M E T H O D O L O G I C A L I S S UE S I N N U R S I N G R E S E A R C H

A dimensional structure of nurse–patient interactions from a caring

perspective: refinement of the Caring Nurse–Patient Interaction Scale
(CNPI-Short Scale)
Sylvie Cossette PhD RN
Associate Professor, Faculty of Nursing, University of Montreal, Montreal, Quebec, Canada

Jose K. Cote PhD RN

Associate Professor, Faculty of Nursing, University of Montreal, Montreal, Quebec, Canada

Jacinthe Pepin PhD RN

Professor and Vice-Dean, Faculty of Nursing, University of Montreal, Montreal, Quebec, Canada

Nicole Ricard PhD RN

Professor, Faculty of Nursing, University of Montreal, Montreal, Quebec, Canada

Louis-Xavier D’Aoust
BSc Nursing Student and Research Assistant, Faculty of Nursing, University of Montreal, Montreal, Quebec, Canada

Accepted for publication 29 November 2005

Correspondence: C O S S E T T E S . , C O T E J . K . , P E P I N J . , R I C A R D N . & D ’ A O U S T L - X . ( 2 0 0 6 ) Journal

Sylvie Cossette, of Advanced Nursing 55(2), 198–214
Faculty of Nursing, A dimensional structure of nurse–patient interactions from a caring perspective:
University of Montreal,
refinement of the Caring Nurse–Patient Interaction Scale (CNPI-Short Scale)
C.P. 6128,
Aim. This paper reports the development of a short version of the Caring Nurse–
succ. Centre-Ville,
Montreal, Patient Interaction Scale.
Quebec H3C 3J7, Background. Since the 1980s several instruments have been developed to assess
Canada. external aspects of caring. They involve using an inductive process of knowledge
E-mail: sylvie.cossette.inf@umontreal.ca development to investigate the underlying structure of caring, and few reflect an
explicit underlying caring theory. We developed the Caring Nurse–Patient Interac-
doi: 10.1111/j.1365-2648.2006.03895.x tions Scale (CNPI-Long Scale) based on both inductive and deductive processes to
assess attitudes and behaviours associated with Watson’s 10 carative factors. Two
issues led us to abridge our original 70-item scale into a more concise Short Scale
(CNPI-Short Scale). First, many of our subscales were moderately to highly corre-
lated, which is an empirical reflection of the theoretical non-independence of the
carative factors. Secondly, a 70-item questionnaire was difficult to be deal with in
the clinical research setting with severely ill patients because of its length.
Method. Items selected were determined by factor analysis, with specific theoretical
and empirical requirements. Data were collected in September 2003 from 377
nursing students beginning their first, second or third year of a nursing programme.
Results. The Short Scale comprises 23 items, reflecting four caring domains:
Humanistic Care (four items), Relational Care (seven), Clinical Care (nine) and
Comforting Care (three). All items are related to their theoretical domain alone (i.e.
factor loading ‡0Æ40). Alpha coefficients for the four domains were adequate (0Æ63–
0Æ74, 0Æ90–0Æ92, 0Æ80–0Æ94 and 0Æ61–0Æ76 respectively).

198
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Methodological issues in nursing research Caring nurse–patient interactions: short scale development

Conclusions. The CNPI-Short Scale, has potential for use in clinical research set-
tings, particularly when questionnaire length is an issue. It is a useful tool for
research aimed at demonstrating that caring is indeed fundamental to nursing.

Keywords: caring, Caring Nurse–Patient Interaction Scale, instrument develop-

ment, nursing, patient–nurse interactions, psychometric evaluation

emerges from the analysis and may be used to describe the

Introduction
Watson (1979, 1988) has described caring as a way of
being, rather than a way of doing. In light of this, any
attempt to measure caring can only refer to its external
manifestations. However, if caring is at the core of nursing,
measuring it to assess its effect on health is justified. The
dimensionality of caring is crucial because the construct is
viewed differently by theoreticians and dissimilar dimen-
sions have been proposed. We developed the Caring Nurse–
Patient Interactions Scale (CNPI-Long Scale) (Cossette et al.
2005) to assess attitudes and behaviours associated with
Watson’s 10 carative factors. Two reasons led us to abridge
our original scale into a more concise version (CNPI-Short
Scale). First, many of our subscales were moderately to
highly correlated: this is an empirical reflection of the
theoretical non-independence of the carative factors. Sec-
ondly, the lengthy 70-item questionnaire was problematic in
the clinical research setting, particularly with severely ill
patients (Strickland 2003). This shortened scale is based on
three a priori caring domains that were synthesized from the
original 10 carative factors.
structure.
In the inductive process, concepts emerge from similarities
and differences in empirical indicators assessed by individual
items. These factors can be compared with those already in
use in a particular theory or be ‘labelled’ as new concepts.
The deductive approach is used to verify facts or theories and
implies that certain patterns already exist. This approach
channels researchers’ choices in conducting the analysis. It
can also establish whether a proposed structure is empirically
supported by data.
The design and objectives of a particular study depend on
which approach is chosen. For example, if the goal is to
discover an underlying structure when considering a specific
set of items, then none of the items originally involved will be
removed and standard criteria will be set to determine the
number of ‘emerging’ factors. The most widely used criterion
is that, unless the particular factor has shown an eigenvalue
‡1, it is not considered to be ‘emerging’ (Kaiser 1974).
Second is that items may not be retained if they do not load
strongly on a particular emerging factor. In this study, we use
both parameters.

Dimensional structure of existing caring tools (scales)

Background
The most extensive review of the literature on caring in
nursing science (Swanson 1999) summarized the substantial
body of knowledge on theoretical and empirical aspects of
caring published since 1980. Swanson has already observed
the lack of connectedness that constrained the development
of theory and the evaluation of the effectiveness of various
healthcare interventions. With this in mind, we focussed our
literature review on studies that examined the dimensionality
of caring scales (e.g. Watson 2002).
The dimensional structure of a scale: inductive and deductive
approaches
Factor analysis is a useful quantitative analysis technique for
examining the dimensional structure of a scale. Relationships
between a set of items are examined to discover an underlying
factorial ‘structure’ (Rummel 1970). A typology of empirical
concepts, based on similarities in characteristics of items,
We examined eight main instruments: the Caring Ability
Inventory (CAI; Nkongho 1990); Caring Satisfaction (CARE-
SAT; Larson & Ferketich 1993); Caring Behaviour Inventory
(CBI; Wolf et al. 1994); Caring Behaviour Assessment Tool
(CBA; Stanfield 1991); Caring Efficacy Scale (CES; Coates
1997); Caring Dimension Inventory (CDI; Lea et al. 1998,
Watson et al. 1999); Caring Attributes, Professional Self, and
Technological Influence Instrument (CAPSI; Arthur et al.
2001) and the Caring Behaviours Scale (CBS; Lin 2001). Two
other instruments, the Organisational Caring Climate Ques-
tionnaire (OCCQ) and the Peer Group Caring Interaction
Scale (PGCIS), focus on organizational caring rather than
patient caring (Hughes 1993, 1998). These instruments were
elaborated from empirical reviews of the literature on caring
and related concepts.
There were three patterns of scale development in the
studies we examined. The first was exploratory analysis that
did not have any a priori categorization of themes. Authors of

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Table 1 Summary of the factorial structures of existing caring instruments
Author/sample/scale
Nkongho (1990)/543 participants
including 462 students from a large
metropolitan university with varied
‘majors’ and 75 nurses attending a
professional conference/CAI: inquires
about thoughts and feelings on other
people in general, reflecting the degree of
a person’s ability to care (strongly
disagree to strongly agree, seven-point
scale)
Stanfield (1991)/104 adults hospitalized
on the medical-surgical units/CBA:
assesses perceptions of caring behaviours
(no importance to strong importance,
five-point Likert scale)

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Theoretical underpinning of the scale
Mayeroff (1971) as well as the general
literature on caring, plus open-ended
interviews with 15 adults
80 items grouped into eight themes
1 – knowing (awareness of others as
being separate and having unique needs)
2 – alternating rhythms (fluctuation in
the scope of caring: doing and nothing)
3 – patience (allowance for time and
room for self-expression and exploration)
4 – honesty (seeing others as they are;
genuine and true-to-oneself)
5 – trust (allows other to grow)
6 – humility (continuous learning)
7 – hope (anticipation of growth with
caring)
8 – courage (occurs with the direction
of growth; its outcome is unknown)
Watson’s theory of human caring
(1979, 1988)
63 items grouped into seven themes
1 – humanism/faith–hope
2 – helping/trust
3 – expression of positive/negative
feelings
4 – teaching/learning
5 – supportive/protective/corrective
environment
6 – human needs assistance
7 – existential/phenomenological forces
Analysis and methodological criteria
Analysis: principal component analysis
with varimax rotation
Criterion for determining the number of
factors: examination of eigenvalues in
the scree plot and interpretability of
factors
Criteria for selecting items: items
retained if factor loading >0Æ30 on a
given factor and <0Æ30 on a secondary
factor
Analysis: principal component analysis
with varimax rotation
Criterion for determining the number of
factors: minimum loading of three items
for a factor to be identified
Criteria for selecting items
No items were discarded
Items were classified under a
particular factor if factor loading
>0Æ40
Results
37 items, grouped into three factors (% of
S. Cossette et al.
variance not reported)
F1 – ‘Knowing’ includes 14 items
reflecting original Theme 1
F2 – ‘Courage’ includes 13 items
reflecting the ability to deal with the un-
known [all items are negatively worded
(e.g. I don’t know.. I do not…, or reflect
uncaring e.g. I’m afraid…)]
F3 – ‘Patience’ includes 10 items
reflecting tolerance and persistence
Bi-dimensionality: not reported
Correlations between factors varied from
0Æ19 (F2–F3) to 0Æ42 (F1 and F2)
63 items, grouped into four factors (total
variance explained is 50Æ4%). Total
number of items below >63 because
loading >0Æ40 is reported for all factors)
F1 – ‘Caring’ includes 55 items
belonging to the seven original themes (32
items loaded at >0Æ40, only on F1)
F2 – ‘Support’ includes 16 items
belonging to the original themes 1, 2, 4, 6
and 7 (three items loaded at >0Æ40, only
on F2)
F3 – ‘Sensitivity to individual needs’
includes six items belonging to original
themes 1, 6 and 7 (none loaded at >0Æ40,
only on F3)
F4 – ‘Presence’ includes four items
belonging to original themes 1 and 9 (no
items loaded at >0Æ40, only on F4)
Bi-dimensionality: 23 items loaded on
more than one factor at >0Æ40 and three
items failed to load to any factor at 0Æ40
Correlation between factors: not reported
 Table 1 (Continued)
Author/sample/scale
Larson and Ferketich (1993)/268
hospitalized adult medical-surgical
patients, surveyed within 48 hours
before discharge from hospital
CARE-SAT: inquires whether patients did
‘experience’ specific nursing actions or
attitudes (strongly disagree to strongly
agree, 10-point scale)

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201
Theoretical underpinning of the scale
Authors discuss various writings on
caring, none explicitly; enumerates a list
of caring needed by cancer patients
50 items of the CARE-SAT in addition to
11 added items, grouped into six original
themes
1 – accessibility (nurse availability to
patient)
2 – anticipation (anticipating changes
in the patient’s situation)
3 – comfort (physical and emotional
support)
4 – trusting relationship (conveying a
sense of commitment and understanding)
5 – explanation and facilitating
(teaching, clarifying and advocacy)
6 – monitoring and follow-up
(professional competency)
Analysis and methodological criteria
Analysis: principal component analysis
with varimax rotation
Criterion for determining the number of
factors: eigenvalue >1
Criteria for selecting items: factor loading
>0Æ50 on a factor, with a spread of 0Æ20
with another factor
Results
29 items, grouped into three factors
(46Æ9% of the variance explained)
F1 – ‘Assistive‘’, 12 items explaining
Methodological issues in nursing research
34Æ8% of the variance. Includes items
belonging to original themes 1, 2, 3, 4 and
5 (basic nurse caring behaviours such as
explaining things and checking on the
patient frequently)
F2 – ‘Benign Neglect’, 11 items
explaining 7Æ3% of the variance; includes
items belonging to original themes 1, 4, 5
and 6 (10 of 11 are negatively keyed,
denoting non-carative nursing
behaviours)
F3 – ‘Enabling’; includes six items
explaining 4Æ8% of the variance; includes
three items belonging to original themes
2, 4 and 5 (assist patients to understand
and actively participate in their illness
management; e.g. help clarify thinking
with regard to the disease)
Bi-dimensionality: four items loaded
>0Æ40 on a secondary factor; 20 items
loaded >0Æ20 on a secondary factor
Correlation between factors: not reported
Caring nurse–patient interactions: short scale development
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Table 1 (Continued)
Author/sample/scale
Hughes (1993)/317 nursing students/
OCCQ: inquires if statements accurately
describe the climate or atmosphere at
individual’s school of nursing, when
considering organizational and teacher
support (strongly disagree to strongly
agree, six-point scale)
Hughes (1993, 1998)/873 nursing stu-
dents, from 87 nursing schools/PGCIS:
inquires if statements accurately describe
the climate or atmosphere at the
individual’s school of nursing when
considering peer support (strongly
disagree to strongly agree, six-point scale)

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Theoretical underpinning of the scale
Noddings’ (1984) conceptualization of
the components of a moral education for
a caring curriculum; generation of items
from qualitative studies
39 items grouped into four themes
1 – modelling (14 items)
2 – dialogue (nine items)
3 – practice (nine items)
4 – confirmation (seven items)
Content domain specification and gen-
eration of items from a qualitative study
with 10 junior student nurses followed by
content validity
16 items grouped into two themes
1 – Behaviours (nine items) (presence:
placing oneself at the disposal of another
through behaviours; sensitivity:
awareness of the attitudes, feelings of
another; peer supportive: encouragement
and emotional support)
2 – giving assistance (seven items)
(Inter-actional events during which
student assisted their peers in the
resolution of a particular need or
problem, e.g. sharing information)
Analysis and methodological criteria
Analysis: maximum likelihood extraction,
with varimax rotation
Criteria for selecting items: no items were
deleted on the basis of factor analysis
Analysis: maximum likelihood extraction,
with varimax rotation
The 16 items were selected before the
factor analysis on the basis of
methodological criteria (length,
homogeneity, sensitivity and content
domain) and easiness to understand
Results
39 items, grouped into four factors
S. Cossette et al.
explaining 55% of the variance
F1 – ‘Modelling/dialogue’ includes
eight of 14 items belonging to the original
modelling themes and 5/9 items belonging
to the original dialogue theme
F2 – ‘Uncaring behaviours’ includes one
positively worded item from the dialogue
theme and one from the confirm/affirm
theme; all other items are negatively
worded
F3 – ‘Practice’ includes six items from
the practice theme and two from the
modelling scale
F4 – ‘Confirmation/affirmation’
includes five items from the confirmation
theme and one item from the dialogue
theme
Bi-dimensionality: seven items loaded at
<0Æ40 on a secondary factor
Correlation between theoretical factors
ranged from 0Æ66 (between dialogue and
practise) to 0Æ91 (between confirmation
and modelling)
16 items, grouped into two factors
explaining 59% of the variance
14 of the16 items loaded on their original
theoretical scale
F1 – ‘Behaviours’ includes eight of nine
items belonging to the original ‘beha-
vioural’ theme.
F2 – ‘Giving assistance’ includes 6/7
items belonging to the original ‘Giving
assistance’ theme
Bi-dimensionality: nine items load at
>0Æ40, on more than one factor
Correlation between factors: not reported
 Table 1 (Continued)
Author/sample/scale
Wolf et al. (1994)/541 participants: 278
nurses and 263 hospitalized patients who
were in secondary or tertiary settings/CBI:
inquires if items represent ‘caring’
(strongly disagree to strongly agree, four-
point scale)

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Coates (1997)/47 novice nurses/CES:
inquires about the respondents’ degree of
confidence about their ability to express a
caring orientation and to develop caring
relationships (strongly disagree to
strongly agree, six-point scale)
203
Theoretical underpinning of the scale
Review of nursing, social, psychological,
and philosophical literature on caring and
of Watson’s theory (1979, 1988) 43
items; no a priori theoretical link to a
specific caring theme
Watson’s theory of human caring (1979,
1988) and Bandura and Ullmann’s the-
ory of self-efficacy (Bandura & Ullmann
1965)
Form A and B: 30 items not grouped
under specific domains but which
reflected the spirit of Watson’s theory
(1979, 1988) (23 positively worded
items and seven negatively worded items
in Form A and positively and half-neg-
atively worded items in form B)
Short form: 12 items
Analysis and methodological criteria
Analysis: principal component analysis,
with varimax rotation
Criterion for determining the number of
factors: eigenvalue >1
Criteria for selecting items: items were
discarded if factor loaded <0Æ40 on any
factor; items were kept if they were bi-
dimensional (loading >0Æ40 on more
than one factor)
Used expert evaluation to determine
which factors were bi-dimensional
Analysis: exploratory factor analysis; no
other details
Criteria for removing items
From 46 to 30 items: items removed on
the basis of a failure to exhibit a pattern
of significant relationship with other
items
From 30 to 12 items: selected 12 items
with the highest factor loading on the
exploratory factor analysis (selected 30
items from the 46 original scale based on
highest factor loading)
Results
42 items, grouped into five factors (54Æ4%
of the variance explained)
F1 – ‘Respectful deference to other’: 12
items explaining 36Æ5% of the variance
Methodological issues in nursing research
F2 – ‘Assurance of human presence’: 12
items explaining 6Æ0% of the variance
F3 – ‘Positive connectedness’: nine
items explaining 4Æ5% of the variance
F4 – ‘Professional knowledge and skill’:
five items explaining 4Æ2 % of the vari-
ance
F5 – ‘Attentiveness to the other’s
experience’: four items explaining 3Æ2%
of the variance
Bi-dimensionality: 13 items loaded at
>0Æ40 on a secondary factor
Correlations between factors varied from
0Æ48 (F1–F5) to 0Æ75 (F1–F2)
12 items, grouped into three factors (69%
of the variance explained) (Coates 1996
unpublished data, information taken in
Watson 2002)
Bi-dimensionality: not reported
Correlation between factors: not
reported
Caring nurse–patient interactions: short scale development
204
Table 1 (Continued)
Author/sample/scale
Lea et al. (1998), Watson et al. (1999)/
1998 study: 1430 nurses from medical,
surgical, geriatric and psychiatric wards
as well as student nurses from a college of
nursing; 1999 longitudinal study:
n ¼ 168, 124 nurses and 90 students at
entry, 12 months and 24 months after
entry in a nursing programme/CDI:
inquires if respondents consider the
aspects of nursing practice to be ‘caring’
(strongly disagree to strongly agree,
five-point scale)

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Theoretical underpinning of the scale
Review of nursing literature, Leininger’s
caring construct (1985), Grobe and
Hughes (1993) taxonomy, and Larson
and Ferketich’s scale (1993)
25 items without a priori belonging to a
particular theme, while reflecting three
themes
1 – instrumental
2 – affective
3 – professional
Analysis and methodological criteria
Analysis: principal component analysis,
with varimax rotation
Criteria for determining the number of
factors: eigenvalue >1 (1998) and scree
plot (1999)
Criteria for removing items
No items were discarded
Items were classified to a particular
factor when factor loading was the
highest (>0Æ40)
S. Cossette et al.
Results
1998 study: 35 items, grouped into four
factors (% of variance not reported)
F1 – ‘Psychological aspects of care’ in-
cludes 12 items with two of them also
loading on the second and third factors
(e.g. listening to patient)
F2 – ‘Technical and professional as-
pects of care’ includes nine items (meas-
uring the vital sign) with one of them also
loading on the first factor
F3 – ‘Personal disposition or altruism’
includes two items (e.g. putting the needs
of the patient before your own)
F4 – ‘Inappropriate involvement in-
cludes two items (e.g. sharing personal
problem with a patient)
Confirmatory factor analysis in 1998
produced similar results and a similar
structure was reported in 1999
Bi-dimensionality: three items are loading
at >0Æ40 on a secondary factor in
1998 br/>Correlation between factors:

0Æ16 (F1–F4) to 0Æ60 (F1–F2):
1999: a similar four-factor structure for
time 1 and 2; a five factor structure for
time 3
 Table 1 (Continued)
Author/sample/scale
Lin (2001)/297 Taiwanese nursing
students/CBS: respondents were asked to
describe their caring behaviours in clinical
practice
Arthur et al. (2001)/1910 nurses working
in clinical settings, from 11 countries/
CAPSTI: question asked of respondent
not reported; five-point answer scale

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CAI: Caring Ability Inventory; CASPI: Caring Attributes, Professional Self, and Technological Influence Instrument; CBA: Caring Behaviour Assessment Tool; CBI: Caring Behaviour
Inventory; CBS: Caring Behaviours Scale; CDI: Caring Dimension Inventory; CES: Caring Efficacy Scale; CARE-SAT: Caring Satisfaction; OCCQ: Organisational Caring Climate
Questionnaire; PGCIS: Peer Group Caring Interaction Scale.
205
Theoretical underpinning of the scale
Qualitative interviews with 15 Taiwanese
nursing students and nurses
Designed to be sensitive to Taiwanese
culture
56 items grouped into three themes
1 – helping the patient through the
Illness trajectory (18 items)
2 – patient advocacy (23 items)
3 – knowing the patient (15 items)
Literature review and qualitative
interview to generate items
60 items, grouped into three themes
1 – theoretical perspectives (13 items)
reflecting what caring means
2 – practical perspectives (41 items)
reflecting what nurses do when they are
caring
3 – pedagogical perspectives (seven
items) reflecting how caring is learned or
taught
Analysis and methodological criteria
Analysis: principal component analysis,
with varimax rotation
Criteria for determining the number of
factors
First analysis eigenvalues >1, scree
plot, item loading at >0Æ40 and parsi-
mony and theoretical congruence of each
factor
Second analysis: three factors were
forced
Criteria for removing items: no items
were removed
Analysis: principal component analysis,
with varimax rotation
Criterion for determining the number of
factors: two weaker factors removed
Criteria for removing items: items were
removed if weak or conflicting loading
(not loading on the hypothetical
dimension)
Results
Three factors explaining 57Æ4% of the
variance
F1 – ‘Helping the patient through the
illness trajectory’, 32 items explaining
26% of the variance (includes all 18 items
from theme 1 and 12 items from other
themes)
F2 – ‘Patient advocacy’, 15 items
explaining 17Æ8% of the variance (13
were originating from Theme 2 and the
remaining from other themes
Methodological issues in nursing research
F3 – ‘Knowing the patient’, nine items
explaining 13Æ6% of the variance (in-
cludes three items from theme 3 and six
items from Theme 2)
Bi-dimensionality: 13 items loaded at
>0Æ40 on a secondary factor
Correlation between factors: not reported
31 items, grouped into four factors
explaining 44Æ49% of the variance
F1 – ‘Caring communication’, 10 items
explaining 15Æ96% of the variance. Not
clear from which themes the items were
originating, e.g. talking to patients
F2 – ‘Caring involvement’, eight items
explaining 11Æ67% of the variance (all
items are negatively worded) e.g. doesn’t
give patients all the information they need
F3 – ‘Caring advocacy’, seven items
explaining 9Æ83% of the variance. In-
cludes items from practical expertise;
e.g. speaking on behalf of patients
F4 – ‘Learning to care’, five items
explaining 7Æ02% of the variance.
Includes items from the original pedago-
gical perspective theme, e.g. caring is
learned by modelling in clinical settings
Bi-dimensionality: three items from F2
also loaded at >0Æ40 on F1
Correlation between factors: not reported
Caring nurse–patient interactions: short scale development
S. Cossette et al.
the CBI (Wolf et al. 1994) based their scale on Watson’s
theory. Five factors emerged, using the eigenvalue ‡1
criterion: ‘respectful deference to the other’, ‘assurance of
human presence’, ‘positive connectedness’, ‘professional
knowledge and skill’ and ‘attentiveness to the other’s
experience’. Wolf et al. suggest that a link between the
factors ‘assurance of human presence’, ‘positive connected-
ness’ and ‘attentiveness to the other’s experience’ is a
transcendental aspect of caring.
Watson et al. (1999) and Lea et al. (1998) based the items
for their CDI on the literature. Emerging factors included
‘psychological aspect of care’, ‘technical and professional
aspect of care’, ‘personal disposition or altruism’ and
‘inappropriate involvement’. They view ‘psychosocial aspect
of care’ as similar to the ‘being with’ notion in Jean Watson’s
theory, the ‘emotional labour’ construct proposed by James
(1992) and the ‘affective’ aspects of caring identified by
Clifford (1995). James believes that this emotional aspect of
caring is the most invisible care component. The ‘profes-
sional-technical’ aspects are linked to James’s ‘physical
labour’ and to Clifford’s ‘doing for’ aspects. Coates (1997)
used a similar technique with the CES, but little information
is available in the paper. In these analyses, no items were
dropped: factors were allowed to emerge freely, the only
constraint being an eigenvalue ‡1. Themes emerging from the
CBI and CDI show few similarities, particularly in labelling.
In summary, the first pattern is exploratory or inductive, in
which newly labelled factors were allowed to emerge.
However, in only a few situations were the emerging factors
compared with those already existing in the literature.
The second pattern also involves exploratory analysis, but
with added a priori categorizations of caring themes. These
may be based on explicit theories or on conceptualizations.
For instance, Nkongho’s CAI (1990) includes eight themes
that are based on Mayeroff’s conceptualization (1971). The
objective was to identify a factorial structure while requiring
items to be strongly related to the emerging factors. Nkongho
reported three emerging factors: ‘knowing’, ‘courage’ and
‘patience’. All of the items that composed the ‘knowing’
factor were part of the a priori ‘knowing’ caring theme. The
two other factors were composed of items that were part of
several other factors. Items grouping with factor 2 were all
negatively worded. Items grouping with factor 3 reflected
‘tolerance’ and ‘persistence’. However, none of these themes
were clearly identified as a priori.
We also found similar patterns in two other scales. The
CARE-SAT (Larson & Ferketich 1993) was based on six a
priori themes not related to a specific theory or conceptua-
lization. In this three-factor structure, the factors grouped
items that were originally attached to several a priori themes.
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The CBA (Stanfield 1991), based on Watson’s Theory of
Caring (1979, 1988), is similar and based on seven a priori
themes. The emerging structure consisted of four factors,
each also composed of a mix of items that were part of
several a priori themes.
Hughes (1998) proposed a priori themes without reference
to a specific theory or conceptualization (four for the OCCQ
and two for the PGCIS). Results tended to support the
underlying a priori themes because the emerging factors
grouped items that already belonged to their a priori caring
themes. Once again, negatively worded items grouped
together; this resulted in a slightly different emerging factorial
structure than that originally proposed.
In this second pattern, the analysis also served to reduce the
number of items which allowed a clearer factorial structure
for the CAI and CARE-SAT. This was not the case for the
CBA, the OCCQ and the PGCIS, for which all items were
kept, irrespective of their psychometric properties. Most of
the themes for the CAI, CARE-SAT and CBA were not clearly
supported by data, while the a priori themes were more
clearly supported for the OCCQ and PGCIS. The second
pattern of scale development therefore reflects a combination
of deductive and inductive approaches.
The third, largely deductive, pattern was to propose a priori
themes. In this process, investigators may choose to retain, or
remove, items that are the most representative of the themes. In
the development of CAPSI, Arthur et al. (2001) proposed three
a priori caring themes and, while caring theorists such as
Leininger (1985) and Watson (1979, 1988) are mentioned as
sources for the generation of items, no specific theory was
behind the conceptualization. They began the analysis with 60
items and ended up with 31 because items that were not
strongly related to a specific emerging factor were dropped.
Results tend to support the a priori structure of the caring
themes. Emerging factors 1 and 2 reflect the ‘theoretical
perspective’ (factor 1 includes positively worded items and
factor 2 includes negatively worded items). Factor 3 reflected
the ‘practical dimension’ and factor 4 reflected the ‘pedagogical
dimension’. Deduction was also involved in the case where two
weak factors not a priori defined were removed, as well as items
not related to the a priori caring themes. However, induction
also occurred by allowing four factors to emerge, while three
had originally been proposed.
Lin (2001) used a similar approach to develop CBS. She
proposed a series of items that were based on qualitative
interviews. To strengthen content validity, the number of
items was reduced from 97 to 56. Initial factor analysis
yielded more than the three factors she anticipated and the
emerging factors were not clearly interpretable. Instead, by
relying on the standard eigenvalue ‡1 criterion, she forced a
Methodological issues in nursing research
three-factor structure representative of the three original
caring themes. Here, both deduction and induction occur:
factors not clearly interpretable were removed and items were
selected based on an inductive process.
The study
Aim
The aim of these studies was to describe what constitutes
caring in nursing. However, as Swanson (1999) has reported,
there is a lack of cohesion among them because they do not
build on prior research or theory. This is counter-productive.
For instance, Watson’s theory proposes 10 carative factors,
but in a previous work, we reported that none of the existing
scales was built on a 10-factor structure (Cossette et al.
2005). To fill this gap, we developed the CNPI-Long Scale,
specifically built on her 10-factor structure. Although we did
not perform factorial analysis, we did observe that the inter-
relationships among the 10 subscales were moderate to high,
at least in part empirically reflecting the theoretical intercon-
nection between the 10 factors. While theoretically sound,
such high correlations are methodologically difficult when
assessing the independent contribution of each subscale to
patient outcomes. In addition, we observed that our 70-item
scale was sometimes difficult to use in clinical studies,
particularly where the duration of the questionnaire is an
important consideration, such as with severely ill patients.
Our objective, therefore, was to develop a shortened version
of our original CNPI scale and assess its validity and
reliability.
Theoretical framework
The initial CNPI-Long Scale was based on Watson’s (1979,
1988) theory because the factors she identified provide clear
guidelines for nurse–patient interaction (Tomey & Alligood
2002). According to Watson’s theory, the nurse must develop
and sustain an authentic helping–trusting caring relationship
with the patient in order to promote healing and health and
to foster the patient’s dignity and humanity. She identifies 10
carative factors for both therapeutic relationships and clinical
activities.
• F1, formation of a humanistic-altruistic system of values;
• F2, instillation of faith–hope;
• F3, cultivation of sensitivity to one’s self and to others;
• F4, development of a helping–trusting, human caring
relationship;
• F5, promotion and acceptance of the expression of positive
and negative feelings;

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Caring nurse–patient interactions: short scale development
• F6, systematic use of a creative problem-solving caring
process;
• F7, promotion of transpersonal teaching–learning;
• F8, provision for a supportive, protective and/or corrective
mental, physical, societal and spiritual environment;
• F9, assistance with gratification of human needs;
• F10, allowance for existential-phenomenological-spiritual
forces.
To achieve our objective in this study it was necessary to
reduce the number of dimensions so that each could be
assessed with a reasonable number of items. We therefore
grouped the 10 carative factors into three caring domains:
Humanistic Care, Relational Care and Clinical Care. The first
three factors reflect the philosophical aspect of caring
(Watson 1979, 1988). They are interdependent and reflect
the individual’s value system. They were grouped theoretic-
ally into our first domain: Humanistic Care.
Watson (1979, 1988) also emphasizes the therapeutic
relationship, which is dependent on the humanistic domain,
but goes beyond it. She states that factors 4 and 5 are highly
related and constitute the major elements of a therapeutic
relationship. To develop such a relationship, the nurse must
take into account the patient’s perceptions of a particular
situation – best represented in F10. Creative problem-solving
underlies all carative factors; however, it is particularly
prominent in the therapeutic relationship. The nurse attempts
to appreciate the patient’s perceptions of a situation with the
goal of optimizing the link between mind and body (F6). We
thus grouped factors 4, 5, 6 and 10 into a second caring
domain: Relational Care.
We created a third domain for factors 7, 8 and 9. These
three carative factors reflect the nurse’s response and clinical
skills needed to respond to patient health problems. We
grouped these factors into a third caring domain: Clinical
Care.
Sample
Our convenience sample composed of 377 students at the
beginning of the first, second or third year of a 3-year
baccalaureate nursing programme.
Data collection
Data were collected in September, 2003. The student
volunteers were then given the CNPI-Long Scale (70 items)
and a socio-demographic questionnaire to complete within an
hour. For each scale item, no more than 2% of data were
missing: this was replaced with the modal response for the
respective item.
207
S. Cossette et al.
The development of our original scale is described
elsewhere (Cossette et al. 2005). To validate the CNPI-Short
Scale, respondents were asked to score each of the 70 items of
the scale (from 1, ‘not at all’ to 5, ‘extremely’) on three
dimensions: Importance, competence and realism.
Ethical considerations
The Chair of the Health Sciences Ethics Committee of the
University of Montreal approved the study. Students were
given an explanation of the study, the nature of their
participation, assured of confidentiality and anonymity, and
the voluntary nature of their participation.
Data analysis
We used exploratory factor analysis, with varimax rotation,
to investigate patterns of inter-relationships among items. We
examined the scree plot to get a visual impression of the
number of factors emerging. According to Garson (2005),
‘When the drop ceases and the curve makes an elbow toward
less steep decline, Cattell’s scree test says to drop all further
components after the one starting the elbow’. We used an
orthogonal (varimax) rotation to identify the items that most
discriminated among the three caring domains and to
minimize inter-correlations among emerging factors. Items
were retained only if they were grouped along with the
counterpart that was originally attached to a particular
caring domain. For example, items from the F1, F2 and F3
carative factors of the Long Scale were theoretically attached
to the Humanistic Care domain (19 items). Twenty-five items
were theoretically attached to the Relational Care domain
and 26 to the Clinical Care domain. We calculated alpha
coefficients to assess internal consistency and Pearson coef-
ficients to examine the strength of the relationships among
the domains and assess their relative independence. We also
assessed, using Pearson coefficients, how strongly the three
domains selected for the Short Scale were reflective of each of
the 10 carative factors of the original scale.
Results
Socio-demographic characteristics
The sample (n ¼ 377) was largely composed of women
(80Æ1%), and their average age was 26Æ5. Slightly more than
half (57Æ6%) were in their first year of a nursing programme.
A quarter was in second year and the remainder in the final
year. In addition to nursing, 41% reported having also begun
or finished a prior university programme. Most participants
208
were enrolled in a baccalaureate programme designed for
students following junior college general health sciences
preparation. The remaining students (12Æ2%) were already
Registered Nurses and a little less than half had regular part-
time employment; of those, the majority (88Æ4%) worked in a
general or specialized hospital care environment. Slightly
more than half of the students were born in Canada. Full
details are presented in Table 2.
Validity of the Short Scale: new dimensional structure of
the scale
For the factor analysis we totalled the respondents’ scores for
the three dimensions, for each item. Scales for each item,
therefore, varied between 0 and 15. Suitability of data was
estimated using the Kaiser–Meyer–Olkin index. The index
for this sample was 0Æ94, which is considered to be
exceptional for a factor analysis (Kaiser 1974).
The scree plot indicates four main factors, as shown by a
break in the straight line between the fourth and fifth
components. The first four factors explained 14Æ84, 13Æ31,
7Æ45 and 5Æ89% of the variance. Nineteen items loaded
primarily on the first statistical factor, with 10 theoretically
attached to Relational Care, five to Humanistic Care and four
attached to Clinical Care. This first factor was therefore
labelled ‘Relational Care’. Ten items loaded primarily on the
second factor. Of these, nine were theoretically attached to
Clinical Care; the other was theoretically attached to Rela-
tional Care. Our second statistical factor was labelled
‘Clinical Care’.
Table 2 Socio-demographic characteristics of the sample (n ¼ 377)
% (n)
Gender (% women) 80Æ1 (302/377)
Age (range 18–55) (mean ± SD ) 26Æ5 ± 7Æ6
Country of origin (% born in Canada) 59Æ4 (224/377)
Baccalaureate level (1, 3)
First year 57Æ6% (217/377)
Second year 26% (98/377)
Third year 16Æ4% (62/377)
Registered Nurse (% yes) 12Æ2% (46/377)
Lapse of time since the nurse collegial Mean of 3 years:
diploma among Registered 56Æ5% (26/46)
Nurses (n ¼ 46) <1 year
Employment status among Registered
Nurses (n ¼ 45)*
Regular full-time 26Æ7% (12/45)
Regular part-time 42Æ2% (19/45)
Occasional part-time 26Æ7% (12/45)
Not working 4Æ4% (2/45)
*One nurse did not indicate their employment status.

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Methodological issues in nursing research
Ten items loaded primarily on the third factor, among which
six were also theoretically attached to Clinical Care, three
were attached to Relational Care and one to Humanistic
Care. However, the six items attached to Clinical Care
indicated comfort as opposed to factor 2 which indicated
‘Clinical Care’. As such, the third factor was labelled
‘Comforting Care’.
The fourth factor included eight items, among which four
were theoretically attached to Humanistic Care, two to
Clinical Care and two to Relational Care. We labelled the
fourth factor ‘Humanistic Care’. The first analysis, therefore,
indicated that 47 items tapped the first four statistical factors,
among which 29 were grouped with their counterparts.
Our goal was to reduce the number of items, while keeping
the theoretical caring domains relevant. However, as the
original Clinical Care domain was divided into ‘clinical’ and
‘comforting’ care, we accepted this distinction and pursued
the analysis with four caring domains in mind. We also took
the theoretical attachment of items to their particular
domains into consideration. If, for instance, an item theor-
etically attached to Relational Care was loading primarily on
the first statistical factor, Relational Care, it was retained. If
it was attached to another domain it was removed. Bi-
dimensional items (those that primarily loaded on their
theoretical domain, but also loaded on a secondary factor
with a coefficient ‡0Æ40) were also removed. Based on these
criteria, the nine incorrectly classified items were removed
from the Relational Care factor (factor 1). For factor 2 –
Clinical Care, one item incorrectly classified was removed.
Six items were removed from factor 3 – Comforting Care.
Among these six, four were incorrectly classified and two
were correctly classified while bi-dimensional with other
statistical factors. The four incorrectly classified items were
removed for factor 4 – Humanistic Care.
Next, we carried out the same analysis a second time with
the remaining 27 items. A four-factor structure emerged with
factor 1, including seven items attached to Relational Care,
and factor 2 including nine items attached to Clinical Care.
Factor 3 included seven items: four attached to Humanistic
Care and three attached to Relational Care. Factor 4 included
four items attached to Comforting Care, of which one was bi-
dimensional, i.e. also loading ‡0Æ40 on another statistical
factor. The three items of factor 3 attached to Relational Care
and the bi-dimensional item of factor 4 were removed in the
latest analysis. Removing these items resulted in a clear 23-
item solution, explaining 64Æ45% of the variance (22Æ56%,
22Æ07%, 10Æ41% and 9Æ41%, respectively, for factor 1 –
Clinical Care (nine items), factor 2 – Relational Care (seven
items), factor 3 – Humanistic Care (four items) and factor 4 –
Comforting Care (three items). All items loaded at more than

2006 The Authors. Journal compilation
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Caring nurse–patient interactions: short scale development
0Æ40 on the theoretical factor to which they were primarily
attached (Table 3). No items were bi-dimensional.
Reliability of the Short Scale
For the remainder of the analyses presented here, the original
answer format was retained. For each item, the scores vary
from 1 to 5. We assessed internal consistency and, as shown
in Table 4, alpha coefficients varied from 0Æ63 to 0Æ74 for
Humanistic Care, from 0Æ90 to 0Æ92 for Relational Care, from
0Æ80 to 0Æ94 for Clinical Care and from 0Æ61 to 0Æ76 for
Comforting Care.
Relationships between the four CNPI-Short Scale domains
Pearson coefficients, shown in Table 4, between the Human-
istic Care and Relational Care domains varied from 0Æ47 to
0Æ63. Coefficients between the humanistic and Clinical Care
domains varied from 0Æ38 to 0Æ55 and from 0Æ46 to 0Æ71
between the relational and Clinical Care domains. Coeffi-
cients between comforting and humanistic (0Æ35 to 0Æ54),
relational (0Æ41 to 0Æ57) and Clinical Care domains (0Æ49 to
0Æ68) were moderate.
Relationships between the four domains of the CNPI-
Short Scale and the 10 factors of the CNPI-Long Scale
The Short Scale is composed of four caring domains, while
the original scale was built on a 10-carative factor structure;
therefore, we explored which of the 10 factors of the original
scale are essentially captured by the four domains of the Short
Scale.
Results showed that, overall, patterns are similar for each
dimension (importance, competency and realistic). As shown
in Table 5, the relationships for the Short Scale Humanistic
Care domain were 0Æ72 with the F1 – humanism carative
factor of the original scale, 0Æ73 with the F2 – hope factor and
0Æ52 with the F3 – sensitivity factor (on the importance
dimension). This indicates that the strongest relationships
between the Humanistic Care are with F1 – humanism and
F2 – hope, followed to a lesser extent by F3 – sensitivity.
Results were similar for the competency and reality aspects.
The Short Scale Relational Care domain is more strongly
related to the F6 – problem-solving and F10 – spirituality
factors of the original scale than to F4 – helping relationship
and F5 – expression of emotions factors for the importance,
competence and realistic dimensions. The Short Scale Clinical
Care domain was more related to the F9 – needs factor for the
three dimensions evaluated. Lastly, the Comforting Care
domain was almost equally represented by F9 – needs, F7 –
209
S. Cossette et al.

Table 3 Items and factor loading of the Caring Nurse–Patient Interaction-Short Scale

Item Factor loading

Clinical Care
Know how to give the treatments (e.g. intravenous injections, bandages etc.) 0Æ88 0Æ09 0Æ07 0Æ04
Know how to operate specialized equipment (e.g. pumps, monitors, etc.) 0Æ87 0Æ06 0Æ08 0Æ02
Check if their medications soothe their symptoms (e.g. nausea, pain, constipation, anxiety, etc.) 0Æ75 0Æ17 0Æ15 0Æ28
Give them indications and means to treat or prevent certain side-effects of their medications or treatments 0Æ75 0Æ25 0Æ10 0Æ12
Know what to do in situations where one must act quickly 0Æ68 0Æ23 0Æ10 0Æ13
Help them with the care they cannot administer themselves 0Æ67 0Æ25 0Æ19 0Æ32
Show ability and skill in my way of intervening with them 0Æ66 0Æ35 0Æ19 0Æ24
Closely monitor their health condition 0Æ52 0Æ24 0Æ28 0Æ16
Provide them with the opportunity to practice self-administered care 0Æ45 0Æ32 0Æ26 0Æ31
Relational Care
Help them to look for a certain equilibrium/balance in their lives 0Æ17 0Æ85 0Æ13 0Æ09
Help them to explore what is important in their lives 0Æ17 0Æ84 0Æ22 0Æ06
Help them to clarify which things they would like significant persons to bring them 0Æ25 0Æ78 0Æ18 0Æ07
Help them to explore the meaning that they give to their health condition 0Æ26 0Æ78 0Æ16 0Æ10
Help them to recognize the means to efficiently resolve their problems 0Æ21 0Æ75 0Æ21 0Æ21
Help them to see things from a different point of view 0Æ11 0Æ74 0Æ22 0Æ17
Try to identify with them the consequences of their behaviour 0Æ24 0Æ68 0Æ05 0Æ35
Humanistic Care
Consider them as complete individuals, show that I am interested in more than their health problem 0Æ10 0Æ20 0Æ73 0Æ11
Encourage them to be hopeful, when it is appropriate 0Æ16 0Æ32 0Æ69
0Æ03
Emphasize their efforts 0Æ10 0Æ29 0Æ65 0Æ15
Do not have an attitude of disapproval 0Æ25
0Æ01 0Æ61 0Æ28
Comforting Care
Respect their privacy (e.g. do not expose them needlessly) 0Æ08 0Æ14 0Æ25 0Æ78
Take their basic needs into account (e.g. sleeping, hygiene, etc.) 0Æ35 0Æ21 0Æ23 0Æ68
Do treatments or give medications at the scheduled time 0Æ39 0Æ28
0Æ04 0Æ61

Table 4 Alpha coefficients (on the diagonal) and Pearson correlation Discussion
coefficients for the four caring domains
The 10 carative factors identified by Watson (1979, 1988)
Caring Nurse–Patient
Interaction-Short Humanistic Relational Clinical Comforting
served as the theoretical framework for our original 70-item
Scale (number of items) Care Care Care Care CNPI-Long Scale. However, in clinical studies the length of
the questionnaire was sometimes problematic. In addition,
Humanistic Care (4) 0Æ63
we observed that the inter-correlations among the 10
0Æ74
0Æ68 subscales were high, suggesting some overlap between the
Relational care (7) 0Æ47 0Æ90 measure of the 10 carative factors. This overlap is theoret-
0Æ63 0Æ92 ically acceptable because it is obvious that they are not
0Æ49 0Æ90 independent in clinical practice. The outcome of the present
Clinical Care (9) 0Æ55 0Æ48 0Æ80
study is a shortened version of the original scale, the CNPI-
0Æ52 0Æ71 0Æ94
0Æ38 0Æ46 0Æ88 Short Scale, that is still theoretically bound to Watson’s
Comforting Care (3) 0Æ40 0Æ41 0Æ56 0Æ70 human caring theory and had strong psychometric proper-
0Æ54 0Æ57 0Æ68 0Æ76 ties. The resulting four-factor structure incorporates 23
0Æ35 0Æ45 0Æ49 0Æ61 items. All items were grouped into and with the caring
First row: importance; second row: competence; third row: realistic domain to which they were theoretically attached, and not
aspect of caring. to other domains.
Using factor analysis, we retained only four items from the
teaching and F8 – environment for the importance and Humanistic Care domain (vs. 19 for the original
competence domain whereas, for the realistic dimension, a scale ¼ 21%) and seven the Relational Care domain (vs.
higher correlation was observed with the F9 – needs carative 25 ¼ 28%). This suggests that attitudes and behaviours
factor. within the humanism domain are more difficult to identify

210
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 Methodological issues in nursing research Caring nurse–patient interactions: short scale development

and refer more to an internal way of being than external

Comforting

Coefficients in bold emphasise the relationships between the original 10 carative factors of the CNPI-Long Scale that were theoretically attached to the caring domains in the CNPI-Short
manifestations. They reflect the personal value system (Wat-

Care

0Æ45
0Æ43
0Æ53
0Æ62
0Æ46
0Æ50
0Æ63
0Æ68
0Æ67
0Æ38
son 1988). In this shortened version, the four items for the
Clinical Humanistic Care come exclusively from the F1 – humanism
and F2 – hope factors, and no items were retained from F3 –
Care

0Æ48
0Æ51
0Æ41
0Æ39
0Æ40
0Æ58
0Æ78
0Æ60
0Æ93
0Æ37
sensitivity. Items for Relational Care come from the F6 –
problem-solving and F10 – spirituality factors, with no items
Relational

retained from F4 and F5. The items we kept are more

Table 5 Pearson correlations between the four domains of Caring Nurse–Patient Interaction (CNPI)-Short Scale and the 10 factors of the CNPI-Long Scale

independent of each other than items that were rejected (i.e.

0Æ59
0Æ70
0Æ77
0Æ69
0Æ71
0Æ88
0Æ68
0Æ74
0Æ60
0Æ86
care

those assessing F3 – sensitivity, F4 – helping relationship and

F5 – expression of emotions). We can speculate that these
Humanistic
Realistic

three later carative factors tapped an underlying construct

behind the four retained domains and were not related
0Æ79
0Æ77
0Æ55
0Æ53
0Æ59
0Æ59
0Æ55
0Æ52
0Æ46
0Æ55
care

specifically to a particular one.

Comforting

Items related to Humanistic Care refer to a nurse’s attitude

and behaviours with regard to a patient’s own capacities and
Care

0Æ58
0Æ60
0Æ63
0Æ65
0Æ56
0Æ61
0Æ76
0Æ80
0Æ77
0Æ50

abilities (internal resources). This implies an attitude of

empowerment (i.e. considering them as complete individuals,
Clinical

encouraging them to be hopeful, emphasizing their efforts and

Care

0Æ49
0Æ68
0Æ65
0Æ54
0Æ60
0Æ75
0Æ89
0Æ79
0Æ97
0Æ64

not, themselves, exhibiting an attitude of disapproval). Items

retained in Relational Care pertain to the nurse respecting the
Relational

patients’ perceptions while assisting them to recognize the

meaning associated with their health situation (e.g. helping
0Æ59
0Æ83
0Æ83
0Æ65
0Æ78
0Æ93
0Æ77
0Æ74
0Æ77
0Æ89
care

them find an equilibrium, to explore what is important in their

Competence

Humanistic

lives, to explore the meaning that they give to their health

conditions and to see things from a different point of view).
Care

0Æ80
0Æ81
0Æ66
0Æ70
0Æ70
0Æ67
0Æ64
0Æ69
0Æ57
0Æ64

Twenty-six items were theoretically attached to the

original Clinical Care carative factors, including F7, F8 and
Comforting

F9 carative factors items which were part of the CNPI-Long

Scale. Our results suggest that Clinical Care is empirically
Care

0Æ55
0Æ47
0Æ41
0Æ58
0Æ50
0Æ48
0Æ64
0Æ63
0Æ71
0Æ40

represented by a combination of clinical and Comforting

Care items, the subdomains including nine and three items
Clinical

respectively. These 12 items represent 46% of the 26 items

Care

0Æ61
0Æ58
0Æ49
0Æ58
0Æ54
0Æ58
0Æ78
0Æ66
0Æ88
0Æ43
CNPI-Short Scale (4 domains)

originally attached to Clinical Care. Clinical Care is therefore

the domain mostly dominant in the Short Scale, followed by
Relational

All Pearson R coefficients are significant at P < 0Æ001.

Relational Care and Humanistic Care. Clinical Care is the

0Æ58
0Æ71
0Æ77
0Æ66
0Æ68
0Æ90
0Æ67
0Æ76
0Æ63
0Æ87

most visible and tangible of nurses’ work; items retained in

care

this domain represent almost all the expertise required for

Humanistic
Importance

clinical assessment and monitoring, symptom management

and treatment, and procedures. Comforting Care items are
Care

0Æ72
0Æ73
0Æ52
0Æ55
0Æ59
0Æ56
0Æ63
0Æ51
0Æ58
0Æ51

more representative of the hidden work of nursing (Collière

1986, 1996). While the latter items are often described as
CNPI-Long Scale (10 factors)

F5 – expression of emotions

‘low-tech’ and low prestige, they are of primary importance

F4 – helping relationship

to promote healing and health, and enhance the quality of

F6 – problem-solving

care (Wolf 1999, Duffy & Hoskins 2003). As Watson (1988)

F8 – environment

F10 – spirituality

suggests, the caring nurse–patient relationship protects,

F1 – humanism

F3 – sensitivity

F7 – teaching

enhances and preserves the patient’s dignity, humanity and

F9 – needs
F2 – hope

wholeness. Items forming part of this subdomain in the

present study include, for instance, respecting the patient’s
Scale.

privacy and taking their basic needs into account.

2006 The Authors. Journal compilation
2006 Blackwell Publishing Ltd 211
S. Cossette et al.
What is already known about this topic
• Measuring caring to assess its effect on patient health
outcomes is a priority.
• The objective in measuring caring is to label and des-
cribe some of its aspects, even though the concept is not
particularly empirical.
• Theoretical linking of the existing scales with nursing
theories is uncommon because most were developed
using inductive processes, which allowed caring themes
to emerge from data.
What this paper adds
• A new, short version of the Caring Nurse–Patient
Interaction Scale – the CNPI-Short Scale – was con-
structed in accordance with Watson’s Theory of Human
Caring.
• Evidence of validity and reliability of the Short Scale is
presented.
• This scale is suitable for use when the brevity of the
questionnaire is an important consideration.
The factors proposed by Watson are not independent in
theory or in practice. However, in attempting to measure
abstract constructs such as subdomains of caring, it is
necessary to avoid redundancies empirically indicated by
high inter-correlations between subdomains, while still
remaining faithful to the theoretical orientation behind the
measure. In clinical research, this is essential because the
objective is to identify which subdomains are of importance
for a particular patient or circumstance. One feature of the
CNPI-Short Scale is the moderate relationships between the
four caring domains. These moderate relationships are
advantageous in clinical research, to assess the contribution
of each domain on health outcomes. Intercorrelations were
considerably lower than those observed in the original CNPI-
Long Scale. In addition, we compared the Long and Short
Scales to discover which factors in the original 10-carative
factor structure were most strongly represented in the new
four-domain structure. We observed that the CNPI-Short
Scale covers most of the 10 carative factors of the original
scale.
In the literature, the number of factors in exploratory
analysis was allowed to emerge predominantly on the basis of
statistical criteria (see Table 1). It is not surprising that the
items that were part of the emerging statistical factors in
many methodological studies were not those belonging to the
caring themes. While this technique permits the discovery of
212
caring domains by allowing data to group among themselves,
the number and quality of the factors will always change with
new samples because factors are data-dependent. A conse-
quence of this would be the possibility that an endless
number of caring domains might eventually emerge: this
would impede the development of a body knowledge that is
based on current theories (Paley 2001). In contrast, the
contribution of our study is that it retains a combination of
inductive and deductive approaches.
Watson’s theory is widely applied in education, research
and Clinical Care, perhaps because it gives clear indications
to nurses about attitudes and behaviours that are associated
with healing and health. Although caring has been studied for
more than 20 years, the development of this body of
knowledge would have been more organized if existing
theories had been refined and further developed. However,
most scales were developed in exploring caring domains
without tempting to verify any specific theory, while all
scholars are expressing their theoretical allegiance to caring
as the essence of nursing (Table 1).
Study limitations
This study had limitations. Empirical considerations obvi-
ously come into account in the development of the CNPI-
Short Scale. In addition, while a large sample size is more
easily attained with a sample of nurses and students, it would
also be interesting to verify the domain structure with
samples of patients and families. This is one challenge for
future work. It is also our intention to implement a
confirmatory factor analysis to study the factorial structure
of the CNPI-Short Scale.
Conclusion
It is imperative for nursing to move on from describing caring
as a research goal to documenting its effects on patient
outcomes. Attempting to measure caring involves document-
ing the caring work done by nurses, which is often not
perceived both by themselves and those outside the field
(Lawler 1991, Wolf 1999). This analysis contributes to the
existing literature on caring by proposing a theory-driven
Short Scale that will be useful in clinical research to examine
links between caring and patient outcomes.
A comprehensive assessment of caring should include all 10
carative factors if researchers and clinicians are to be guided
by Watson’s theory. The long version of the CNPI-Long Scale
is an example. However, in clinical research, our shorter
version will prove useful, particularly for patients who
cannot cope with a long questionnaire. It is to be hoped that

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2006 Blackwell Publishing Ltd
Methodological issues in nursing research
research into caring measurement body of knowledge will
reach theoretical saturation and render more accessible
description of nursing in clinical practice. We conclude with
a note of caution. If endlessly expanded, this concept of
caring in nursing might not survive: it might eventually
incorporate almost every possible theoretical combinations of
words and expressions that would be impossible to compre-
hend in clinical practice.
Acknowledgements
This study was supported in part by a Junior Research
Fellowship held by Sylvie Cossette (2001–2005) from the
Fonds de la recherche en santé du Québec (FRSQ) (13125-
342) and the Fondation de recherche en sciences infirmières
du Québec (FRESIQ). The authors thank the students and
academic staff of the University of Montreal, Faculty of
Nursing.
Author contributions
SC, JP and NR were responsible for the study conception and
design and drafting of the manuscript; SC performed data
collection and data analysis; SC obtained funding and
provided administrative support; SC provided statistical
expertise; SC, JC, JP, NR and LXD made critical revisions
to the paper; SC supervised the study.
References
Arthur D., Pang S. & Wong T. (2001) The effect of technology on the
caring attributes of an international sample of nurses. International
Journal of Nursing Studies 38, 37–43.
Bandura A. & Ullmann L. (1965) Research in Behavior Modification:
New Developments and Implications. Holt, Rinehart and Win-
ston, Toronto, ON, Canada.
Clifford C. (1995) Caring: fitting the concept to nursing practice.
Journal of Clinical Nursing 43, 37–41.
Coates C.J. (1996) Development of the Caring Efficacy Scale: Self-
Report and Supervisor Versions. Unpublished. University of
Colorado Health Sciences Center, Denver, CO, USA.
Coates C. (1997) The caring efficacy scale: nurses’ self-reports of
caring in practice settings. Advanced Practice Nursing Quarterly
3(1), 53–59.
Collière M.-F. (1986) Invisible care and invisible women as health
care-providers. International Journal of Nursing Studies 23(2),
95–112.
Collière M.-F. (1996) Soigner… le premier art de la vie. InterÉdi-
tions, Paris.
Cossette S., Cara C., Ricard N. & Pepin J. (2005) Assessing nurse–
patient interactions from a caring perspective: report of the
development and preliminary psychometric testing of the Caring

2006 The Authors. Journal compilation
2006 Blackwell Publishing Ltd
Caring nurse–patient interactions: short scale development
Nurse–Patient Interactions Scale. International Journal of Nursing
Studies 42, 673–686.
Duffy J.E. & Hoskins L.M. (2003) The Quality-Caring Model
:
blending dual paradigms. Advances in Nursing Sciences 26(1), 77–
88.
Garson D.G. (2005) Quantitative Research in Public Administration.
Retrieved from North Carolina State University, Programs in
Public Administration Web site http://www2.chass.ncsu.edu/
garson/pa765/factor.htm on November 4, 2005.
Grobe S.J. & Hughes L.C. (1993) The conceptual validity of a tax-
onomy of nursing interventions. Journal of Advanced Nursing 18,
1942–1961.
Hughes L.C. (1993) Relationships among the organizational char-
acteristics of baccalaureate schools of nursing and the student-
perceived organizational climate for caring. Unpublished doctoral
dissertation, University of Texas, Austin, TX.
Hughes L. (1998) Development of an instrument to measure caring
peer group interactions. Journal of Nursing Education 37, 202–
207.
James N. (1992) Care ¼ organisation þ physical labour þ emo-
tional labour. Sociology of Health and Illness 14, 488–509.
Kaiser H.F. (1974) An index of factorial simplicity. Psychometrika
39, 31–36.
Larson P.J. & Ferketich S.L. (1993) Patients’ satisfaction with nurses’
caring during hospitalisation. Western Journal of Nursing
Research 15, 690–707.
Lawler J. (1991) Behind the Screens: Nursing, Somology and the
Problem of the Body. Churchill Livingstone, New York.
Lea A., Watson R. & Deary I.J. (1998) Caring in nursing: a multi-
variate analysis. Journal of Advanced Nursing 28, 662–671.
Leininger M.M. (1985) Transcultural care diversity and universality:
a theory of nursing. Nursing and Health Care 6, 208–212.
Lin P.-F. (2001) Development and psychometric evaluation of the
Caring Behaviors Scale of Baccalaureate Nursing Student in Tai-
wan. Unpublished doctoral dissertation, Boston College School of
Nursing, Boston.
Mayeroff M. (1971) On Caring. Harper & Row, New York.
Nkongho N.O. (1990) The caring ability inventory. In Measurement
of Nursing Outcomes. Volume 4: Measuring Client Self-Care and
Coping Skills (Strickland O.L. & Waltz C.F., eds), Springer, New
York, pp. 3–16.
Noddings N. (1984) A Feminine Approach to Ethics and Moral
Education. University of California Press, Berkeley, CA.
Paley J. (2001) An archaeology of caring knowledge. Journal of
Advanced Nursing 36(2), 188–198.
Rummel R.J. (1970) Applied Factor Analysis. Northwester Univer-
sity Press, Evanston.
Stanfield M.H. (1991) Watson’s caring theory and instrument
development. Dissertation Abstracts International 52(8), 4128B.
Strickland O.L. (2003) Patient outcomes and measures: special con-
siderations. Journal of Nursing Measurement 11(2), 91–95.
Swanson K.M. (1999) What is known about caring in nursing sci-
ence. In Handbook of Clinical Nursing Research (Hinshaw A.S.,
Feetham S.L. & Shaver J.L.F., eds), Sage, Thousand Oaks, CA,
pp. 31–60.
Tomey A.M. & Alligood M.R. (2002) Nursing Theorist and Their
Work, 5th edn. Mosby, St Louis, MO.
213
S. Cossette et al.
Watson J. (1979) Nursing: The Philosophy and Science of Caring.
Little Brown, Boston, TX.
Watson J. (1988) Nursing: human science and human care. A theory of
nursing. National League for Nursing Publications 15–2236, 1–111.
Watson J (2002) Assessing and Measuring Caring in Nursing and
Health Science. Springer, New York.
Watson R., Deary I.J. & Lea A. (1999) A longitudinal study into the
perceptions of caring among student nurses using multivariate
214
2006 The Authors. Journal compilation
2006 Blackwell Publishing Ltd
analysis of the Caring Dimensions Inventory. Journal of Advanced
Nursing 30, 1080–1089.
Wolf Z.R. (1999) Making nursing work visible inside and outside the
profession. Pennsylvania Nurse 54(1), 21–24.
Wolf Z.R., Giardino E.R., Osborne P.A. & Ambrose M.S. (1994)
Dimensions of nurse caring. Image – The Journal of Nursing
Scholarship 26, 107–128.