Published on International Journal of Health, Nursing, & Medicine
Publication Date: June 26, 2019
Chukwuma Adaobi, Oppong Patience & Atianashie Miracle
Catholic University College of Ghana
University of Cape Coast
We sightseen the impact of gender role coordination (masculinity (manliness); and femininity (womanliness)) on student nurses caring behavior and critical thinking. The Background presented that, Caring and critical thinking are at the core of professional nursing education. Previous studies revealed inconsistent findings regarding the impact of gender roles on caring behavior and critical thinking. Design and Methods: We employed a quantitative correlational study. Nursing students (N=449; female=310, male=139) who had at least had one month of clinical practice experience were recruited from four universities in Ghana. Students’ ages ranged from 19 to 29 years (Mean age=21.24 years, SD=1.28). Data were Collected from August 2018 to march 2019, using three questionnaires: Critical Thinking Disposition Inventory (CTDI), Caring Assessment Report Evaluation Q-sort Scale (CARE-Q), and Bem Sex Role Inventory (BSRI). Partial least squares structural equation modelling and generalized linear models were conducted to test the research model and hypotheses. However, Results Findings indicated that students who reported higher caring and masculinity presented greater critical thinking (ß=.37 and ß = 0.24, respectively; ps<.001). Students’ gender, age, femininity, or clinical practice experience, however, were not significantly associated with critical thinking (ß = -0.01, ß = 0.09, ß=.10, and ß=0.01, respectively; ps>.05). In addition, students who reported higher masculinity and femininity presented greater caring behavior (ß=.22 and ß=0.38, respectively; ps<.001). Students’ gender, age or clinical practice experience were not significantly associated with caring behavior (ß=.04, ß=.03, and ß = -0.05, respectively; ps>0.05). The findings confirmed a direct influence of caring and masculinity on critical thinking. Masculinity indirectly affected critical thinking via caring behavior. Caring and masculinity accounted for 34.4% of the variance in critical thinking, and masculinity and femininity accounted for 29.1% of the variance in caring behavior. In Assumption: Our study confirms the consequence of age, gender role, and caring behavior on critical thinking. We Acclaim that the cultivation of nursing care conduct focus on students’ gender role coordination. In addition, clinical nurse educators, when working with male students on patient caring, should consider their gender role Coordination and support male nursing students’ ways of presenting caring conducts.
Keywords: Gender character, Nurses’ behavior, Critical thinking, Caring behaviors.
Loving and critical thinking are at the core of professional nursing tutelage. Perhaps Caring or loving behavior is a subjective experience and involves a physiologic rejoinder in patients (Morse et al., 2013), which also anguishes students’ critical thinking (Chen et al., 2018; Pai et al., 2013). Nursing, however, is a female-oriented profession. Contemporary, the number of male nurses has been increasing, but many face gender role strain in the current nursing environment (Keogh and Gleeson, 2006). There is a myth that female nurses are more caring and have more feminine traits, whereas male nurses have more masculine traits (Abrahamsen, 2004). These beliefs, however, could mislead educators. Understanding gender roles in nursing can help nursing educators to have more effectual Philosophy approaches with students.
More a moment ago, Adams (2016) noted that the provision of caring behaviors, which we identify as at the core of nursing, faces challenges due to changes in the medical environment, political climate, and the complexities of patient care. In this regard, nursing professionals and theorists of caring behavior provide various insights into the core of nursing behavior, from which the definition of caring behavior can be clarified or redefined. We expect that the findings of this study of the relationships between gender role, caring behavior, and critical thinking can contribute to future revisions or amplification of the definition of caring.
What is already known about the topic?
a. Students’ presentation of caring behavior affects their critical thinking.
b. Gender has no significant effect on students’ perceptions of caring behaviors and critical-thinking dispositions.
c. Male nurses face gender role strain in the current nursing environment because there is a myth that female nurses are more caring, as it is a feminine trait, whereas male nurses’ masculinity is not considered to be related to caring.
Newfangled points of this paper or what it adds;
a. There are no sex differences in the presentation of caring behavior, critical thinking, masculinity, or femininity.
b. Nursing students who reported higher femininity presented greater caring behavior than did their less feminine counterparts but did not show better critical thinking. Students’ femininity was only indirectly associated with their critical thinking through their caring behavior.
c. Nursing students who reported higher masculinity presented greater caring behavior and critical thinking as compared to their less masculine counterparts
d. Gender aforementioned is not a paramount prognosticator of moderate comportment or critical thinking; rather, the key variable is students’ gender character.
2. Caring behavior and critical thinking
Ennis (1962) defined critical thinking as ‘the correct assessing of statements’ (p. 81), while Paul et al. (1990) defined it as the process of conceptualizing, applying, analyzing, synthesizing, or evaluating information from observation, experience, self-reflection, reasoning, or communication. Critical thinking is related to caring behavior, which stems from having special affection or concern for the recipient of care (Leira, 1994). Morse et al. (2013) surveyed caring and branded two magnitudes: a subjective experience and a physiological response. Thayer-Bacon (1993) accentuated that, without caring, a person cannot be a good critical thinker. Benner and Wrubel (1989) and Ben-Sira (1990) demonstrated that caring actions are vital for nurses in providing care to patients because they help nurses to understand their own thinking and attitudes. Zimmerman and Phillips (2000) noted that taking a caring perspective can stimulate critical-thinking ability in nursing students. Clearly, there is a relationship between care and critical thinking. Previous studies indicated that there is a positive relationship between caring behavior and critical-thinking disposition (Arli et al., 2017; Pai et al., 2013), and further research showed that critical thinking also could be predicted by caring behavior (Chen et al., 2018; Pai et al., 2013).
3. The relationship among caring, critical thinking, age, and gender roles
Previous study found that nurses who were older, had worked longer, and had a higher education level and a more prestigious position/ title had greater critical-thinking ability than did their counterparts (Chang et al., 2011). Hunter et al. (2014), however, found that age and sex did not predict students’ critical-thinking skills. Ghadi et al. (2012) examined critical thinking among male and female undergraduate students in Malaysia and found that there was no significant sex difference. Salahshoor and Rafiee (2016) investigated the relationship between critical thinking and sex among Iranian English-as a- foreign-language learners and also found that men and women did not significantly differ in their application of critical-thinking skills.
Nurses’ age, sex, and experience influence the quality of care that they provide (Crossan and Mathew, 2013; Routasalo, 1999). Previous studies show that older nurses reported higher perceptions of their own caring behavior than did younger ones (Khademian and Vizeshfar, 2008; Li et al., 2016). Among Chinese clinical care nurses, attitude and behavior were positively associated with age and seniority (Jiang et al., 2015). Nevertheless, Labrague et al. (2017) found that there were no significant correlations between caring behavior, educational level, and family structure of student nurses, except for age (p= .002, η2 : eta-squared=0.141). In addition, sex had no significant effect on students’ perceptions of their own caring behaviours (Khademian and Vizeshfar, 2008). These findings are in contrast with earlier research, showing that there was a significant correlation between caring and gender traits in nurses (Laurella, 1997).
4. Literature presented above led us to develop the following hypotheses:
Hypothesis 1. Caring behavior will be absolutely associated with critical thinking.
Hypothesis 2. Gender (male as a reference) will be absolutely associated with caring behavior and critical thinking.
Hypothesis 3. Age will be certainly associated with caring behavior and critical thinking.
Hypothesis 4. Clinical practice experience will be positively associated with caring behavior and critical thinking.
Hypothesis 5. Masculinity and Femininity will be positively associated with caring behavior and critical thinking.
5.1 Study design and procedure
This quantitative correlational cum naturalistic study was approved by the Academic Review Board of Ghana. University of Energy and Natural Resources; Catholic University College of Ghana, Initially, we obtained the administrative assistance of the school nursing department through an e-mail request. Then, the investigator described the purpose of the research to the students in each classroom. Students completed the questionnaire in, incognito after their informed consent was obtained. A convenience sample of 460 nursing students was recruited from these universities in Taiwan. All participants had more than one month of clinical experience. Data were collected from August 2016 to March 2019. A power analysis for t-tests (the difference between independent means for the two groups) was calculated using G*power. The four input parameters were two-tailed, α=0.05, effect size (f2)=0.5, and power=0.80. A sample size of 64 was required for each group. In addition, for the generalized linear model (GLM), we again used four input parameters (two-tailed, α=0.05, effect size (f2)=0.15, and power=0.80). A sample size of 343 was needed. For the partial least squares structural equation modelling (PLS-SEM) analysis, we calculated the sample size based on the rules of degrees of freedom (df) = p(p+1)/2-q (MacCallum et al., 1996), in which p is the number of observed variances to be estimated, and q is the number of free parameters to be estimated. In this study, 12 observed variances and 35 free parameters were estimated (12 factor loadings, 12 for errors, and 11 for the correlations among the latent factors). This yields 43 degrees of freedom to achieve a power value of 0.80, for which a sample size of 294 was needed (MacCallum et al., 1996). Therefore, our sample size of 449 (response rate=97.61%) was sufficient.
Three instruments were used, including the Ghana Critical Thinking Disposition Inventory (GCTDI), Caring Assessment Report Evaluation Q-sort Scale (CARE-Q), and Bem Sex Role Inventory (BSRI). The content validity of these scales was examined by two nursing experts, and all content rationality and cogency indices (CVIs) exceeded 0.89.
5.2.1. Ghana Critical Thinking Disposition Inventory (GCTDI)
Critical thinking was measured using 20 questions from the GCTDI (Yeh, 1998, 1999). This scale has four dimensions: systematicity/ analyticity (9 items), open-mindedness (4 items), inquisitiveness (3 items), and reflective thinking (4 items). Each question is answered using a 6-point Likert-type scale (1 = never to 6 = always), and higher scores indicate higher critical-thinking intention and skill. The subscale score ranges are 9–54, 4–24, 3–18, and 4–24, respectively. A previous study noted that the Cronbach’s αs of the dimensions ranged from 0.83to 0.92 (Yeh, 1999). Recent research indicated that the composite reliability of the scale was 0.97 (Chen et al., 2018).
5.2.2. Caring Assessment Report Evaluation Q-sort Scale (CARE-Q)
Caring behavior was measured using 40 questions from the CAREQ (Chen et al., 2012). The scale has three dimensions: sense of security (16 items), comfort (16 items), and accessibility (8 items). Each question is answered using a 5-point Likert-type scale (1=strongly disagree to 5 = strongly agree), and higher scores indicate more caring behavior. The subscale score ranges are 16–80, 16–80, and 8–40, respectively. A previous study noted that the Cronbach’s αs of the dimensions ranged from 0.91 to 0.93 (Chen et al., 2012), and the composite reliability of scale was 0.97 (Chen et al., 2018).
5.2.3. Bem Sex Role Inventory (BSRI)
Sex role orientation was measured using 16 items from the BSRI (Wang et al., 1997). The scale has two dimensions: masculine instrumentality (8 items) and feminine expressiveness (8 items). Each question is answered using a 7-point Likert-type scale (1 = strongly disagree to 7=strongly agree), and higher scores indicate a greater sex role orientation. The subscale scores range from 8 to 56. A previous study noted that the Cronbach’s αs of the dimensions were>0.77 (Wang et al., 1997; Wang and Wang, 2007).
5.3. Data analyses
First, descriptive statistics were conducted to examine data distributions. The results from a series of bivariate tests (independent t- tests) were used to determine reported caring behavior, critical thinking intention and skills, and gender role orientation per sex. Second, we tested the relationship among all variables through the PLSSEM analysis. Finally, a GLM was conducted to examine the interaction effects of age and femininity on critical thinking. In this study, descriptive statistics and GLM analyses were conducted using SPSS version 20.0 (SPSS Inc., Chicago, IL, USA). PLS-SEM with bootstrapping was conducted, using Smart PLS version 3.2.7 (Ringle et al., 2015) to test the hypotheses. Two-tailed p-values<.05 were considered significant. A standardized root mean residue (SRMR) value of less than 0.05 and a normed fit index (NFI) value above 0.90 would indicate acceptable goodness of fit of the model (Henseler et al., 2014; Henseler et al., 2016). 5.4 Validity and Reliability Gideon (2002) states that validity and reliability are two characteristics which any good researcher should focus on while designing a study, analyzing the results and judging the quality of the study. According to Gideon (2002) in a research work, all the rights things must be measured. Care should be taken such that, the appropriate item is measured (validity); in addition, careful attention should be paid to how the measurement is being made (reliability). This study therefore took into consideration these two key factors during the course of the research work. 6. Results 6.1. Participants’ characteristics Participants’ ages ranged from 19 to 29 years (M=21.24 years, SD=1.28). More than half of the samples (69%) were female. Most participants (85.2%) had religious beliefs, and most (84.2%) perceived their family, in terms of income, as well off. All participants had at least 144 h of practicum experience in foundational nursing. Students’ clinical practice experience ranged from 144 to 1,456 h (M =162.04 h). Approximately half of the participants reported having other practicum experience (e.g., medical-surgical, pediatric, obstetrics) (Table 1). For comparisons between men and women, t-tests for key variables were used. As shown in Table 2, there were no sex differences for age, clinical practice experience, caring behavior, critical-thinking skills, or gender role orientation. Table 1 Participant characteristics (N=449). Table 2 Descriptive statistics (N=449). Females (n=310) Males (n=139) Note: α = Cronbach’s alpha; Diagonal elements in the correlation column are the square root of the average variance extracted for each latent variable. ** p<.01. 6.2. Association among research variables and model testing Table 3 shows the validity, reliability, R-squared (R2), and correlations between variables. The composite reliability (CR) and average variance extracted (AVE) for caring behavior and critical thinking were greater than 0.90 and 0.80, respectively, which are acceptable values per Hair et al.’s (2014) guidelines of 0.70 and 0.5, respectively. The Cronbach’s αs for all variables were above 0.80, which also satisfies the criterion for reliability (> 0.70; Cronbach, 1951). To examine discriminant validity, we calculated the square root of the AVE for both caring behavior and critical thinking. The results of the two values were greater than their highest correlation with any other construct (Table 3), which satisfies the criterion posited by Fornell and Larcker (1981). Other variables, such as age, gender, and clinical experience, were a single, observed indictor, and, thus, their CR, AVE, Cronbach’sαs, and discriminant validity were 1.00 (Ringle et al., 2015). In addition, critical thinking was significantly and positively associated with caring (r=0.52, p < .01), masculinity (r=0.45, p < .01), and femininity (r=0.40, p < .01). A higher level of masculinity and femininity were linked to higher reporting of caring behavior (r=0.43, p < .01). A positive association was found between masculinity and femininity (r=0.55, f<0.01). In addition, age was significantly and positively associated only with clinical practice experience (r=0.51, p < .01). Clinical practice experience was significantly and positively associated with age only, and the correlation with other variables was not significant. Table 3 Validity, reliability, R2, and correlations of variables (N=449). Table 4 Estimated relationships between critical thinking and key research variables (N=449). 7. Discussion In this study, we compare differences in age, clinical practice experience, caring behavior, critical thinking, masculinity, and femininity between male and female student nurses. Critical thinking was an outcome variable, and age, clinical practice experience, gender role orientation (masculinity and femininity), and caring behavior were predictor variables. We found no sex differences in caring behavior, critical thinking, masculinity, or femininity. This is consistent with previous research that indicated that sex did not predict students’ critical skills (Ghadi et al., 2012; Hunter et al., 2014; Salahshoor and Rafiee, 2016). Our results also are in keeping with those of Khademian and Vizeshfar (2008) and Laurella (1997), who noted that sex had no significant effect on students’ perceptions of caring behaviors. It is noteworthy, however, that our research sample showed no significant sex differences in masculinity and femininity. This finding echoes earlier research that indicated that androgynous nurses scored higher on measures of caring behavior than did those who were deemed either masculine or feminine (Laurella, 1997). In this study, students’ femininity was positively associated with caring behavior. There was no significant correlation, however, between femininity and critical thinking. This is consistent with the belief that women are more caring than are men. Our research shows, however, that, among both sexes, those who reported higher masculinity presented greater caring behavior and critical thinking than did their less masculine counterparts. Our research stands in contrast to previous findings that sex had no significant effect on students’ perceptions of caring behaviours (Khademian and Vizeshfar, 2008). In sum, we found that caring behavior, masculinity, and the interaction between female x age can positively predict critical thinking. Therefore, we posit that sex itself is not a chief predictor of caring behavior and critical thinking; rather, the key variable is students’ gender role. As such, the cultivation of both masculinity and femininity among nursing professionals is vital. In addition, because caring behavior was positively associated with critical thinking, which is consistent with past research (Arli et al., 2017; Chen et al., 2018; Pai et al., 2013), caring behavior should be emphasized to cultivate students’ critical-thinking abilities. As Thayer-Bacon (1993) noted, without caring, an individual cannot be a good critical thinker. 8. Limitations There are two limitations to this study. First, this study is limited by its cross-sectional design, which hinders the ability to infer causation. Thus, future studies should utilize a longitudinal design. Second, the study used convenience sampling, which perhaps limits the generalizability of the results to other populations of nursing professionals; thus, replication in future research is warranted. 9. Conclusion and implications in practice Our research confirms that caring can stimulate critical-thinking ability in nursing students and that critical thinking can be predicted by caring behavior, which is consistent with previous research (Chen et al., 2018; Pai et al., 2013; Zimmerman and Phillips, 2000). Importantly, our research model elucidates the relationship between age, gender role, caring, and critical thinking. The findings can be used to implement strategies to promote nursing students’ critical thinking. Specifically, the cultivation of nursing care behavior should include attention to students’ gender role orientation. In addition, the stereotypes associated with male nurses should be examined. Further research also should examine other related factors that may influence critical thinking ability as a means to improve the model. We also recommend that clinical nurse educators, when working with male students in regard to patient care, should consider individual gender role orientation and support male nursing students’ ways of showing caring behaviors. 10. Ethical approval The study design and procedures were approved by the academic review board of Ghana Sunyani regional hospital 16079). written informed consent was obtained from all participants.