise patients when appropriate. Liu, Mok, and Wong (2006) emphasized that nurses need to find positive meanings, possibilities, and hope in situations that may appear bleak. It is also clear that, through caring, nurses can help shape patients' illnesses as positive experiences in which patients experience respect, dignity, comfort, and the feeling that the caregiver is there for them. Support for this act of caring is provided in the literature. Riccio (2000) found the patients' desire to have nurses spend more time with them and share feelings. These all lead to patients fulfilling higher order needs and self-actualization at that particular stage of life, and Saudi patients have indicated these caring behaviors to be important.

The supportive/protective/corrective environment subscale encompasses the basic needs of a patient, which includes basic information about his or her daily routine, delivering basic physical care comfort (i.e., pain medication, backrubs, and being gentle), ensuring a neat environment, and being cheerful. These items were rated as most important by patients (see Table 2).

Lynn (2007) also identified these items from the mentioned subscale as the most important caring behaviors. Lynn showed that patients are very clear about what they want from nurses in terms of specific knowledge, attitudes, and behaviors. Another group of patients emphasized the importance of the nurses conveying messages that nothing in the care of the patient was too much trouble. Nurses should be compassionate, be engaged in the care of the patient (i.e., smiling, using humor, using gentle touch, and being kind, friendly, and warm), and consult with the patient and his or her family. This type of engagement in patient care was also supported by Liu et al. (2006), who found that when cancer patients described caring behavior, such behavior reflected caring attitudes that included greeting patients, being affable, speaking in a gentle voice, and approaching patients with a smile.

The subscale related to human needs assistance encompasses the technical aspects of nursing care. This subscale was rated as the third most important by Saudi patients, a finding supported by Hayes and Tyler-Ball (2007) who noted the primary importance to patients of this subscale.

Discrepancies between patient perceptions of most important caring behaviors and those most frequently attended to by the nursing staff indicate that most items attended to by nurses less frequently (five items ranked fourth, fifth, sixth, eighth, and ninth and four items ranked second, third, seventh, and tenth) correspond with the teaching/learning subscale and helping/trust subscale, respectively. This was also found by a study on patient satisfaction receiving home nursing care (Riccio, 2000), in which patients rated the professional aspects of nurses very high but were dissatisfied with their instructions.

Although the mentioned teaching/learning and helping/trust behaviors were categorized as less frequently attended to, they still scored above 3 out of a total possible score of 5, which is satisfactory.

The researchers believe that, in this multicultural environment, the teaching/learning and helping/trust subscales require effective communication between patient and nurse and a relationship of trust based on truth and respect. This is in line with a study by Liu et al. (2006), in which patients reported that they required adequate explanations and that these explanations helped them feel more secure and safe and less anxious. Patients also reported that these explanations enhanced communication.

However, nurses must first understand the patient's language. In Saudi Arabia, nearly all patients are native Arabic speakers, but they are cared for primarily by nurses who know little Arabic. Language is an integral part of how culture functions. A study in Saudi Arabia, for example, found that tension developed between nurses, patients, and families when nurses were not fluent in Arabic. This lack of fluency resulted in miscommunication that could negatively influence the nurse-patient relationship (Halligan, 2005). According to Green-Hernandez and Quinn (2004) several studies have shown that, if a nurse is able to speak a few words or phrases of the patient's language, the patient tends to interpret that as a desire to connect. Such lowers communication barriers and invites trust.

The findings indicated that female patients perceived six caring behavior subscales as more important than did their male counterparts. They also perceived five caring behavior subscales to be more frequent. The literature offers no explanation for such findings. Perhaps women rated these caring behavior subscales as more important because they have traditionally been the source of care for their immediate family and may, therefore, expect similar care when they are dependent on others. In addition, Arab men tend not to show or verbalize their emotions, which may influence their perceptions of caring.

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Study Limitations

The length of the assessment tool and the potential burden of such on patients represented a potential limitation of this study. In addition, patient perceptions could be supplemented in future studies by nurse perceptions and on-site observations with regard to how frequently caring behaviors are attended to by nurses.

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This study demonstrated that Saudi patients perceived overall caring behaviors as more important (97.2%) than frequently occurring (73.7%), with a statistically significant difference for men and women. The supportive/protective/corrective environment subscale was rated as most important and most frequently experienced. Teaching/Learning was important but less frequently experienced.

To improve the frequency of attending to the teaching/learning caring behaviors by staff nurses who cannot speak the language of their patients, we recommend that nursing management strive to provide more language assistance through proficient bilingual interpreters. This may help alleviate language communication barriers and enhance the effectiveness of helping/trust caring behaviors as well. The association between nurses' cultural diversity and the frequency of attending to the caring needs of patients warrants further research.

Jean Watson's theory was developed in a Western cultural setting. This study provides evidence of the applicability of Watson's theory in Middle Eastern cultures. This emphasizes the suitability of using this theory as a basis for educational program curricula for nursing students and a basis for the provision of nursing care in hospitals targeted in this study.

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This research was supported by a grant from the King Abdullah International Medical Research Center at King Saud bin Abdulaziz University for Health Sciences (RC07/007). The authors wish to express appreciation for this grant.

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caring behaviors; Jean Watson's theory; nursing care; patient perception

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