caring behaviors as perceived by nurse practitioners

282 VOLUME 16, ISSUE 7, JULY 2004 JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 283

RESEARCH

Caring Behaviors As Perceived by Nurse Practitioners

Ann Green, PhD, RN,CS, A/G/FNP

INTRODUCTION

Nurse practitioners (NPs) provide essential health care to a variety of populations in the United States. As the number of NPs continues to increase across the nation, outcomes of their care will become an increasing concern as quality of and access to primary care necessitate accountability for practice and reimbursement for services provided (Mundinger et al., 2000; Sederer, Dickey, & Eisen, 1997). Numerous studies have demonstrated that patients are highly satisfied with primary care provided by NPs (Courtney & Rice, 1997; Ferri, 1996; Hamric, Worley, Lindbak, & Jaubert, 1998; Knudtson, 2000; Lane, 1998; Langer & Hurelmyer, 1995; Larrabee, Ferri, & Hartig, 1997; Larson & Ferketich, 1993; McCracken, Klock, Mingay, Ashbury, & Sinclair, 1997; Murphy & Ericson, 1995).

NPs come from a background in which human caring is viewed as the cen-tral focus and essence of nursing and in which therapeutic interpersonal rela-tionships promote helpful and trusting interactions with patients (Watson, 1988). Within a human caring framework the NP can transcend the physical aspect of the patient and access the inner being, which has the capacity to expand human consciousness, to transcend the moment, and to potentiate healing (Watson). These caring relationships are professional, intentional, and knowledge-based and are ongoing sources that liberate and restore the NP’s ability to alter outcomes (Boykin & Schoenhofer, 1997; Duffy, 1992). The Caring Behaviors Inventory (CBI) used in this study was based on Watson’s (1985) carative factors (Wolf, Giardino, Osborne, & Ambrose, 1994).

The focus of outcomes research has been primarily medical, with emphasis on both cost and quality. NPs need to be able to explain the impact of care by using measures of outcomes that reflect nursing practice (Moritz, 1991), to be assertive in defining the uniqueness of interventions they provide, and to document the effectiveness of these interventions. In addition to fostering further research on caring as a unique contribution that NPs make to patient care, identifying these characteristics will help NPs gain insight into their own caring behaviors and further understand caring as a directive of NP practice.

As part of a larger study to predict patient satisfaction with care provided by NPs, nurse practitioners’ perceptions of their own caring behaviors and demo-graphics of the NPs were investigated. The process responsible for quality care outcomes has several components that must be considered when evaluating the totality of NP care, and identifying this process was the purpose of this study. These components are NPs’ perceptions of their own caring behaviors; setting where the service is rendered; and gender, ethnicity, marital status, age, educa-tion, employment environment, and practice specialty of the NP.

PurposeTo investigate nurse practitioners’ (NPs’) per-ceptions of their own caring behaviors and to examine NPs’ demographics as a function of their caring behaviors.

Data SourcesResponses to the Caring Behaviors Inventory (CBI) and a demographic inquiry from 348 NPs in Louisiana.

ConclusionsCBI mean scores and subscale scores were high for all 348 NPs. No statistically significant dif-ference was found between male NPs’ and female NPs’ total mean CBI scores or between urban or rural total mean CBI scores. The interaction between nurse gender and area of practice was not statistically significant.

Implications for PracticeNPs often work in clinic situations where productivity is the most valued characteristic and where little time is afforded for identifying caring behaviors of the NP and/or establish-ing a caring relationship with the patient. NPs must be extremely conscious of the need not to “throw out the baby with the bathwater” and sacrifice characteristics that are inherent in nursing for those emphasized in primary care practice. As their responsibilities in the health care setting continue to expand, NPs must continually evaluate and validate their roles to ensure quality care that satisfies patients.

Key WordsNurse practitioner, caring, perceptions, behaviors.


REVIEW OF LITERATURE

The phenomenon of caring has been studied philosophi-cally (Gaut, 1984; Mayerhoff, 1970; Ray, 1984), theoreti-cally (Leininger, 1981; Swanson, 1991; Watson, 1985), ethically (Cooper, 1991; Noddings, 1984; Parker, 1990), ethnographical-ly (Leininger, 1981, 1984), and in numerous clinical situations (Beck, 1995; Benner, 1984; Bertero, 1999; Brown, 1991; Duffy, 1992; Ekstrom, 1995, 1999; Lucke, 1999; Milne & McWilliam, 1996; Mullins, 1996; Schoeder & Maeve, 1992; Uhl, 1991; Wolf et al., 1994). Caring as a construct for nursing education has also been researched (Bevis, 1978; Boykin & Schoenhofer, 1993; Watson, 1988). Most of the explorations were phenomenologi-cal or naturalistic and focused on the extrapolation of caring characteristics from interpersonal nursing observations and from encounters with other nurses and with patients (Benner, 1984; Duffy, 1992; Jacox, Bausell, & Mahrenholz, 1997; McCall, Thomas, & Bond, 1996; McCracken et al., 1997; Miller, 1990; Oberst, 1984; Parker, 1990; Schoeder & Maeve, 1992; Uhl, 1991; Webb & Hope, 1995).

To guide nursing practice among patients who have AIDS or who are HIV-seropositive, Mullins (1996) identified nurses’ caring behaviors that are perceived as desirable by these popu-lations. Ekstrom (1995) explored the possible differences in perceived nurse caring according to nurse and patient gender. Main effects (p < .05) were demonstrated for gender of nurse on nurses’ and patients’ Importance of Caring (F[1,141] = 5.80, p < .05; F[1,141] = 5.01, p < .05, respectively), with both being lower when the nurse was male. Ekstrom concluded that there are no perceived differences in actual nurse caring provided by male and female nurses, even though gender stereotypes remained regarding certain aspects of caring.

Duffy (1992) studied the relationship between nurses’ car-ing behaviors and the selected outcomes of patient satisfaction, health status, and nursing care costs in 86 hospitalized medical and/or surgical patients and found a statistically significant posi-tive relationship between nurses’ caring behaviors and patient satisfaction (r = .46, p < .001). Wolf and colleagues (1994) used an ex post facto design and the CBI to investigate the relation-ship between nurse caring and patient satisfaction. They found a statistically significant positive correlation between nurse caring and patient satisfaction with nursing care (r = .78, p < .001).

Brunton and Beaman (2000) used the CBI and a demo-graphic questionnaire to explore the relationship between demo-graphic variables, environmental factors, and NPs’ perceptions

of their own caring behaviors. The researchers explored the relationship of the CBI’s five caring dimensions to demographic variables, including sex, marital status, race, basic nursing educa-tion, highest level of education, years of practice, employment environment, specialty, and collaboration with physician. The only significant relationship between the NPs’ demographic variables and their perceptions of their caring behaviors was that between time as an NP and positive connectedness (r = .19, p = .041), indicating that the longer the NPs had been in practice, the more frequently they reported behaviors that made up the caring dimension of positive connectedness. No statistically sig-nificant relationship was found between environmental factors (setting, employment environment, and specialties) and the NPs’ perception of their caring behaviors. Andrews, Daniels, and Hall (1996) and Beck (1999) explored tools to identify and measure caring. Andrews and colleagues concluded that the CBI was the most user-friendly due to the language consistency, short time needed for completion, instructions that are easy to read and understand, and easy analysis of the results. Beck noted that only in the CBI was caring conceptualized as an interpersonal inter-vention—that is, as an intimate exchange between the nurse and patient that can enhance the growth of both parties.

METHOD

The research design consisted of two phases: (a) descrip-tive and (b) predictive modeling. This article focuses on the descriptive phase of the study, which was designed to explore the perceptions of caring behaviors by male and female NPs in rural and urban settings and to identify the demographics of the NPs. Demographic variables included ethnicity, marital status, age, basic education, highest level of education, employment environment (clinic affiliation), practice specialty, and physician on-site (see Table 1). The second phase of the study determined predictors of patient satisfaction with NP care.

INSTRUMENTATION

This study used the modified CBI to measure perceptions of NPs’ caring behaviors. Wolf developed the 43-item Likert-scaled CBI in 1981. Further development of the tool identi-fied the dimensions of nurse caring through exploratory factor analysis of 278 nurse responses and 263 patient responses to the revised 43-item CBI (Wolf et al., 1994). The CBI is grounded in Watson’s (1985) theory of transpersonal caring and included 43 items with a 4-point Likert scale used to elicit caring responses. Test-retest reliability for the modified CBI on the nurse sample was r = .96, with an alpha coefficient of .83. The internal consistency reliability on the combined nurse and patient sample was .96. A panel of four nurse experts estab-lished content validity, and construct validity was established by comparing nurse and patient responses on total scores of both groups. Internal consistency reliability on the combined nurse and patient sample was .96. An unpaired t test indicated

AuthorAnn Green, PhD, RN, BC, A/G/FNP, is a Family, Adult, and Geriatric Nurse Practitioner at the Sterlington Rural Health Clinic in Sterlington, Louisiana, and an Associate Professor in the Graduate Family Nurse Practitioner Program at Northwestern State University in Shreveport, Louisiana.


Table 1 CBI Mean Score, Standard Deviation, and Minimum and Maximum Mean Score by Demographic Characteristics (N = 348)

Characteristic n M SD Min. Max.

Gender Male 31 5.38 .31 4.74 5.93 Female 317 5.45 .34 3.98 6.00 Total 348 5.44 .33 3.98 6.00 Ethnicity No response 1 5.07 5.07 5.07 European American 319 5.44 .33 3.98 6.00 African American 20 5.45 .36 4.40 5.98 Other 8 5.60 .34 4.95 6.00 Total 348 5.44 .33 3.98 6.00Marital status Married 261 5.46 .33 3.98 6.00 Widowed 5 5.44 .48 4.88 6.00 Divorced 42 5.43 .33 4.64 5.95 Single 39 5.37 .34 4.40 5.93 Total 347 5.44 .34 3.98 6.00Age 26–35 73 5.40 .38 3.98 6.00 36–45 125 5.48 .32 4.74 6.00 46–55 125 5.42 .34 4.33 6.00 56–65 23 5.55 .22 5.07 5.93 66–75 1 5.02 5.02 5.02 Total 347 5.44 .33 3.98 6.00Basic education Associate degree 39 5.46 .32 4.95 5.98 Bachelor’s degree 140 5.40 .33 4.33 6.00 Diploma 54 5.51 .30 4.88 5.98 Master’s degree 115 5.45 .36 3.98 6.00 Total 348 5.44 .33 3.98 6.00 Highest education level Bachelor’s degree 16 5.60 .24 5.12 5.93 Master’s degree 304 5.43 .33 3.98 6.00 Nursing doctorate 5 5.75 .19 5.45 5.91 Nonnursing docctorate 10 5.31 .49 4.33 5.98 Certificate 4 5.65 .27 5.40 5.95 Total 339 5.44 .33 3.98 6.00Area of practice Rural 97 5.45 .33 4.45 6.00 Urban 247 5.43 .33 3.98 6.00 Total 344 5.44 .33 3.98 6.00 Employment environment Rural health clinic 50 5.41 .30 4.74 6.00 Physician’s office 94 5.47 .31 4.40 6.00 Group practice 34 5.46 .32 4.81 5.98 University hospital clinic 35 5.34 .35 4.67 5.98 Regional hospital clinic 41 5.31 .32 4.87 6.00 Community hospital clinic 16 5.24 .40 4.33 5.79 Other 78 5.47 .36 3.98 5.98 Total 348 5.44 .33 3.98 6.00


Table 1, continued

n M SD Min. Max.Practice specialty No response 3 5.44 .43 5.00 5.86 Family 206 5.42 .31 4.45 6.00 Pediatric 44 5.54 .29 4.81 6.00 Women’s health 33 5.46 .38 4.33 5.98 Adult health 26 4.45 .28 4.81 5.98 Geriatrics 6 5.07 .26 4.79 5.52 Acute care 19 5.39 .54 3.98 5.98 Neonatal 8 5.65 .24 5.33 5.95 Total 345 5.44 .33 3.98 6.00Physician on-site No 72 5.43 .35 4.40 5.98 Yes 251 5.44 .34 3.98 6.00 Sometimes 20 5.54 .25 5.12 6.00 Total 343 5.44 .34 3.98 6.00

Note. CBI = Caring Behaviors Inventory.

that the groups were different at baseline (t = 3.01, df = 539, p = .003; Wolf et al.).

An exploratory factor analysis using principal components method with varimax rotation resulted in six factors, with eigenvalues greater than 1, constituting 56.8% of the total variance. Conceptual fit between the items in each factor was determined, one item was deleted, and five dimensions resulted, which included (a) respectful deference to the other, (b) assurance of human presence, (c) positive connectedness, (d) professional knowledge and skill, and (e) attentiveness to the other’s experience. Alpha coefficients for the five dimen-sions were (a) .89, (b) .92, (c) .85, (d) .82, and (e) .8 (Wolf et al., 1994). Wolf ’s modified CBI, used for the current study, included 42 items with a 6-point Likert scale. Wolf created the 6-point Likert scale to increase variability of responses: (a) 1 = never, (b) 2 = almost never, (c) 3 = occasionally, (d) 4 = usu-ally, (e) 5 = almost always, and (f ) 6 = always. The scores of the 42 items were calculated for a total mean score and stan-dard deviation. For the five subscales, responses were totaled and reported as the subscales’ mean and standard deviation. To allow the CBI to fit studies with different populations of nurses or patients, Wolf and colleagues (1994) gave permis-sion to modify the CBI’s directions to participants.

Cronbach’s alpha coefficients for the six subscales and/or overall scale scores have been reported by other researchers who have used the CBI. Urden’s (1996) study revealed high coefficient scores for the subscales: (a) Respectful Deference to the Other, .99; (b) Assurance of Human Presence, .96; (c) Positive Connectedness, .96; (d) Professional Knowledge and Skill, .93; and (e) Attentiveness to the Other’s Experience, .93. The alpha coefficient for the overall scale score for Urden’s study was .98. The Cronbach’s alpha coefficient for the CBI overall scale score for Coogan’s (1996) study was .95 and for Swan’s (1998) study was .96.

DESCRIPTION OF THE SAMPLE

A list of all licensed NPs in the state of Louisiana was obtained from the Louisiana State Board of Nurses. All 689 licensed NPs, 66 (9%) male and 623 (91%) female, were invited to participate in the study and were mailed a letter of solicitation, an instruction sheet, a statement of consent, the demographic questionnaire, and the CBI, along with a self-addressed, stamped envelope for return of the questionnaires. Three hundred and forty-eight (51%) of the NPs, 31 (8.9%) male and 317 (91.1%) female, returned CBIs, with representation comparable to the initial 689 NPs invited to participate in the study. The major-ity of the 348 NPs were European American (91.7%), women between the ages of 36 and 55 (71.8%), and married (75%). Most of those practitioners had a master’s degree in nursing (87.4%), were family NPs (59.2%), and practiced in an urban setting (71%) in a physician’s office (27%) with the physician on-site most of the time (72.1%). There was a reported mean duration of practice of 72.4 months (SD = 93.16).

Five CBIs were returned with only a handwritten note stating that further involvement in the study would not be possible. The primary reason given for declining was that the NPs’ collaborat-ing physician did not want them to take the time from a busy clinic practice to complete the CBI or to obligate themselves to collecting data from patients, a process that would occur in the second phase of the larger study.

Protection of Participants The study met the requirements for exemption, and the

Internal Review Board of the university attended by the researcher granted written permission. In addition, permission to conduct the study was granted by oral and/or written consent of the authorities in the different clinical settings where the study was conducted. The study was noninvasive, and participants


were informed of their anonymity and their right to participate or not to participate in the study.

ANALYSIS

To analyze the present study, the Statistical Package for the Social Sciences was used. Descriptive statistics (frequency and percentage) were obtained on the demographics for all partici-pating NPs (348). CBI mean, standard deviation, and mini-mum and maximum mean scores by NP demographics were calculated. CBI subscales mean, standard deviation, and mini-mum and maximum scores for the 348 NPs who responded were also obtained. Analysis of variance (ANOVA) was used to determine if the CBI total mean scores differed according to demographics.

FINDINGS

To determine the relationships of the NPs’ demographics to their perceptions of their own caring behaviors, CBI mean scores (ranging from a possible 1 to 6) were calculated for each of the demographic variables (see Table 1). CBI total mean scores were high, 3.98 to 6.00 (M = 5.44, SD = .33). Female NP CBI total mean scores were M = 5.45 (SD = .34), and male NP CBI total mean scores were M = 5.38 (SD = .31).

Means, standard deviations, and ranges of scores on the CBI subscales for the 348 NPs who responded were as follows: (a) Respectful Deference to the Other (12 items; M = 5.64, SD = .32); (b) Assurance of Human Presence (12 items; M = 5.48, SD = .35); (c) Positive Connectedness (9 items; M = 5.16, SD = .45); (d) Professional Knowledge and Skill (6 items; M = 5.39, SD = .45); and (e) Attentiveness to the Other’s Experience (3 items; M = 5.46, SD = .41). For the 348 responding NPs, the Respectful Deference to the Other subscale total mean scores ranged from 4.08 to 6.00; the Assurance of Human Presence subscale total mean scores ranged from 4.08 to 6.00; the Positive Connectedness subscale total mean scores ranged from 3.78 to 6.00; the Professional Knowledge and Skill subscale total mean scores ranged from 3.83 to 6.00; and the Attentiveness to the Other’s Experience subscale total mean scores ranged from 4.00 to 6.00 (see Table 2). Cronbach’s coefficient alpha for the 42-item CBI was .94.

ANOVA was used to determine if the CBI total mean scores differed according to the NPs’ demographics. Main effect results of the ANOVA of CBI total mean scores by the NPs’ gender and area of practice (rural and urban) revealed no statistically significant difference between total mean CBI scores of male and female NPs, F(1, 340) = 1.51, p = .22. No statistical difference was found in CBI total mean scores from urban and rural clinics, F(1, 340) = 0.30, p = .59. Also, the interaction between nurse gender and area of practice was not statistically significant, F(1, 340) = 0.76, p = .38 (see Table 3).

Main effect results of the ANOVA of CBI total mean scores of the NP employment environment and practice specialty revealed no statistically significant difference in total mean CBI scores of NPs working in a variety of environments, F(6, 303) = 1.73, p = .11. No statistical difference was found in CBI total mean scores from various practice specialties, F(7, 303) = 1.74, p = .10. Also, no statistically significant interaction between employment envi-ronment and practice specialty was found, F(28, 303) = 1.25, p = .19 (see Table 4). For NP employment environments and practice specialties, see Table 1.

DISCUSSION

Approximately one half of the accessible population of NPs in Louisiana participated in the study. The findings are generaliz-able to that location but may not be generalizable to other states or regions or to the nation. The majority of the participants were European American women, and the majority of the NPs had a master’s degree in nursing. The youngest group (ages 26 to 35) comprised 73 NPs, about one fifth of the sample. The sample had only 28 NPs who were not European American and may not represent the ethnic variations found in other locations.

CBI mean scores and subscale mean scores were high for all 348 NPs participating in the study. From the participating 348 NPs, a sole female NP from a rural clinic perceived herself as most caring for all subscales, with the highest CBI mean score of 6. She also wrote a comment on the bottom of the questionnaire, stating that “any nurse practitioner who does not score a perfect score on the questionnaire should be ashamed.” I was concerned that participants’ fear of appearing uncaring would affect their responses. However, the variability in the scores, even though minimal, was comparable to that reported in the literature reviewed (Brunton & Beaman, 2000; Wolf et al., 1998).

Table 2 CBI Subscales Mean, Standard Deviation, and Minimum and Maximum Score of NPs (N = 348)

Subscale Mean SD Min. Max.Respectful Deference to the Other 5.64 .32 4.08 6.00Assurance of Human Presence 5.48 .35 4.08 6.00Positive Connectedness 5.16 .45 3.78 6.00Professional Knowledge and Skill 5.39 .45 3.83 6.00Attentiveness to the Other’s Experience 5.46 .41 4.00 6.00

Note. CBI = Caring Behaviors Inventory.


Gender of the NP was a relevant variable in the study. Of specific interest were male NPs’ perceptions of caring and whether male NPs’ perceptions of caring were different from those of female NPs. There was a concern that few of Louisiana’s limited number of male NPs would participate in the study. As previously stated, relative to the small number of male NPs (66) practicing in the state of Louisiana, there was a large male NP participation (31) in the study. No statistically significant differ-ence was found between the male NPs’ and the female NPs’ total mean CBI scores. All NPs reported high mean CBI scores, indi-cating that they perceived themselves as very caring. No studies reviewed had explored the relationship of male and female NPs’ perceptions of their caring behaviors to gender differences in CBI mean scores, so comparison with this study’s results is not possible.

Location or area of practice of the NP was also a variable of interest in the study. Would the NPs who practiced in a rural health clinic score higher on the CBI than those NPs who practiced in an urban clinic? Having practiced in both rural and urban clinics, the researcher is aware that rural clinics are often perceived as being less hectic than urban clinics and as allowing more nurse-patient interaction time. In addition, the rural NP often practices alone and is well-known by the patients who visit the clinic. Urban clinics are often less personable and faster paced and may have more than one NP, in addition to the physician, seeing patients. There were 97 rural clinics and 247 urban clinics represented in the study. Four respondents indi-cated no practice area. Both areas of practice, rural and urban, were well represented by both male and female NPs. Nine male NPs practiced in rural areas and 22 in urban areas. Eighty-eight female NPs practiced in rural areas, and 225 practiced in urban areas. No literature was found that explored perception of caring behaviors by male and female NPs in rural and urban settings, so again, there is no way to conduct a comparison that would further elucidate these findings.

IMPLICATIONS FOR PRACTICE

This study’s results are congruent with the literature, which indicates that NPs perceive themselves as very caring primary health care providers. NPs often work in clinic situations where

productivity is the most valued characteristic, and little time is afforded for identifying caring behaviors of the NP and/or estab-lishing a caring relationship with the patient. This situation was evident in the comments of 5 NPs among the 341 who declined to complete the CBI. The primary reason for declining was that the NPs’ collaborating physician did not want them to take the time from a busy clinic practice to complete the CBI or to obli-gate themselves to collecting data from the patients. Caring did not seem to be a primary concern in these situations, even though most of these facilities value patient satisfaction with care. NPs must be extremely careful not to sacrifice characteristics inherent in nursing as they strive to create a more productive primary care practice. “NPs must embrace caring, not simply as a task or pro-fessional obligation but as an extension of their own being and nursing identity” (Brunton & Beaman, 2000, p. 455).

IMPLICATIONS FOR EDUCATION

Caring is a universal phenomenon practiced among all cul-tures and is innately human (Boykin & Schoenhofer, 1993). Education of NPs should promote the art and science of caring and should be grounded in a practice model that is based on the process of caring. One such model is Dunphy’s circle of caring, which is a synthesized view of advanced practice nursing in pri-mary care that superimposes the nursing process on a traditional medical model. The model’s description of caring includes the NP’s perception of caring about and for the patient (Dunphy & Winland-Brown, 2000). Often students are placed in situations, both with faculty and preceptors, where only the medical model is practiced and valued, and the student loses the uniqueness that nursing brings to the setting. Care must be taken to include faculty and preceptors who encompass caring in practice and are able to nurture, promote, and monitor caring behaviors in students.

IMPLICATIONS FOR RESEARCH

The CBI has proven to be both a reliable and valid tool to measure caring of nurses. However, the CBI may not be sensitive to primary care NP-patient situations and relation-

Table 3 Analysis of Variance of CBI Total Mean Scores by Gender of NP and Area of Practice (Rural and Urban; N = 348)

Source SS df MS F p ESBetween participants Nurse gender 300.42 1 300.42 1.51 .22 .004 Area of practice 59.02 1 59.02 0.30 .59 .001 Nurse gender X area of practice 150.50 1 150.50 0.76 .38 .002Within participants 67,484.34 340 198.48

Note. CBI = Caring Behaviors Inventory; NP = nurse practitioner.


ships. NPs may be reluctant to answer questions that would deem them “less caring.” In developing a theory of patient satisfaction with NP care, Linder-Pelz (1982) cautioned that perceptions of care/caring were always subjective in nature and that characteristics of the NP and characteristics of the patient must be considered when exploring totality of care/caring. To compare patients’ perceptions of NPs’ caring behaviors with the NPs’ perceptions of their own caring behaviors, the CBI could also be simultaneously administered to patients and to the NPs providing care. Perceptions of care and caring behaviors may be influenced by many variables and may best be captured by using both quantitative and qualitative methods. In-depth interviews of NPs and their patients would reveal caring themes that would contribute to further instrument development. These instru-ments would need to be precise, concise, valid, and reliable. NPs must constantly consider their behaviors in delivering care, as these behaviors may affect patients’ perceptions of care. As their responsibilities in the health care setting continue to expand, NPs must continually evaluate and validate their roles to ensure quality care that satisfies patients. Analysis of CBI scores revealed no statistically significant differences corresponding to the NP demographic variables defined for the study. Future research should seek to determine whether caring behaviors as perceived by NPs are predictors of patient satisfaction.

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Table 4 Analysis of Variance of CBI Total Mean Scores by NP Employment Environment and Practice Specialty (N = 348)

Source SS df MS F p ES Between participants Employment environment 1,915.96 6 319.33 1.73 .11 .03 Practice specialty 2,247.25 7 321.04 1.74 .10 .04 Employment environment X practice specialty 6,458.05 28 230.65 1.25 .19 .10Within participants 56,020.79 303 184.89

Note. CBI = Caring Behaviors Inventory; NP = nurse practitioner.


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