Evaluating Changes in Caring Behaviors of Caritas Coaches Pre and Post the Caritas Coach Education Program

OBJECTIVE The aim of this study was to examine program effectiveness in changing Caritas leadership, self-caring behaviors, and perceptions of coworkers of participants who completed the Caritas Coach Education Program (CCEP). BACKGROUND The CCEP has been a highly successful education program for individuals who wish to intellectually and experientially learn to teach, live, and practice human caring theory. METHODS A pretest-posttest descriptive design was used to evaluate changes in perceptions of self-caring, caritas leadership, and coworker behaviors after completion of CCEP. RESULTS The mean scores of all measures improved significantly. CONCLUSIONS After completion of CCEP, participants demonstrated statistically significant changes in 3 caritas measures: leadership, coworker, and self-rating. Caritas Coach participants exhibited the greatest change in their self-caring scores.

Healthcare education and practice have become more complex, high risk, and technology and business focused, demanding healthcare practitioners who are able to perform in expanded roles, possess greater expertise and knowledge, and assume more responsibility. 1 The Caritas Coach role provides an avenue for healthcare professionals to both meet the demand for high risk care and be caring literate. 1 Without a theory-based curriculum and practice, care becomes a task, based in cognition and skill, without a framework to guide and provide the ethical, moral, epistemological, and ontological framework needed in education and practice today.
Caring science provides the disciplinary framework and theory for healthcare practice, education and research, 2 and foundation for all healthcare practitioners and educators. Caring science offers a way forward in the postmodern healthcare era, helping us to resolve the dichotomy of the objective and subjective world we live and work in. Caring science offers a more holistic and clear perspective on professional values, ethics, professionalism, safety, cultural and spiritual sensitivity, empowerment, health and healing, and care. 1,3 The Caritas Coach Education Program (CCEP) was developed to become a model for an elevated advanced caring science practitioner, the caritas coach, who embodies these principles, ethics and ways of being.
The purpose of this article is to report the evaluation outcomes of an intensive and interactive theoryguided professional educational program: the Watson Caring Science Institute CCEP. The purpose of the program is to transform self and systems with an intentional Caritas Consciousness/Caritas Ways of Being that integrates and restores caring-healing and love into our life and work/world. It focuses on self-caring as the foundation for living out the philosophy, theory, and science of human caring.
Much has been written over the last few years about burnout and its effect on caregiver stress and delivery of care. 4,5 The focus for many studies is the work environment and how the environment improves or worsens working conditions and subsequent caregiver outcomes. Pashaeypoor et al 6(p237) recently identified 3 domains of barriers found in the literature that interfere with nurses implementing theory in practice, specifically implementing Watson's theory of Human Caring/Science. The 3 identified barriers included organizational (workplace/environmental management barriers), practitioner-level, and educational barriers. While the organizational-management environment is important, perhaps attention to theory-guided professional self-caring practices could mitigate some of the barriers and negative effects of the work environment. Educational barriers of theory implementation include the failure of nurses to know and observe the prerequisites of human caring. 7 Furthermore, the lack of language to recognize, articulate, and practice the universals of human caring contributes to the educational barriers. 6,7 A recommendation offered to overcome educational barriers to human caring theory-guided practice is to continue to provide educational opportunities for the value-based processes of Watson's theory and their prerequisites. 6,7 Overcoming Organizational-Educational-Practice Barriers The CCEP is 1 example of how nurses and other practitioners can overcome some of the organizationaleducational barriers to implementing Human Caring Science Theory 2 in their personal and professional life worlds. The program was created in 2008 by Jean Watson and Watson Caring Science Institute, in collaboration with caring science scholars who envisioned a more biogenic 8 healthcare system (life-giving and life-receiving) based in caring science, with Caritas Coaches leading the way. Caritas Coaches are advanced caring science practitioners (nurses and other professionals), who embody caring science and caring literacies. Caritas Coaches are able to share transformative theoretical knowledge, experiences, and insights to create communities that are focused in Caritas (love and care), healing, wholeness, and health, beginning with their own self-care. The CCEP integrates a caring science curriculum as the pedagogical framework for teaching, learning, and living the theory. The program is accredited by the American Nurses Credentialing Center, offers contact hours through Watson Caring Science Institute (www.watsoncaringscience.org), and is approved by the American Holistic Nurses Association.
Consistent with the recommendations of Pajnkihar et al, 9 the content of CCEP is based on the curricular threads of the universal values of Caritas Processes and core concepts of caring science. 10 As these threads are explored and synthesized, caring literacy develops and Caritas Coaches become fluent in the language and meaning of caring science and in how to embody, articulate, and translate to others. It is in the living of caring science that Caritas Coaches lead the way to transformation within self and in the organizations where they practice.
Only 1 research study 1 has focused specifically on Caritas Coaching. The study, a hermeneutic phenomenological exploration of graduates of the Watson Caring Science Institute CCEP, explored the lived experience of Caritas Coaches and those experiences affecting role development and implementation in practice, as well as impact on the provision of healthcare. The study revealed that CCEP graduates learned to be Caritas Coaches through reflection, community, and literacy in caring science, which empowered coaches to find their voice, as well as the inner strength to live a life aligned with caring science and their own personal values. 1 "Caring Science provided the theoretical framework from which to define the role and its effect on the coach and all those each coach came in contact with." 1(p80) The current study examined program effectiveness in changing Caritas leadership and self-caring behaviors of participants who completed CCEP, as well as their perceptions of caring behaviors of their coworkers. The goal of the study was to determine whether levels of these behaviors and perceptions changed after completion of the theory-guided education program.

Design
This program evaluation study used a single-group pretestposttest design to evaluate intraindividual change before and after completing an educational program. The education program, described in greater detail below, consisted of a 6-month hybrid (onsite and online) didactic and experiential program culminated with a project that incorporated learnings gained during the program.

Sample and Setting
The sample consisted of 2 cohorts of 69 individuals who completed the 6-month CCEP between April 2018 and April 2019. All participants attended the onsite didactic and experiential program at the beginning and end of the education program as well as the online portion that occurred between the 2 onsite sessions.

Procedures
The University of Arizona institutional review board (IRB) deemed the study nonhuman subjects research. After IRB review, and upon enrollment into the CCEP, individuals were recruited through an email, sent by 1 of the coinvestigators. A reminder email was sent before the education program began to all enrolled individuals. Three weeks before completion of the education program, an email asking participants to complete the posteducation survey was sent by 1 of the coinvestigators, and a 2nd reminder email was sent before graduation from the program. Participants were asked to create a unique identifier that could be used to connect pretest and posttest surveys to evaluate their changes in scores. The identifier did not include any information that would allow identification of a participant.

Measurement
Measures consisted of a demographic survey and 3 indicators of caring behaviors. The demographic questions included items asking about years of practice, discipline, practice setting, professional practice model used by their practice site, participant age, employment status, gender, and educational level. The measurement scales included The Watson Caritas Leader Score©, the Watson Caritas Coworker Score©, and the Watson Caritas Selfcare Score ©.
Each of these Caritas Scores consists of 5 items measured on a 7-point scale from never to always. The Caritas Leadership measure was a new measure that evaluated the participant's perceptions of their leadership of others. All Caritas Score items are based on Watson's Human Caring theory 2 and adapted from a psychometrically sound instrument developed to measure patient perceptions of caring behaviors of staff. 11 The Watson Caritas Self-rating Score© measures perceptions of selfcaring based on caritas behaviors of loving kindness, meeting basic needs of self, having helping and trusting relationships, creating an environment that enables flourishing and valuing beliefs, and faith to promote success. The scale has shown acceptable internal consistency reliability (Cronbach's a = .89) in previous unpublished research studies. The Watson Caritas Coworker Scale© measures perceptions of caring behaviors of coworkers. The scale has shown acceptable internal consistency reliability (Cronbach's a = .90) in previous unpublished research.
The CCEP CCEP Curricular Structure As noted above, the purpose of the CCEP is to prepare participants to implement theory-guided human caring science in their lives, personally and professionally. Caritas Coaches become self-aware, self-knowledgeable, intentional, and conscious through inner reflective work and emersion in the theory. They learn micropractices that promote self-acceptance, self-compassion, and self-love. Caring science curriculum provides a "moral, sacred foundation to health, healing, knowledge, and praxis/ practices within the human-universe relations [that] we share." 12(p75) The CCEP curriculum included in this study is a 6-month-long hybrid program, a combination of onsite and online study, created in the spring of 2015.
Participants are required to attend an onsite program twice, once at the beginning of the program and once at the end of the program. The onsite program is combined with online learning consisting of 6 months of online discussion and reflection incorporating multiple ways of knowing, Being, Belonging, and Becoming through Watson Caring Science Faculty coaching. The online experience intentionally creates a community of support or Caritas/Communitas, connecting and purposefully exploring caring science themes and core concepts that enable each participant to synthesize, integrate, experience, and translate caring science into personal and professional practice and to help others. This online community is created as a safe sacred space that promotes authentic, in-depth exploration, and personal/professional growth.

Results
The pre-CCEP survey was completed by 71 individuals and the post-CCEP survey was completed by 57 individuals. Some of the discrepancy was a result of individuals who were accepted to the program but for various personal reasons not enrolling or delaying enrollment to a later cohort. Not all individuals who completed the program completed both a pretest and posttest survey, which resulted in a final sample size of 42 paired responses.

Sample Demographics
Most (92.9%) of the sample consisted of registered nurses filling many roles, ranging from bedside clinical nurses to chief nurse executives and nursing faculty. They were employed full-time (95.2%) and were female (88.1%). Most participants were older (59.6% were ≥41 years), well educated (41% had master's degrees, 21% had doctoral degrees), and had been in healthcare for more than 20 years (38%). Most were employed in acute care (62%) and used Watson Human Caring Theory (71%) as their professional practice model.

Measure Psychometrics
All measures exhibited satisfactory internal consistency reliability, with Cronbach's a values >.83. Because the Caritas Leader scale was used for the 1st time in this sample, exploratory factor analysis was performed to evaluate its structure. Principal components with varimax rotation resulted in a single factor with 54% explained variance. All items loaded on the single factor, with loadings between 0.67 and 0.79, demonstrating good initial evidence for construct validity.

Caritas Scores
Following completion of CCEP, participants demonstrated statistically significant changes in all 3 caritas measures. Caritas Coach participants exhibited the greatest change in their self-caring scores, with an improvement of 0.69 points. Table 1 presents the mean, standard deviation, and t test scores for all measures.

Discussion
This is the 1st program evaluation of the Watson Caring Science Institute CCEP. The findings related to leadership, coworkers, and self-caring affirm the focus and direction of the CCEP theory-guided educational program. Although all 3 Caritas measurements demonstrated change, before and after the program, the most change was in Caritas self-caring. This significant change is consistent with the theory and practice of human caring philosophy and science and demonstrates 1 theory-guided educational model for addressing the barriers between theory in practice.
As affirmed in this study, 1 way forward in overcoming both organizational and educational barriers is learning to comprehend, integrate, and live out theory of Caritas Process 1, "Practice of loving kindness and equanimity to self and other." 2(p31) This study validates self-caring as the starting point and foundation for theory-guided, philosophy, and science of human caring. Furthermore, consistent with the intention of the CCEP, that is, transformation of self/system, comes from within, starting with self-caring.
Limitations of the study are the small sample size, with highly educated participants. Many participants were employed in organizations where Human Caring Science was the basis of the professional practice model. The results may not reflect those from a sample with less exposure to the theory, where the magnitude of change could be greater as a result of lower scores at baseline. Further research is needed to test the findings in larger, more diverse samples.
These findings have relevance to leaders who are considering changing organizational culture to reflect human caring values and behaviors. Integrating individuals who have completed the Caritas Coach program into the organization while providing administrative support to their efforts could perhaps accelerate leader and staff behavior changes and changing values.

Conclusion
As nursing seeks to advance as a distinct professional discipline of caring, healing/health for all, it requires discipline-specific, value-guided education-professional practice, based in theory and philosophy of human caring science. Current struggles and barriers exist within organizations as well as educational curricular structures and pedagogies, which interfere with translating and implementing theory-guided professional practice. Although numerous hospitals and educational programs incorporate or include Watson Caring Science Theory as part of their mission or statements, there continue to be gaps and barriers to authentic professional theoryguided knowledge and practices of human caring and healing for self/other.
The CCEP exists as 1 theory-guided educational option for practitioners and educators alike. This option offers an immersion in Caritas Processes embedded in the values, ethic, philosophy, theory, and practices of Unitary Caring Science. 10 It is through such basic Caritas premises that professionals are more able to sustain authentic personal and professional caring healing/health in their lifeworld.
All systems and organizations today may benefit from overcoming conventional workplace, environmental, and practitioner educational barriers. By integrating self-caring, self-knowing, and self-love as foundation of Human Caring Science, the CCEP program offers a hopeful paradigm for authentic transformation from within.