International Journal of Nursing Studies 38 (2001) 511521

A 35-item version of the caring dimensions inventory (CDI-35): multivariate analysis and application to a longitudinal study involving student nurses
Roger Watsona,*, lan J. Dearyb, Amandah Lea Hoogbruinc
b a School of Nursing, University of Hull, Hull HU6 7RX, UK Department of Psychology, The University of Edinburgh, Edinburgh EH8 9JZ, UK c Nursing Faculty, Kwantlen University College, Surrey, British Columbia, Canada

Received 20 May 2000; received in revised form 15 October 2000; accepted 20 October 2000

Abstract The present study was designed to investigate the perceptions of caring among student nurses and how these develop throughout the course of a programme of pre-registration nurse education. A 35-item version of the caring dimensions inventory was administered to a cohort of nursing students in a department of nursing in Scotland at entry to the programme, after 12 months and after 24 months on the programme. Caring was largely perceived through a technical dimension, demonstrated by factor analysis, but other dimensions such as intimacy, support and unnecessary and inappropriate aspects of nursing also became apparent as students progressed through the programme. # 2001 Elsevier Science Ltd. All rights reserved.
Keywords: Care; Caring; Nursing; Factor analysis; Longitudinal study

1. Introduction The measurement of caring has been advanced signicantly in recent years by the development of the 25-item version of the caring dimensions inventory (CDI-25). This inventory has been applied successfully in a longitudinal study involving student nurses (Watson et al., 1999a), in a study of nurse practitioners (Walsh, 1999) and has been reported as having excellent psychometric properties (Beck, 1999). The stimulus for the development of the CDI-25 was the paucity of research into caring using quantitative methods and deciencies in much of the quantitative research reported prior to its development (Lea and Watson, 1996). Furthermore, in order to study caring in relation

to other variables, for example, personality, stress levels and coping mechanisms, it is essential to have a reliable instrument (Watson et al., 1999a). This is congruent with Valentines (1991, p. 100) argument that in order for nursing to advance caring: . . . it must also advance the empirical measurement of caring in a way that withstands the scrutiny of the scientic community. Whilst acknowledging that caring is an elusive concept and that caring in nursing is poorly dened (Watson and Lea, 1997), the CDI-25 was developed by operationalising 25 distinct aspects of nursing which were veriable in the literature as described by Watson and Lea (1997). The CDI-25 is, essentially, a selfassessment of perceptions of caring. There is a stem question (do you consider the following aspects of your nursing practice to be caring) and for each of the items in the questionnaire (e.g. listening to a patient;

*Corresponding author. Tel.: +44-1482-466698; fax: +441482-466694. E-mail address: r.watson@nursing.hull.ac.uk (R. Watson).

0020-7489/01/$ - see front matter # 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 7 4 8 9 ( 0 0 ) 0 0 1 0 7 - 3

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measuring the vital signs of a patient; making a nursing record about a patient) the respondent is required to indicate on a 5-point Likert scale ranging from strongly agree to strongly disagree whether or not they perceive caring in this way. In a previous postal survey data were gathered from 1430 nurses and student nurses using the CDI-25 (Watson and Lea, 1997). Data were analysed using multivariate analysis, including factor analysis (exploratory and conrmatory), analysis of variance, Mokken scaling and stepwise multiple regression analysis. A four-factor structure was apparent on exploratory factor analysis (Lea et al., 1998) with a factor representing psychosocial aspects of caring (item examples: listening to a patient; sitting with a patient) and a factor representing professional and technical dimensions of caring factor (item examples: observing the eects of a medication on a patient; measuring the vital signs of a patient). Two smaller dimensions related to appropriate (item example: being cheerful with a patient) and inappropriate giving of self (item example: keeping in contact with a patient after discharge) in nursing were also observed. This structure was supported by conrmatory factor analysis (Lea et al., 1998). The 25 items of the CDI-25 had high internal consistency (Cronbachs alpha=0.91; Watson and Lea, 1997) and Mokken scaling (a technique for extracting cumulative, hierarchical scales from multivariate data), produced a reliable scale (H=0.46; Rho=0.92) incorporating 12 items from the 25-item questionnaire (Watson and Lea, 1997). Using the 12-item version, it was demonstrated that nurses more readily endorse psychosocial aspects of caring over professional and technical aspects: and those more strongly endorsing professional and technical aspects also more strongly endorse psychosocial aspects. Using the same 12 items it was demonstrated that there is a signicant but low correlation between age and score on the Mokken scale: older nurses more readily incorporate professional and technical aspects into their perception of caring than younger nurses, although this may be due to a cohort eect. Men more readily incorporated psychosocial aspects of nursing in their perception of caring than women. These ndings were conrmed by stepwise multiple regression analysis using the factor scores for the psychosocial factor and the professional and technical factor (Watson and Lea, 1998). Nurses working in dierent clinical areas perceive caring dierently (Lea and Watson, 1999). For example, surgical nurses perceive caring in more technical and professional terms than nurses working in medical wards. However, it is not known if this observation is the result of dierences in the nurses before entering their respective clinical areas or if exposure to these clinical areas inuences perceptions of caring. The 12item scale has been applied in research into the

perceptions of caring among nurse practitioners (Walsh, 1999). This research was designed to test the hypothesis that nurse practitioners would be relatively highly technically oriented at the expense of psychosocial aspects of care. In fact, it was demonstrated that nurse practitioners when compared with nurses working in hospital were more inclined to score highly on psychosocial aspects of care. According to Walsh (1999) this indicated that, despite their training in extended nursing practice, these nurses had retained the psychosocial dimension to their care } contrary to expectations. The two smaller factors, from the CDI-25 referred to above, only had two items each loading on them. Both of these factors are related to involvement with or giving of self to the patient in ways other than providing either technical or psychosocial care. However, due to the small number of items loading on each, they require further investigation (as indicated by Lea et al., 1998) because they may simply be artefacts of the large sample size of the study, described above, in which the CDI-25 was originally developed. Alternatively, they may be genuine latent dimensions of caring which could be investigated by introducing further items, related to those loading on these putative factors, into the CDI-25. 1.1. Longitudinal investigations A longitudinal study involving the population of student nurses in a department of nursing in Scotland veried the four factor structure of the CDI-25 (Watson et al., 1999b). Throughout the study the factor representing the professional and technical aspects of nursing became more congruent with a similar factor in the original study in which the CDI-25 was developed. The development of the perception of caring among this population of nurses was also investigated by comparing the incorporation of items from the CDI-25 into a Mokken scale with the same 25 items incorporated into a nursing dimensions inventory (NDI). The NDI contains a dierent stem question and dierent responses to elicit the student nurses perceptions of the importance of aspects of nursing to them as a nurse (Watson et al., 1999a). At entry to a programme of nurse education, the items incorporated into a Mokken scale from the CDI-25 were few compared with the NDI suggesting that nurses conceptualise nursing better in terms of the importance of aspects of nursing than as caring. However, at 12 months into the programme of nurse education the number of items incorporated into a Mokken scale from both the CDI-25 and the NDI was similar and there was little dierence in the actual items which were incorporated. It appears, at the start of a nurse education programme, that the perception of caring and the perception of nursing dier. However, they are more congruent after exposure to a nurse education programme. The implication for the present

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study is that some aspects of the perceptions of caring remain the same, as evidenced by factor analysis, and other aspects dier over time as evidenced by Mokken scaling. 1.2. The present study The present study was designed to investigate further the underlying structure of caring and this was addressed by the addition of new items to the original CDI-25. These additional items were incorporated specically to probe the putative dimensions concerned with appropriate and inappropriate self-giving suggested by the two smaller factors extracted in the original study (Lea et al., 1998) described above. The number of items related to inappropriate and appropriate self-giving aspects of nursing were intended both to provide anchors for the concept of inappropriate care (item example: making a patient do something, even if he or she does not want to) and items around which there would be some ambiguity, especially amongst inexperienced student nurses (item example: dealing with everyones problems at once), items around which there would be ambiguity amongst all nurses and student nurses (item example: praying for a patient) and items about which there could be little ambiguity regarding their value as caring actions (item example: arranging for a patient to see his or her chaplain). Ten new items were added to the CDI-25 and these were deliberately selected by the authors on the basis that they would load on putative underlying dimensions of the CDI-25 which were present in a previous study (Lea et al., 1998) but which had few items loading on them.

and on future occasions. All students participated on the rst day of the study and approximately 50% of the students dropped out of the study over 24 months. 2.2. Sample The sample consisted of the population of student nurses in a department of nursing in Scotland who were undertaking their nurse education between 1996 and 1999. These demographic details have previously been reported by Watson et al. (1999b). Students of adult nursing and mental health nursing were undertaking an 18 month common foundation programme before specialising in their respective branches. The majority of nurses at time 1 and time 2 were intending to undertake the adult branch of their nurse education programme, the majority was female and the median age was 23 at time 1 (n 168), 23.5 at time 2 (n 124) and 24.5 at time 3 (n 90). There were 20 midwifery students in the study at time 1 and time 2 but these were all lost at time 3 because their timetable was dierent from their colleagues and incompatible with the study. Statistical analysis: data were analysed by exploratory factor analysis using principal components analysis (PCA) followed by oblique rotation using SPSS for Windows version 9.0. Factor analysis reduces multivariate data to fewer underlying dimensions (Hair et al., 1987), or factors, which explain the shared variance in the data (Dillon and Goldstein, 1984). PCA, while not strictly speaking a method of factor analysis, enables as much of the total variation in the data to be explained in as few factors as possible, and also provides a rationale for selecting the number of latent factors present. The number of factors extracted at each point in time was decided upon using the scree slope method of analysis (Child, 1990) as opposed to the eigenvalues greater than one rule which can overestimate the number of factors (Cli, 1988). In order to characterise factors a rotational procedure was used which maximises the loading (correlation) of items with their putative factors while minimising the loadings of these items with the remaining putative factors (Kline, 1994). Putative factors were further analysed for internal consistency, which is one form of reliability (Polit and Hungler, 1995), using Cronbachs alpha. The primary objective in factor analysing these data was, due to the longitudinal nature of the present study, to study the latent structure of the CDI-25 over time in order to see if there are changes between entry to nurse education and 12 and 24 months after entry. A secondary objective was to compare the CDI-35 with the CDI-25 in order to see if further information was gained on the putative factors related to self-giving referred to in the Introduction. Data were entered into a database for exploratory factor analysis and Cronbachs

2. Procedure 2.1. Design The design was a longitudinal survey using questionnaires for data collection. Data were collected from a cohort of student nurses upon entry into nurse education (time 1), at 12 months (time 2) and 24 months (time 3) after entry. Questionnaires were distributed to 168 student nurses, completed and returned in the presence of at least one of the investigators (IJD & RW). The CDI-35 is shown in Table 1. Students were on their rst day of a Diploma in Higher Education in Nursing in a department of nursing in Scotland. Permission was granted to approach the students from the management of the College, ethical permission was not required. The students were given a full explanation of the purpose of the study by two of the investigators (IJD & RW). Condentiality was assured and the students were given the option of not participating in the study on that day

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Table 1 35-item caring dimensions inventory (CDI) Stem question: Do you consider the following aspects of your nursing practice to be caring? Response on a 5-point Likert scale: 1 (strongly disagree) to 5 (strongly agree) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35.
a

Assisting a patient with an activity of daily living (washing, dressing, etc.)a Making a nursing record about a patienta Feeling sorry for a patienta Getting to know the patient as a persona Explaining a clinical procedure to a patienta Being neatly dressed when working with a patienta Sitting with a patienta Exploring a patients lifestylea Reporting a patients condition to a senior nursea Being with a patient during a clinical procedurea Being honest with a patienta Organising the work of others for a patienta Listening to a patienta Consulting with the doctor about a patienta Instructing a patient about an aspect of self-care (washing, dressing, etc.)a Sharing your personal problems with a patienta Keeping relatives informed about a patienta Measuring the vital signs of a patient (e.g. pulse and blood pressure)a Putting the needs of a patient before your owna Being technically competent with a clinical procedurea Involving a patient with his or her carea Giving reassurance about a clinical procedurea Praying for a patient Dealing with everyones problems at once Observing the eects of a medication on a patienta Making a patient do something, even if he or she does not want to Assuring a terminally ill patient that he or she is not going to die Staying at work after your shift has nished to complete a job Coming to work if you are not feeling well Being cheerful with a patienta Arranging for a patient to see his or her chaplain Providing privacy for a patienta Keeping in contact with a patient after discharge Appearing to be busy at all times Attending to the spiritual needs of a patient Items included in the original 25-item version of the CDI (Watson & Lea, 1997).

alpha using the Statistical Package for the Social Sciences (SPSS; Bryman and Cramer, 1999). Wrigley and Nehaus coecients of congruence between factors were calculated using software written and supplied by Professor John Crawford, Department of Psychology, University of Aberdeen, Scotland.

national pattern. The median age and age range of the sample remained stable throughout the study and 54% of the sample remained at time 3. No midwives participated at time 3 because their timetable was not compatible with the protocol of the study. 3.1. Principal components analysis

3. Results The relative proportions of males and females reect national patterns (National Board for Nursing, Midwifery & Health Visiting (Scotland), 1998) for the gender balance in nursing. Likewise, the higher proportion of adult branch students over other branches and the entry of mature students into nurse education reect the

The number of factors extracted at time 1, time 2 and time 3, respectively, was six, ve and ve from the CDI35. The percentages of variance explained by the rst unrotated principal components at time 1, time 2 and time 3 were, respectively, 20.5, 20.9 and 22.8. Therefore, although separable dimensions of caring are implied in the results, a moderately large amount of the individual dierences in caring among our subjects may be

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Table 2 Principal component analysis followed by oblique rotation of six factors from the data obtained from the CDI at time 1 showing items which load on factors in bold for clarity, decimal points are not shown and loadings are only shown to two decimal places. Cronbachs alphas and the correlation matrix of factors are shown at the foot of the table Derived oblimin factor solution Item 14 18 9 5 25 20 2 15 21 6 17 26 29 27 33 24 12 7 30 31 28 22 19 16 3 13 11 32 8 23 35 4 10 34 1 Cronbachs alpha 1 2 3 4 5 6 First unrotated principal component 78 69 74 71 51 70 40 66 58 47 50 09 09 18 03 07 22 44 39 34 30 33 13 33 02 72 34 50 53 19 20 51 63 12 34 Factor 1 79 78 77 71 67 67 56 56 56 51 47 08 02 14 24 04 29 26 24 14 16 19 13 21 00 56 13 34 41 03 01 28 46 18 29 85 1.00 0.35 0.12 0.17 0.025 0.043 Factor 2 02 01 09 15 23 03 35 07 19 08 42 59 58 49 45 39 38 02 01 03 24 29 07 11 19 11 11 06 06 44 04 20 29 07 07 55 1.00 0.02 0.07 0.07 0.16 Factor 3 24 12 20 10 12 05 15 11 08 27 00 01 00 22 09 10 26 72 71 64 60 43 33 00 15 21 21 12 11 16 19 15 09 10 10 51 Factor 4 37 07 18 36 06 51 23 32 25 14 06 09 09 16 08 37 23 15 11 04 13 29 11 73 57 57 53 12 01 12 04 38 41 00 02 02 Factor 5 17 21 24 24 02 22 09 40 21 32 34 09 08 34 35 01 28 15 18 42 22 10 26 04 23 35 24 68 62 60 56 52 48 05 21 68 Factor 6 01 13 14 00 14 03 16 36 41 43 28 01 13 01 32 37 24 13 29 21 07 08 07 17 21 12 09 15 26 10 09 19 23 67 57 60

1.00 0.02 0.12 0.01

1.00 0.07 0.04

1.00 0.11

1.00

accounted for in a broad, general factor common to almost all items exemplied by the loadings of items under the rst unrotated principal components in Tables 24.

3.2. Rotation of factors The results of the PCA followed by rotation of factors is shown in Tables 24. Rotational procedures are

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Table 3 Principal component analysis followed by oblique rotation of ve factors from the data obtained from the CDI at time 2 showing items which load on factors in bold for clarity, decimal points are not shown and loadings are only shown to two decimal places. Cronbachs alphas and the correlation matrix of factors are shown at the foot of the table Derived oblimin factor solution Item 13 15 10 7 4 5 11 16 17 18 9 14 2 6 25 21 1 33 29 23 24 30 3 32 31 22 8 35 19 28 26 34 12 20 27 Cronbachs alpha 1 2 3 4 5 First unrotated principal component 67 80 70 67 59 66 64 28 55 71 53 74 51 49 46 68 37 05 17 02 23 11 23 34 16 40 38 03 28 17 07 03 46 39 08 Factor 1 86 79 73 73 71 63 59 57 48 44 12 50 20 03 03 44 16 03 13 15 39 05 13 05 03 08 32 05 21 14 00 31 21 10 18 78 1.00 0.21 0.05 0.06 0.04 Factor 2 22 50 36 21 16 35 42 11 46 77 75 73 72 64 61 53 51 13 06 05 13 01 22 23 05 34 12 11 19 05 11 13 43 34 03 82 1.00 0.07 0.17 0.11 Factor 3 03 16 21 16 03 04 01 24 02 15 16 03 13 17 39 38 11 67 65 62 50 47 46 29 22 31 01 02 04 09 30 16 12 34 21 48 Factor 4 05 04 02 29 34 32 20 19 11 09 30 09 05 39 40 29 09 12 02 21 03 34 05 70 69 54 49 42 26 16 12 09 13 28 08 52 Factor 5 17 03 10 20 05 22 01 11 18 05 11 04 20 20 11 06 21 08 33 01 05 04 28 01 07 16 20 34 06 68 60 53 50 38 37 52

1.00 0.07 0.06

1.00 0.06

1.00

applied in factor analysis in an eort to nd simpler and more easily interpretable factors while keeping the number of factors xed (Kim and Mueller, 1978). Rotation was applied here to maximise the loadings (equivalent to correlations) of individual items in the

CDI-35 on the putative factors which they constituted while minimising the loadings on the remaining factors. It is conventional to seek loadings of greater than 0.40 of items on putative factors (Child, 1990) and loadings which are as low as possible on the remaining factors.

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Table 4 Principal component analysis followed by oblique rotation of ve factors from the data obtained from the CDI at time 2 showing items which load on factors in bold for clarity, decimal points are not shown and loadings are only shown to two decimal places. Cronbachs alphas and the correlation matrix of factors are shown at the foot of the table Derived oblimin factor solution Item 14 18 9 21 25 20 15 5 2 22 17 32 1 12 24 16 23 3 33 35 8 10 34 13 7 31 4 11 6 28 30 29 26 19 27 Cronbachs alpha 1 2 3 4 5 First unrotated principal component 64 67 65 65 74 68 68 63 54 68 60 59 46 47 00 15 19 06 05 50 46 65 02 56 46 60 34 35 38 18 41 04 08 29 01 Factor 1 75 74 72 72 71 67 65 64 62 58 58 54 49 45 04 14 02 07 11 30 21 49 20 46 24 47 15 36 45 01 30 03 01 19 06 89 1.00 0.05 0.26 0.03 0.15 Factor 2 13 19 03 03 25 19 05 14 02 02 12 21 17 20 69 63 59 53 52 04 07 04 37 22 04 04 04 13 04 23 00 38 13 08 26 60 1.00 0.04 0.01 0.08 Factor 3 11 16 21 10 35 24 20 33 04 58 33 42 09 36 18 07 38 04 09 67 66 64 53 53 50 48 33 11 01 20 22 14 03 13 39 62 Factor 4 06 08 02 31 11 07 23 11 06 10 25 11 20 17 09 05 16 22 41 17 38 05 16 09 19 09 63 58 46 18 32 11 12 06 15 34 Factor 5 02 09 02 11 24 27 39 00 19 05 02 13 20 12 16 11 15 14 07 19 27 23 17 00 49 39 38 06 22 67 59 54 47 45 41 59

1.00 0.04 0.06

1.00 0.01

1.00

The factors represent underlying dimensions of the CDI35 and they are subsequently characterised by the items which load on them. For example, in a previous study (Lea et al., 1998) it was demonstrated that there was a psychosocial dimension to the CDI-25 (item examples:

listening to the patient; sitting with the patient) and a professional and technical dimension (item examples: measuring the vital signs of a patient; being technically competent with a clinical procedure). These underlying dimensions represent unidimensional scales

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derived from the overall CDI-25 which may be used to measure these respective dimensions. In Tables 24 items with loadings greater than 0.40 on rotated components are shown in bold. Loadings are shown only to two decimal places without decimal points. Bearing in mind that it is the individual items of which factors are comprised which characterises them, it is customary to apply labels in order to describe the latent dimension which is being represented by the factor. Moreover, it should be noted that the order in which factors are extracted is arbitrary. The labels ascribed to factors in the present study are shown in Table 5. Factors, described here as technical, supporting and intimacy were extracted at time 1, time 2 and time 3. The technical factor is characterised by items which indicate technical and professional aspects of nursing (item examples: consulting with the doctor about a patient; measuring the vital signs of a patient), the supporting factor is characterised by items which indicate helping the patient with spiritual matters (item examples: arranging for a patient to see his or her chaplain; attending to the spiritual needs of a patient [time 2 and time 3 only]) and the intimacy factor is characterised by items which indicate getting to know patients and becoming involved with them (item examples: getting to know the patient as a person; being with a patient during a clinical procedure [time 1 and time 2 only]). It should be noted that the factor, labelled here as intimacy, only has three items loading on it at time 3. Two factors, labelled involvement (item examples: sharing your personal problems with a patient; listening to a patient) and working hard (item examples: assisting a patient with an activity of daily living; appearing busy at all times) were only apparent at time 1 and only had four and two items, respectively, loading on them. A further factor labelled inappropriate/unnecessary aspects of nursing is described at time 1 (item examples: making a patient

do something, even if he or she does not want to; dealing with everyones problems at once). In addition to the three factors identied above which are present at time 1, time 2 and time 3 there are two factors which are present at time 2 and time 3 and these are labelled unnecessary (item examples: praying for a patient; feeling sorry for a patient) and inappropriate (item examples: making a patient do something, even if he or she does not want to; staying at work after your shift has nished to complete a job). The unnecessary aspects of nursing factor includes nursing actions which, in themselves, are not inappropriate or unprofessional but which would not normally be expected of a nurse. The inappropriate aspects of nursing factor, on the other hand, includes nursing actions which, in addition to being unnecessary, are certainly not recommended aspects of nursing practice and which may even be deemed unprofessional. Generally speaking, the intercorrelation between factors (Tables 24) is low and only the internal consistency of the technical factor (Tables 24) was greater than 0.80 at time 1, time 2 and time 3. The congruence between putative factors across time is shown in Table 6 (coecients close to unity indicate good congruence and coecients greater than 0.9 indicate that the same factor was being extracted). The congruence between the unrotated principal components is high between all times (Table 6a) indicating that the same general caring factor was being extracted. The only

Table 6 Congruence between factors across time Time 1 (a) Time Time Time (b) Time Time Time (c) Time Time Time (d ) Time Time Time (e) Time Time (f) Time Time 1 2 3 1 2 3 1 2 3 1 2 3 2 3 2 3 Time 2 Time 3

Table 5 Labels ascribed to factors extracted in the present studya Time 1 1. Technical 2. Inappropriate/ unnecessary 3. Supporting 4. Involvement 5. Intimacy 6. Working hard
a

Time 2 1. Intimacy 2. Technical 3. Unnecessary 4. Supporting 5. Inappropriate

Time 3 1. Technical 2. Unnecessary 3. Supporting 4. Intimacy 5. Inappropriate

Factors are shown in the order in which they were extracted in order that the above table may be compared directly with Tables 24. The labels all refer to aspects of nursing.

Unrotated principal component 1 0.94 1 0.94 0.90 Technical factor 1 0.90 1 0.82 0.91 Supporting factor 1 0.55 1 0.50 0.67 Intimacy factor 1 0.55 1 0.50 0.22 Unnecessary factor } 1 } 0.54 Inappropriate factor } 1 } 0.55

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other factor showing good congruence was the technical factor between time 1 and time 2 and time 2 and time 3 (Table 6b).

4. Discussion In common with a previous report from this study, there is considerable attrition with the sample size being reduced by almost 50% throughout the course of the study. This is a feature of longitudinal studies (Watson, 1998) and it takes considerable eort between data collection points to maintain sample size in such studies (Robinson et al., 1998) and the investigators tried to maintain interest in the project among the students by promising to provide feedback on the project to any students who wished to have it. Some feedback from analysis of the rst wave of data from time 1 was provided when the investigators met the students at time 2. Otherwise, regular contact was maintained with the management of the college and with lecturers who met the students, to indicate when the next wave of data collection would take place and how important the participation of the students was. As noted above, the midwifery students were all lost at time 3 in the present study. The relevance of sample size in the present study is that it should be sucient to produce reliable factors (Kline, 1994). While a range of subjects-to-variables ratios (where a variable is an item or question in an inventory to be factor analysed) from 2:1 to 10:1 has been suggested with a ratio of 5:1 being recommended (Ferguson and Cox, 1993) it has also been suggested that the minimum sample size is more important to the stability of factors (Guadagnoli and Velicer, 1988). Kline (1994) suggests a sample size of 100 is suciently representative to avoid having to replicate studies. In the present study the subjects-to-variables ratio of 5:1 was satised at time 1 and the sample size was just below the suggested minimum of 100 at time 3. 4.1. Development of the CDI-35 The objective of this study was to develop the CDI-35 by the addition of items which might expand some of the putative dimensions of the CDI-25 for which there was only weak evidence from previous studies (Watson et al., 1999b). Specically, these dimensions were related to appropriate and inappropriate aspects of self-giving (Lea et al., 1998). Moreover, by including additional items, further renement of the factor structure previously obtained by Lea et al. (1998) might be observed. Five factor model despite the observation of a six factor solution at time 1 in the present study the outcome of the study will be presented purely as a ve factor solution to the analysis of the CDI-35. The fact that a six factor solution was obtained at time 1 followed

by ve factor solutions at time 2 and time 3 may be an indication of the way in which the student nurses, at entry to their education programme, perceive caring. It is likely that they will perceive caring in a less structured way early in their nurse education, represented by a greater number of underlying dimensions and with dimensions which are less easy to interpret clearly. For example, one of the factors at time 1 was labelled inappropriate/unnecessary because items related to both concepts loaded on it. There was also a factor with only two items loading on it, labelled here working hard because the two items were related to being busy and helping patients } something which may, indeed, provoke some anxiety in new nursing students but which, later in their studies, becomes assimilated into other aspects of caring. The original, large scale, study (Lea et al., 1998) in which the CDI-25 was developed indicated that there were four latent dimensions to caring, albeit that two of these dimensions had very few items associated with them. A four factor structure was supported in a longitudinal study involving student nurses but there was also evidence for a ve factor structure to the CDI-25 after 24 months involvement in a programme of nurse education. In the present study a ve factor structure to the CDI-35 was evident at time 2 and time 3 and, in terms of the labels ascribed to the factors (a largely subjective exercise), the factors were identical at time 2 and time 3 and two of the factors at time 2 and time 3 were labelled the same as two of the factors at time 1. However, as described above, the labelling of factors is a largely subjective exercise and the true measure of whether or not factors is the same is their congruence which can be calculated objectively. The unrotated principal components were congruent between time l, time 2 and time 3 indicating, as previously reported (Lea et al., 1998; Watson et al., 1999b), a general factor for caring which is similar in these nursing students at entry to their education programme and throughout. The other factor which was congruent between time 1 and time 2 and time 2 and time 3, but not between time 1 and time 3, was the technical aspects of nursing factor. In a similar study using the CDI-25 (Watson et al., 1999b) the technical factor was observed to be reasonably congruent with a similar factor identied in a previous larger study (Lea et al., 1998) and to be congruent with that factor after 24 months in nurse education. It is clear that this aspect of nursing, the doing aspect (item examples: consulting with the doctor about a patient, observing the eects of a medication on a patient; being technically competent with a clinical procedure; measuring the vital signs of a patient) is more consistently perceived by nurses as a dimension of caring than other, more psychosocial aspects.

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Whereas a single psychosocial aspects of nursing factor was identied in two previous studies (Lea et al., 1998; Watson et al., 1999b), in the present study there appear to be two factors associated with the psychosocial aspects of nursing. These were described as intimacy and supporting aspects of nursing. While these factors were not congruent (i.e. coecients >0.9) at time 1, time 2 and time 3 the coecients of congruence were not negligible. It appears that, upon factor analysis, the CDI-35 has yielded a structure whereby more detail of the psychosocial aspects of nursing is visible. The two aspects of nursing, the appropriate and inappropriate aspects of self-giving, which were putatively identied in previous studies using the CDI-25 (Lea et al., 1998; Watson et al., 1999b) are apparent in the ve factor model for the factor analysis of the CDI35 as the unnecessary and inappropriate aspects of caring identied in the present study. The unnecessary aspects of caring are analogous to the inappropriate aspects of self-giving (item examples: praying for a patient; feeling sorry for a patient) and convey the same idea of going the extra mile for the patient in a way which will not be harmful to the patient but which may lead to emotional exhaustion and burnout in the nurse. The inappropriate aspects of nursing (item examples: coming to work if you are not feeling well; making a patient do something, even if he or she does not what to), in addition to being unprofessional may be damaging to patients. As the students progress through their nurse education programme they more easily perceive and dierentiate these from other aspects of nursing.

the dimensions identied here in nurses who have completed their education and who have had a period of clinical experience.

Acknowledgements This work was supported by a grant to RW from the Nueld Foundation and a grant to RW & ALH from the National Board for Nursing, Midwifery & Health Visiting (Scotland). ALH acknowledges funding from the British Columbia Health Research Foundation, National Health & Research Development Program (Canada), Canadian Nurses Foundation and Sigma Theta Tau International Society. The authors thank Dr. Sue Green and Ms. Emma Ironside, School of Nursing, University of Hull for their useful comments on the manuscript.

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5. Summary and conclusion The present study was based on a longitudinal factor analysis of the CDI-35 in order to identify underlying dimensions of nursing, as perceived by student nurses, and how these might change during the course of a programme of pre-registration nurse education. Most clearly, nursing students perceive the technical dimensions of nursing but other aspects, including the psychosocial dimensions and dimensions which are considered acceptable as caring practices are perceived more clearly as education progresses. The CDI-35 has been used successfully to extend previously putative dimensions of caring and to provide a more detailed insight into aspects which were already established. The present study has demonstrated the utility of attempting to measure caring in student nurses. For the future, due to the problem of attrition in longitudinal studies, the CDI-35 should be applied to a large sample of nurses and student nurses to conrm or otherwise the conclusions of the present study and to look at the stability of

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