A national survey of transpersonal caring competency among emergency room nurses in Saudi Arabia

Article history: Received 5 August 2019 Received in revised form 24 November 2019 Accepted 25 November 2019 Nursing services cuts across all the various departments of medicine and emergency room (ER) nurses are one of the many nursing specialties that offer immeasurable care in health care delivery. The quality of care offered by nurses in the ER is a concern and a study of the transpersonal care offered by ER nurses in Saudi Arabia was investigated in terms of competency, feasibility, importance, frequency, and satisfaction of ER nurses in Saudi Arabia. A total of 1,050 male and female Saudi ER nurses from government and private hospitals in Saudi Arabia were evaluated using Caring NursePatient Interaction Scale (CNPI-70). The mean age was 44.97 years, and the average years in service was 16.38. Most of the ER nurses were female, married and completed an undergraduate degree. It was concluded that Saudi ER nurses possessed good transpersonal caring competency which plays a significant role in the nurse-patient interaction. Further emphasis on improving ER nurses’ transpersonal skills anchored on Watson’s theory is recommended to be integrated on staff development programs to provide quality nursing service to patients and their family members in the ER settings of Saudi Arabia.


Introduction
*Nursing is another word for caring. It is almost impossible to separate the two words because when a patient perceives the arrival of a nurse, they feel very comfortable. Transpersonal care analysis studies the interaction that flows from caregivers to care recipients. Watson (2007) in one of her interview sessions said that humans must be considered as a holistic entity with a body (prone to illness), mind (that can be affected by sickness in the body) and nature. Blasdell (2017) reported that Watson (1988) postulated that caring is a "moral ideal." Therefore, there is a need for nurses who care for patients to apply this awareness.
Saudi Arabia is working towards integrating a patient-centered model within its healthcare system, establishing an environment supporting high-quality health care. Saudis only constitute 32.3% of the total nursing workforce on which they provide 80% of patient care within healthcare settings. Just like any nurses around the world, Saudi nurses face high stress and burnout in the emergency room (ER) (Adriaenssens et al., 2011;García-Izquierdo and Ríos-Rísquez, 2012). Working as a nurse involves the use of physical, mental, emotional and social skills at the same time when dealing with people, most importantly during a life-saving situation. Nurses are the first point of contact to which patients and clients interact with. Nurses absorb stress when dealing with pain, complaints and other situations that need intervention. Over the years, there have been a lot of reforms to harmonize the Saudi nursing program to upgrade the level of knowledge nurses are acquiring, one of which is the transpersonal caring system. One important challenge in the Saudi nursing profession is developing, maintaining and evaluating a unifying competency framework education policy that regulates the training of nurses and the skills and activities of nurses in practice.
Jean Watson developed a theory that focuses on how nurses should care for patients and explain how the act of caring and healing are related and shows how this act promotes better health than just simple medical treatments. The theory was centered on human caring and the care-to-care transpersonal relationships between a nurse and the patient. Following the inherent assumptions in Watson's theory and the competencies defined, in which having care and compassion (feasibility) for patients as the basic attributes, a self-assessment of the competence of ER nursing in Saudi Arabia was done using the CNPI-70 scale. The Caring Nursing-Patient Interaction scale was designed by a team of researchers at the University of Montreal in line with the assumption of Jean Watson on humanistic care delivery. The scale consists of 10 subscales reflecting the 10 carative factor which characterizes how a nurse will interact with a patient on duty. The scale uses a psychometric test to objectively assess the individual ER nurses' competence, feasibility, importance, frequency, and satisfaction. The results from this scale have been found to be very satisfactory. The structure for the science of caring is built upon ten carative factors. The factors are summarized as follows: The emphasis in this research was to initiate a positive mindset that focuses on the needs of nurses and sensitize ER nurses about the ultimately improving the delivery of care to patients in the ER. Watson (2008) was particular about the delivery of the highest quality of care to patients. Therefore, her theory of transpersonal care was seen as a means to an end. Project materials were given to potential subjects to explain the procedures and to better understand Watson's humanistic theory of care applied.
The goals of this project were to make ER nurses become increasingly more aware of self and show kindness to their patients. Therefore, it will put nurses in a better position to pattern with the patient in a transpersonal care relationship with their patients. In the long term, the ER will be a healing environment for patients who will encounter ER nurses that will treat them by the transpersonal care value. This means that ER nurses may not be able to take away the ailment of their patients but can help to lessen the burden to a great extent. Therefore, Nurses play a major role in the desired cultural transformation in the medical world from focusing on "the cure" to focusing on "the care" which is the new outlook of the Institute of Medicine.
The theory of human caring by Watson (1997) guides nurses to act creatively, and do so with a mindset open to all forms of possibility. This gives nurses the opportunity to contribute to the development of the nurse-patient relationship in a manner that they become the environment every patient desire. There are various skills of emergency nursing that basically support their roles. ER nurses are expected to remain calm in the midst of loud noises, strong smells, and high tension. Setting aside personal feelings is a call to all ER nurses. This cannot be learned in the classroom but on the job. Speaking up and remaining assertive at all times is an essential skill of ER nurses. They are the first-line mouthpiece of the patient. Time management is also important in the delivery of emergency nursing services. The ER nurses play characteristic significant roles in initiating patient care and follow up, educating patients on their currents health status and inter-agency communication. All these require the ER nurses' attention and have to be done at the appropriate timing. Every new case in the ER requires specific strategies to handle it. ER nurses are therefore expected to design a personal coping method to fit into the presenting cases and deliver the best services. Seeing patients walk away from the ER because the best care has been offered makes it worth the energy that is expended. Watson (2008) stated that Megan Kelly reported in his work that the use of the model of transpersonal caring in the nursing profession is significant in decision making in practice. It gives nurses a clearer understanding of what it means to be a nurse. Hudon (2011) also reported that various authors have stated that measuring patients' perceptions of care is important. Nurses who engage the transpersonal caring system, according to Watson (2008), have been found to be very productive and providing a positive effect on the satisfaction of patients.

Background
According to Watson (1997), there is the highest level of care (biogenic caring) which considers the body as a complex machine in relation to healing, total well-being. She stated that a transpersonal caring relationship affects both the nurses and patients; that services involving being open and servicing with compassion, dignity, and respect create a relationship of trust that affects both the caregiver and the care recipient. Watson (2002) reiterated in her paper that nursing in this new age should be considered as a concept of conscious caring, intentionality, energy, spirit, and transpersonal framework rather than industrial employees in the hospital or institutions. Watson also reported in her paper that the transpersonal caring theory of nursing is was also described by Longacre et al. (2014) that there is a deeper perspective of International Transpersonal Caring Model which states that nurses come face-to-face with humanity itself and this is the ultimate task of the nursing profession and nurses. Hurdle and Quinlan (2014) reported about their DooR to DooR approach analysis using the transpersonal approach to care in the University of North Carolina concluded that, though the nursing art is to calm and relax patients, the new approach was to heal, respite and comfort hospitalized patients, family members and finally the health care staff. Bailey (2009) in a study was also to refute claims from critics that the theory of transpersonal care paradigm proposed by Watson was so useful in nursing caring and caring knowledge development. Scholars in theology, ecology, ethics, and education have also reported its importance. Fawcett et al. (2001) answered the question of how useful this transpersonal caring theory is in evidence-based practice. The argument was based on the fact that the various knowledge patterns; such as personal, empirical, ethics, aesthetics as explained by Carper (1988), are theoretically based and are various forms of inquiries to prove different pieces of evidence, which are the need for evidence-based practice and not just only empirical knowledge. Carper (1988) emphasized that nursing has shifted from selfdiscipline to medical evidence-based nursing. Watson (2008) stated that scientific problem-solving techniques remain the basic structure of nursing practice, but it should extend above just mere interpretation of knowledge and method, adopting other peoples' phenomena, which are subjective, postulated relative theories, problems of concepts and published data of science. The Attending Nursing Caring Model was designed by Watson and Foster (2003) in a pilot study on pain in the pediatric unit in a hospital. The study used a hospitalist advanced practice concept incorporating both a disciplinespecific and a trans-disciplinary framework. The participants engaged in defining clinical problems relating to pain and finding evidence for its management. The report from the search showed that nurses accept the theory of transpersonal caring in addition to scientific medical therapy than just science-based alone. It was a hope for the hospital and the health care system.
Studies by Quinlan-Colwell (2014) evaluated the caring pattern between a patient with sore pain and satisfaction from the care. They concluded that nurses who administer holistic nursing regime manifest transpersonal links with the pain patients, making them more satisfied with the care received even when the pain has not been eliminated. This shows that the type of care patients receive is a key factor in the healing process. In research by Broscious et al. (2015), it was found that since patients were having the regular presence of the nurses, though there was no statistical significance in the pain reduction, it was showed non-statistically that there was a relationship between the nursing care behaviors and the post-bedtime pain ratings. The patients were more comfortable with the continual visit that allowed transpersonal care attributes to thrive. The study by Costello and Barron (2017) reported that nursing students feel more appreciative of the profession when they were thought about Watson's theory of care in nursing education. Costello and Barron (2017) also reported the satisfaction of senior nursing students when taught about the transpersonal theory of Watson and the process of Caritas. The students gave feedback that they are now more aware of how to give compassionate care to end-of-life patients. In a paper published by Hubert (2018) reported a major advancement in patient care by first-grade entry nurses after a course on experimental learning activities. It showed that improving and developing the attribute of self-care in fresh nursing professionals in the early stage of their career decreases a lack of interest in the job and improves efficiency. In the same publication, Ray and Turkel (2014) emphasized that nurses must understand and utilize the maximum effect the power of transpersonal caring has on patients. Hagerty et al. (2017) examined the principles and importance of interpersonal relationships in the profession of nursing and stating that creating an environment of acceptance, trust, and partnership with patients is vital in health care delivery.

Objectives
This study aimed to determine the competency, feasibility, importance, frequency, and satisfaction of Saudi ER nurses in the practice of carative factors based on Watson's Human Caring Theory (1985). This research work can give insight into why ER nurses display a particular caring attitude on duty.

Method
A descriptive survey design was used with a questionnaire as the main instrument to collect data from the respondents. A total of 1050 Saudi ER nurses conveniently selected from government and private hospitals participated in the study. The entire data collection lasted for one year. Age group, marital status, length of service, gender, and educational background was noted. The instrument used to measure the patients' perception of caring behaviors was the Caring Nurse-Patient Interaction Scale (CNPI-70) developed by Cossette et al. (2005) and was used with permission. A group of ER nurses at different times were requested to make anonymous self-assessment. The approval of the Head of Unit and the Bioethics Committee was obtained at the different hospitals to use the CNPI-70 scale amongst ER nurses in Saudi Arabia. The CNPI-70 contains 70 statements (items) in the form of questions and allocated into 10 subscales. It is consistent with the carative factors outlined by Watson. In subscale 1, Humanism-this means forming a humanistic true system of values (6 items), subscale 2, Hope, which means giving faith (7 items), subscale 3, Sensibility-considering self and others (6 items). Subscale 4, Helping Relationships-human caring by the development of help-trust relationships (7 items). Subscale 5, Expression of Emotion-promoting the acceptance of both positive and negative feelings (6 items), subscale 6, Problem-Solving, creating an active problem-resolving caring pattern (6 items), subscale 7, Teaching-encouraging transpersonal care teaching and learning (9 items). Subscale 8, Environment-giving supportive, protective and corrective physical, social, spiritual and psychological environment (7 items), subscale 9 Needs-Helping with the gratification of human needs (10 items), and subscale 10, Spirituality-this entails allowing the existence of phenomenal spiritual forces (6 items). After the questionnaires were completed, the data were analyzed and tabulated.

Results
The data collected from the survey gave a detailed reflection of the carative interactions in transpersonal care amongst ER nurses in Saudi Arabia. As reflected in Table 1, a typical Saudi nurse in the ER department is female, between 48-51 years old, married, completed a bachelor's degree in nursing, and with an average length of service of 16.38 years. In assessing competency, a large percentage of the respondents gave a rating of 4 (A lot) except for subgroup 10 (spirituality) in which the mean descriptive rating was 3 (moderately). Table 2 presents the summary of ER nurses' competence, feasibility, importance, frequency, and satisfaction of the 10 carative factors. This must have given the impression that a large number of ER in Saudi Arabia show a high level of competence at the ER. A clear pointer to this level of competency is shown in the mean rate (approximately greater than 4) of the numbers of ER nurses in Saudi Arabia who engage in the application of the transpersonal care theories (carative factors). When assessing feasibility, which is a measure of the extent the attitudes or behaviors are implemented clinically, the mean rating was shown to be at a scale of 4 (A lot). This must have also resulted in an improved level of competence in ER care delivery. The importance of each of the various behaviors in the nursing services of the ER nurses was also assessed with the Caring Nurse-Patient Interaction Scale (CNPI-70). The survey showed a higher percentage of the nurses understand how important it is to apply the carative theory. The rating was also on a scale of 4 (A lot). Comparatively, the mean value of those who understand the importance is slightly more than the other factors. The survey also evaluated the frequency at which these attitudes and behaviors have occurred. The occurrence of these attitudes was between a rating of 3 (often) and a rating of 4 (very often). Using subgroup 3, (sensitivity), it means the consent of patients was sought at all times in their treatment plans. On assessing the level of satisfaction, the rating for Humanism and Hope was 3 (no opinion). The respondents seem not to have any information regarding the extent of ER nurses in Saudi Arabia show meekness and kindness to their patients and to what extent they encourage their patients to be hopeful and give the motivation to improve their health. Despite the strong influence of Islam in nursing practice in Saudi Arabia, results showed that nurses were unsatisfied at the level at which nurses help patients exhibit their spirituality in the ER. This would mean that ER nurses were least likely to consider the spiritual needs of the patients.

Discussion
Every branch of the medical profession has some levels of theories that form the basis of the practice. Jean Watson's transpersonal care theory has a very good standard for the nursing profession. This survey which evaluated the transpersonal care activities in ER nurses in Saudi Arabia buttresses this claim further. The sample size (n=1050) was large for the analysis of the competency, feasibility, importance, frequency, and satisfaction among ER nurses.
The competency of every staff in a profession depends on various factors such as level of education, experience, and commitment to service. In Saudi Arabia, ER nurses having more years in practice and education are very competent. This will be seen in the skills they display during patient care at the ER. There are overlapping attributes in the objectives of the objective of this survey because they do not exist in isolation (Cossette et al., 2005). The report obtained from the questionnaire also revealed to what degree the theory of Jean Watson could be implemented.
A high level of feasibility was displayed which must have explained the reason for a proportionate higher competence level. The importance attached to their job was reflected in the response given to the questions in the survey questionnaire. The role played by the ER nurses accepting the theories and working on it has also a major impact on the frequency they apply the concept in the ER and have resulted in maximum patients' satisfaction. The assumption of Rhodes et al. (2011) stressed that a key factor that stimulates the development of the ability of nurses to deliver their services at the ER depends on motivation, adding that, the attitude of employers and personal expectations are the main external factors that determine nurses' competency in relation to feasibility, importance, frequency and satisfaction.
The personal trait that encourages the willingness to be more satisfied with the job plays a significant role as well. It was seen from the CPNI-70 scale that the willingness of nurses to broaden their knowledge of the profession through further learning, curiosity, and engagements in other nursing activities improved their professional skills.   Watson (2008) also stressed the fact that empathy and the ability to accept differences in the delivery of care is vital in improving nursing competency. Furthermore, on the analysis of Saudi Arabia nurses being satisfied with the job, the level of knowledge, previous experience and exposure, and the ability to anticipate and analyze different situations cannot be overemphasized. There was no remarkable difference in all the factors accessed based on age, civil status, and gender. Health education and health promotions are an important part of the nursing services especially in the ER. Elder et al. (2004) noted that nurses tend to deal with types of people, types of behavior, and types of disease, rather than with individuals. BScEcon (1990) noted that while nurses apparently view relationships with patients as an important part of their nursing care, transpersonal skills are "profoundly limited". BScEcon (1990) noted that nurses maintain control over the nurse-patient interaction conversationally. They do this by asking questions that require only a yes/no answer, by presenting leading questions with a limited range of answers, by asking lots of questions in rapid succession without giving the patient time to answer, and by making direct statements. When patients asked questions or provided verbal cues that they were uncertain about something, nurses continued to control the nurse-patient interaction through vague replies or very general comments, by changing the subject, or by failing to acknowledge the question or cue.
The need for continuous staff development has been to be emphasized as one major tool for improving transpersonal caring competency. It gives nurses independence, especially in decision making in the ER. Nursing employers can also adopt the CNPI-70 scale to assess nursing competencies. Further research should focus on how to evaluate the impact of nursing caring behaviors have on patients healing rate.
In this research work, there is a tendency the ER nurses in Saudi Arabia could have responded based on the level of health care delivery obtainable in Saudi Arabia. Some have also responded as if they are the patients. These could affect the scores of each subgroup. Another limitation of this study is that it did not look into association and differences between variables. Having this presented may lead us to understand how these variables affect the transpersonal caring competency among Saudi nurses in the ER.

Conclusion
ER nurses in Saudi Arabia were able to show that competencies involve the use of knowledge, specific skills, and values that are required for qualified health care providers. They were able to prove that updating continuous education in the process of delivering care is essential in the definition of competency in transpersonal care. The CNPI-70 score used in the self-assessment of competencies was able to show that a high percentage of ER nurses in Saudi Arabia were very satisfied with their jobs. It is also important to stress that, when more ER nurses engage in transpersonal caring, it will certainly boost the satisfaction patients receives from the health services delivered in the ER in Saudi Arabia. The journey to a successful ER nursing in Saudi Arabia is to incorporate the Watson Humanistic Theory of Caring on a full scale which will be a major development for the nurses and the unit. In this regard, an improved outcome in the services rendered will be anticipated.

Ethical considerations
The Ministry of Health of Saudi Arabia approved this study. All potential participants were informed of the purpose of the study and were given the choice not to participate. Written informed consent was secured prior to data collection. Confidentiality was a priority in this study, so no personal identifications were requested.