peer reviewed research article on informal assessment

Informal Assessment

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• Maria Araceli Ruiz-Primo 2  

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Maria Araceli Ruiz-Primo

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Michael A. Peters

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Ruiz-Primo, M.A. (2017). Informal Assessment. In: Peters, M.A. (eds) Encyclopedia of Educational Philosophy and Theory. Springer, Singapore. https://doi.org/10.1007/978-981-287-588-4_390

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Research Brief: The Informal Formative Assessment Cycle as a Model for Teacher Practice

• -BACKGROUND

Ruiz-primo, M. A., & Furtak, E. M. (2007). Exploring teachers’ informal formative assessment practices and students’ understanding in the context of scientific inquiry. Journal of Research in Science Teaching , 44(1), 57–84. doi:10.1002/tea.20163

• Original Publication
• Online Article

Informal formative assessment in the classroom takes place when a teacher elicits student thinking and makes immediate use of this knowledge in instruction. In this study, researchers studied three teachers with varying informal assessment practices to explore the nature of informal formative assessment and its connection to student learning.

Authors: BY VANESSA DE LEON & ANNIE ALLEN - MAY 2015

Theoretical background.

Formative assessment (FA) refers to assessment for learning rather than assessment of learning, allowing teachers to use knowledge of student understandings to inform their ongoing instruction (Black, 1993). Ruiz- Primo and Furtak claim that formative assessments can be seen as falling on a continuum from formal to informal. They define informal formative assessments as ongoing strategies that help teachers acquire information from students that can immediately be used in instruction. In the table below (adapted from p. 60 in their paper), the authors usefully distinguish informal and formal formative assessment strategies.

The authors offer a model of “assessment conversation” (Duschl & Gitomer, 1997) in which teachers elicit, recognize, and use student thinking and engagement during instruction. They identify four parts of this informal formative assessment cycle, which they call an “ESRU Cycle”.

• Teacher E licits Response
• S tudent Responds
• Teacher R ecognizes Student Response
• Teacher U ses Student Response

Research Design

Using the “assessment conversation” model, the authors set out to address two research questions: (1) Can this model help to distinguish the quality of informal assessment practices across teachers? (2) Can the quality of teachers’ informal formative assessment practices be linked to student performance? The authors studied the classroom assessment conversations of three 6th/7th grade science teachers. Teachers video recorded lessons they taught in a physical sciences unit using an inquiry-based curriculum, Foundational Approaches to Science Teaching (FAST).

The authors analyzed informal classroom assessment conversations to see how they fit with the ESRU cycle (Elicit, Student Response, Recognize, Use). Additionally, the researchers measured student learning with a multiple choice pre-test and a 38- item multiple-choice test after the investigation was completed. Researchers concluded that teachers who had whole-class conversations that were more consistent with the ESRU cycle had higher learning gains for students. Notably, it was the final step of the cycle (Use) that was vital for gains to be made.

Classroom Example of an Informal Assessment Conversation

This transcript is excerpted from Danielle’s class shown in Table 7 in Ruiz-Primo & Furtak, 2007, p. 73:

1. Danielle: So the first three things you want to do, very important things, you want to label your vertical axis, you want to label your horizontal axis, and then you want to give the whole graph a title. And we’ve done that.

2. So, taking a look at this, am I ready to go? Can I start plotting my points?

3. Student: No.

4. Danielle: Why not?

5. Student: You didn’t…

6. Danielle: What do we need to do? Eric?

7. Student: Put the scale.

8. Danielle: The scales. What do you mean by scales?

9. Student: The numbers.

10. Danielle: “The numbers.” Good. Excellent. I liked that you used the word “scales,” it’s a very scientific word. So, yes, we need to figure out what the scales are, what we should number the different axes.

Reflection Questions

• Read and reflect on this transcript from Danielle’s classroom from Ruiz-Primo & Furtak’s article. Where do you see the steps of the ESRU cycle in action? What is each step accomplishing for the teacher and for the students?
• What examples of this kind of formative assessment can you think of from your own or others’ classroom practice? Which aspects of the ESRU cycle are easier and which are more challenging to accomplish?
• What strategies do you use to give voice to all students in these kinds of informal assessment conversations?
• What supports do teachers need to enact robust informal formative assessment in their classrooms?

Implications for Practice

For teachers: We suggest that less attention be paid to rote procedures in the science classroom, and more attention be paid to knowledge generation in order for students to fully experience scientific inquiry. Further, we suggest that instructional responsiveness—i.e., teachers' ability to take students' ideas and use them to inform instruction and guide learning based on their existing understandings—is essential.

For teacher education and professional development: We suggest that content knowledge alone is not enough to conduct informal formative assessment. Rather, attention to the stages of the ESRU cycle is vital. Additionally, being explicit with pre- and in-service teachers about the differences in a ESRU model versus a traditional IRE/F model (Teacher Initiation, Student Response, Teacher Evaluation/Feedback) of classroom discussion is important for eliciting information to improve student learning. As a result, it is imperative that teachers are provided with the tools necessary to integrate assessment into the course of daily instruction to enact inquiry-based reforms.

Related Briefs

• Bevan, B. (2011). Classroom talk, participation, and learning: Is all talk good talk? : An ISE research brief discussing Atwood et al.'s, "The construction of knowledge in classroom talk."
• Stromholt, S. (2011). Questioning strategies to deepen scientific thinking : An ISE brief discussing Oliveira's, "Improving teacher questioning in science inquiry discussions through professional development."

Related Research

• Black, P. (1993). Formative and summative assessment by teachers. Studies in Science Education , 21, 49-97.
• Duschl, R.A., & Gitomer, D.H. 1997. Strategies and challenges to changing the focus of assessment and instruction in science classrooms. Educational Assessment , 4, 37-73.

Attending to Equity

• Formative assessment practices gives students chances to get meaningful feedback in a low-stakes environment, which supports their learning and helps them develop confidence in their ability to express their understanding.
• Give voice to all students in order to fully engage students in inquiry-based lessons and effectively implement informal formative assessment practices with them.
• Welcome and integrate students’ own experiences as part of the learning environment and development of knowledge.

ALSO SEE STEM TEACHING TOOLS

• #6 Productive Science Talk
• #14 Why NGSS?
• #34 Build an Assessment System
• - BACKGROUND

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Research articles

Formalising informal learning: assessment and accreditation challenges within disaggregated systems.

• Dianne Conrad
• Angela Murphy
• Gabi Witthaus
• Wayne Mackintosh
• Dianne Conrad , Athabasca University, Canada
• Angela Murphy , University of Southern Queensland, Australia
• Gabi Witthaus , University of Leicester, United Kingdom
• Wayne Mackintosh , OER Foundation, New Zealand

This report shares the findings and lessons learned from an investigation into the economics of disaggregated models for assessing and accrediting informal learners undertaking post secondary education. It presents some key economic and governance challenges for universities to consider in implementing OER assessment and accreditation policies. It also includes discussion of findings from a small-scale survey conducted by two of the authors on perceptions, practices and policies relating to openness in assessment and accreditation in post secondary institutions, with a particular focus on the OER universitas (OERu) concept.

• Page/Article: 125-133
• DOI: 10.5944/openpraxis.6.2.114
• Peer Reviewed

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Original research

Formative peer assessment in higher healthcare education programmes: a scoping review, marie stenberg.

Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden

Elisabeth Mangrio

Mariette bengtsson, elisabeth carlson, associated data.

bmjopen-2020-045345supp001.pdf

bmjopen-2020-045345supp002.pdf

All data relevant to the study are included in the article or uploaded as online supplemental information. No additional data available.

Formative peer assessment focuses on learning and development of the student learning process. This implies that students are taking responsibility for assessing the work of their peers by giving and receiving feedback to each other. The aim was to compile research about formative peer assessment presented in higher healthcare education, focusing on the rationale, the interventions, the experiences of students and teachers and the outcomes of formative assessment interventions.

A scoping review.

Data sources

Searches were conducted until May 2019 in PubMed, Cumulative Index to Nursing and Allied Health Literature, Education Research Complete and Education Research Centre. Grey literature was searched in Library Search, Google Scholar and Science Direct.

Eligibility criteria

Studies addressing formative peer assessment in higher education, focusing on medicine, nursing, midwifery, dentistry, physical or occupational therapy and radiology published in peer-reviewed articles or in grey literature.

Data extractions and synthesis

Out of 1452 studies, 37 met the inclusion criteria and were critically appraised using relevant Critical Appraisal Skills Programme, Joanna Briggs Institute and Mixed Methods Appraisal Tool tools. The pertinent data were analysed using thematic analysis.

The critical appraisal resulted in 18 included studies with high and moderate quality. The rationale for using formative peer assessment relates to giving and receiving constructive feedback as a means to promote learning. The experience and outcome of formative peer assessment interventions from the perspective of students and teachers are presented within three themes: (1) organisation and structure of the formative peer assessment activities, (2) personal attributes and consequences for oneself and relationships and (3) experience and outcome of feedback and learning.

Healthcare education must consider preparing and introducing students to collaborative learning, and thus develop well-designed learning activities aligned with the learning outcomes. Since peer collaboration seems to affect students’ and teachers’ experiences of formative peer assessment, empirical investigations exploring collaboration between students are of utmost importance.

Strengths and limitations of this study

• The current scoping review is previously presented in a published study protocol.
• Four databases were systematically searched to identify research on formative peer assessment.
• Critical appraisal tools were used to assess the quality of studies with quantitative, qualitative and mixed-methods designs.
• Articles appraised as high or moderate quality were included.
• Since only English studies were included, studies may have been missed that would otherwise have met the inclusion criteria.

Peer assessment is an educational approach where feedback, communication, reflection and collaboration between peers are key characteristics. In a peer assessment activity, students take responsibility for assessing the work of their peers by giving (and receiving) feedback on a specific subject. 1 It allows students to consider the learning outcomes for peers of similar status and to reflect on their own learning mirrored in a peer. 2 Peer assessment has shown to support students’ development of judgement skills, critiquing abilities and self-awareness as well as their understanding of the assessment criteria used in a course. 1 In higher education, peer assessment has been a way to move from an individualistic and teacher-led approach to a more collaborative, student-centred approach to assessment 1 aligned with social constructivism principles. 3 In this social context of interaction and collaboration, students can expand their knowledge, identify their strengths and weaknesses, and develop personal and professional skills 4 by evaluating the professional competence of a peer. 5 Peer assessment can be used in academic and professional settings as a strategy to enhance students’ engagement in their own learning. 6–8 The collaborative aspect of peer assessment relates to professional teamwork, as well as to broader goals of lifelong learning. As argued by Boud et al , 1 peer assessment addresses course-specific goals not readily developed otherwise. For healthcare professions, it enhances the ability to work in a team in a supportive and respectful atmosphere, 9 which is highly relevant for patient outcome and the reduction of errors compromising patient safety. 10 However, recent research has shown that peer collaboration is challenging 11 and that healthcare professionals are not prepared to deliver and receive feedback effectively. 12 This emphasises the importance for healthcare educators to support students with activities fostering these competences. Feedback is highly associated with enhancing student learning 13 and modifying learning during the learning process 14 as a means for students to close the gap between their present state of learning and their desired goal(s). Peer feedback can be written or oral and conducted as peer observations in small or large groups. 8 Further, it is driven by set assessment criteria, 1 which can be either summative or formative, formal or informal. Summative assessment evaluates students’ success or failure after the learning process, 15 whereas formative assessment aims for improvement during the learning process. 4 16 According to Black and Wiliam, 15 formative peer assessment activities involve feedback to modify the teaching and learning of the students. The intention of feedback is to help students help each other when planning their learning. 4 17 An informal formative peer assessment activity involves a continuous process throughout a course or education, whereas a formal one is designated to a single point in a course momentum. Earlier research on peer assessment in healthcare education has provided an overview of specific areas within the peer assessment process. For example, Speyer et al presented psychometric characteristics of peer assessment instruments and questionnaires in medical education, 18 concluding that quite a few instruments exist; however, these intruments mainly focus on professional behaviour and they lack sufficient psychometric data. Tornwall 12 focused on how nursing students were prepared by academics to participate in peer assessment activities and highlighted the importance of creating a supporting learning environment. Lerchenfeldt et al 19 concluded that peer assessment supports medical students in developing professional behaviour and that peer feedback is a way to assess professionalism. Khan et al 20 reviewed the role of peer assessment in objective structured clinical examinations (OSCE), showing that peer assessment promotes learning but that students need training in how to provide feedback. In short, the existing literature contributes valuable knowledge about formative peer assessment in healthcare education targeting specific areas. However, there seems to be a lack of compiled research considering formative peer assessment in its entirety, including the context, rationale, experience and outcome of the formative peer assessment process. Therefore, this scoping review attempts to present an overview of formative peer assessment in healthcare education rather than specific areas within that process.

This scoping review was conducted using the York methodology by Arksey and O’Malley 21 and the recommendations presented by Levac et al . 22 We constructed a scoping protocol, using a Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols, to present the planned methodology for the scoping review. 23

Aim and research questions

We aimed to compile research about formative peer assessment presented in higher healthcare education. The research questions were as follows: What are the rationales for using formative peer assessment in healthcare education? How are formative peer assessment interventions delivered in healthcare education and in what context? What experiences of formative peer assessment do students and teachers in healthcare education have? What are the outcomes of formative peer assessment interventions? We used the ‘Population Concept and Context’ elements recommended for scoping reviews to establish effective search criteria ( table 1 ). 24

The Population Concept and Context mnemonic as recommended by the Joanna Briggs Institute

Relevant studies identified

The literature search was conducted in the databases PubMed, Cumulative Index to Nursing and Allied Health Literature, Education Research Complete and Education Research Centre. Search tools such as Medical Subject Headings, Headings, Thesaurus and Boolean operators (AND/OR) helped expand and narrow the search. Initially, the search terms were broad (eg, peer assessment or higher education) in order to capture the range of published literature. However, the extensiveness of the material made it necessary to narrow the search terms and organise them in three major blocks. The following inclusion criteria were applied in the search: (1) articles addressing formative peer assessment in higher education; (2) students and teachers in medicine, nursing, midwifery, dentistry, physical or occupational therapy and radiology and (3) peer-reviewed articles, grey literature (books, discussion papers, posters, etc). Studies of summative peer assessment, instrument development and systematic reviews were excluded. We incorporated several similar terms related to peer assessment in the search to ensure that no studies were missed ( online supplemental appendix 1 ). Furthermore, we consulted a well-versed librarian with experience of systematic search 25 to assist us in systematically identifying relevant databases and search terms for each database, control the relevance of the constructed search blocks and manage the data in a reference management system. No limitation was set for year, all studies indexed in the four databases were included until the last search 28 May 2019.

Supplementary data

Study selection.

The process of the study selection and the reasons for exclusion are presented in a flow diagram 26 ( figure 1 ). First, the first author (MS) screened all 1452 titles. Second, MS read all the abstracts, gave those responding to the research questions a unique code, and organised them in a reference management system. The reason for inclusion and exclusion at title and abstract level was charted by the first author and critically discussed within the team (MS, EM, MB and EC). An additional hand search of reference lists was conducted. To cover a subject in full, a scoping review should include search in grey literature. 21 22 Therefore, the grey literature was scoped to find unpublished results by searching Google Scholar, LibSearch and Science Direct. The grey literature mostly contained research posters, conference abstracts, discussion papers and books, but a handsearch revealed original research articles that were added for further screening and appraisal. Finally, the first author (MS) arrived at 81 studies, read them in full-text, and discussed them with the other three authors (EM, MB and EC).

PRISMA flow chart. ERC, Education Research Centre; ERIC, Education Research Complete; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Charting the data

We constructed a charting form to facilitate the screening of the full-text studies ( online supplemental appendix 2 ). Out of the 81 studies, 37 met the inclusion criteria and were appraised for quality using Critical Appraisal Skills Programme (CASP). 27 The reason for conducting a crtitical appraisal of the studies was to enhance the use of the findings for policy-making and practice in higher healthcare education. 28 To investigate the interpretation of the quality instruments, three members of the research team (MS, EM and EC) conducted an initial test assessment of two randomly selected studies and graded them with high, moderate or low quality. Additional screening tools were used for studies with a mixed methods design 29 and cross-sectional studies 30 not available in CASP. When a discrepancy arose, a fourth researcher (MB) assessed the articles independently without prior knowledge of what the others have concluded. This was followed by a discussion among all four researchers to secure internal agreement on how to further interpret the checklist items and the quality assessments. Consequently, to ensure high quality, the studies had to have a ‘’yes’ answer for a majority of the questions. If ‘no’ dominated, the study was excluded. Since earlier reports 31 have raised and discussed the importance of ethical issues in systematic reviews, all screening protocols in this review included ethical considerations, as an individual criterion. The first author critically appraised all 37 articles, and 15 articles were divided between the team members (EM, MB and EC) and independently appraised. Nevertheless, during the screening process all 37 articles were critically discussed using the Rayyan system for systematic reviews 32 before final decision for inclusion. By this procedure, all authors agreed on not only which articles to include, but also the reason for exclusion. The critical appraisal resulted in 18 studies with high and moderate quality ( table 2 ).

Overview of included studies

*High equals majority of items in the critical appraisal tools.

†Twenty-four students included in the intervention, and 19 attended the focus group session.

‡Twelve students received faculty feedback, and 12 students received peer feedback.

OSCE, objective structured clinical examination.

Collating, summarising and reporting results

The analysis process followed the five phases of thematic analysis described by Braun and Clarke, 33 with support of a practical guide provided by Maguire and Delahunt. 34 The first phase included familiarising with the data. Therefore, prior to the coding process, we read all the articles to grasp a first impression of the results presented within the included studies. We then conducted a theoretical thematic analysis, meaning that the results were deductively coded, 33 guided by the research questions. We read the results a second time before starting the initial coding. The codes consisted of short descriptions close to the original text. The codes were then combined into themes and subthemes. The themes were identified with a semantic approach, meaning that they were explicit: we did not look for anything beyond what was written. 33 Finally, we constructed a thematic map to present an overview of the results and how the themes related to each other. The results from the studies are presented narratively.

Consultation

Consultation is an optional stage in scoping reviews. 21 However, since it adds methodological rigour, 22 we presented and discussed the preliminary results and the thematic map with nine academic teachers who are experts within the field of healthcare education and pedagogy. The purpose of the consultation was to enhance the validity of the results of the scoping review and to facilitate appropriate dissemination of outputs. 33 The expert group responded to four questions: Do the themes make sense? Is too much data included in one single theme? Are the themes distinct or do they overlap? Are there themes within themes? 34 The consultation resulted in a revision of a few themes and the way they related to each other.

Patient and public involvement

No patients or members of the public were involved.

The 18 included studies were published between 2002 and 2017 in the USA (6), the UK (6), Australia (3), Canada (2) and the United Arab Emirate (1) ( table 3 ). The studies were conducted in medical (12), dental (2), nursing (2), occupational therapy (1) and radiography (1) educations. Six studies were presented in the framework of an existing collaborative educational model. 35–40 Our review revealed that the most frequent setting for formative peer assessment activities is within clinical skill-training courses, 35 39–47 involving intraprofessional peers. The common rationale for using formative peer assessment is to support students, usually explained by the inherent learning of the feedback process, 35 39 40 43–45 47–51 and to prepare students for professional behaviour and provide them with the skills required in the healthcare professions. 36–38 46–49 52 Table 3 presents the results of the analysis related to the research questions of context, rationale and interventions of formative peer assessment.

Overview and summery of the context, rationale and interventions of formative peer assessment presented in the included studies.

*Appears in how many of the included 18 studies.

The results related to the research questions about the experience of students and teachers and the outcome of formative peer assessment interventions fall within three themes: (1) the organisation and structure of peer assessment activities, (2) personal attributes and consequences for oneself and one’s peer relationships and (3) the experience and outcome of feedback and learning.

The organisation and structure of formative peer assessment activities

In the reviewed studies, students express that the responsibility of faculty is a key component in formative peer assessment, meaning that faculty must clearly state the aim of the peer assessment activity. Students highlight the need to be prepared and trained in how to give and receive constructive feedback. 36 47 50–52 The learning activities need to be well designed and supported by guidelines on how to use them. 35 36 50 52 Otherwise, it could discourage students from participating in the peer activities. 52 Novice students find it difficult to be objective and to offer constructive criticism in a group. 36 46 This emphasises the importance of responsibility from faculty, especially when students are to give feedback on professional behaviour. 52 Some students prefer direct communication with peers when feedback is negative, whereas others think it is the responsibility of faculty. 52 There is some ambiguity regarding whether feedback should be given anonymously or not, 47 52 whether it should bear consequences from faculty or not, 52 whether it should be informal or formal, and whether the peer should be at the same academic level or at a more experienced higher-level. 50 52 Moreover, some students express how they favour small groups 41 49 ; as students in small groups are more active than those in large groups. 41 Students and teachers agree that peer assessment should be strictly formative rather than summative. 42 46 52 Teachers see themselves as key facilitators and express that students value feedback from teachers rather than from peers (in terms of credibility). 51 Students express similar sentiments even if they appreciate the peer feedback. 40 42 44 46 However, teachers confirm the need for training and preparing students early in the education, as well as the need for their own professional development to guide students effectively. 51

Personal attributes and the impact and consequences for oneself and one’s peer relationships

Students generally focus on how peer assessment activities may affect their personal relationships in a negative way. 35 37 42 50 52 They express worry over consequences for themselves and their social relationships 37 40 52 as well as feeling anxious that negative feedback given to a peer may affect the grading from faculty. 52 Moreover, students emphasise the importance of enthusiasm and engagement in listening to peers’ opinions during their collaboration. 36 47 They mention positive personal attributes and behaviours such as being organised, polite and helpful as supportive for peer collaboration. 36 47 Further, they mention the importance of both a positive and close relationship between students and faculty 52 and a positive culture in the learning environment. 40 While students highlight the impact on and consequences for personal relationships, teachers speak of the importance of respect in formative peer assessment, 36 including respect for each other, the learning activity, and the collaboration and interaction. 36 Further, teachers emphasise the importance of students being self-aware, being well prepared and taking own responsibility for the peer assessment activity. 36

The experience and outcome of feedback and learning

According to the students in the reviewed studies, formative peer assessment contributes to developing the skills needed in practice and in their future profession. 35 36 40 41 48 52 They appreciate the opportunity to give and receive feedback from a peer, 35 36 40 42 47 48 50 and they agree that the feedback they received made them change how they worked 42 48 or how they taught their peers. 47 48 They consider activities such as observation of others’ performance as beneficial for learning because they make them reflect on their own performance 35 36 40 41 46 49 50 and help them identify knowledge gaps. 35 40 49 Students with prior experience of peer learning are more likely to provide specific guiding feedback than those without such experiences. 39 Moreover, two studies showed significantly improved test results for students who took part in a peer feedback activity compared with those who did not. 43 49 Further, students thought they could be honest in their feedback and would learn better if the feedback was more in-depth. 35 46 Students at entry level tend to give more positive feedback than senior students; they also focus on practical and clinical knowledge, whereas more senior students focus on communication, management and leadership in their feedback comments. 45 A study exploring what students remember of received feedback points to memories of positive growth, negative self-image and negative attitudes towards classmates. Received feedback sometimes confirmed personal traits the students already knew about. 37 In addition, negative feedback was more likely to result in a change in their work habits and interpersonal attributes. 37 Students expressed some anxiety regarding the usefulness of feedback from low-performing students 40 50 and non-motivated students, which contributes to ineffective interaction and learning. 36 47 Low performing students show lack of initiative, preparation and respect but also improvement in their grades after the peer assessment experience. 47 Furthermore, feedback from peers can be a predictor of a student’s unprofessional behaviour; hence, it could be used as a tool for early remediation. 38 In an evaluation of faculty examiners’ experience of students’ feedback, the faculty express how they consider student feedback to be given in a professional and appropriate way and faculty examiners would have given similar feedback. 42 In an OSCE-examination where a checklist was used, the results showed statistical significance in assessment between faculty examiners and student examiners. 42

We found that formative peer assessment is a process with two consecutive phases. The first phase concerns the understanding of the rationale and fundament of the peer assessment process for students and faculty members. The results indicate that the rationale is to support student learning and prepare them for healthcare professions. The formative peer assessment activities support students’ reflection on their own knowledge and development when mirrored in a peer by alternating the roles of observer and observed. 53 54 It further contributes to skills as communication, transfer of understandable knowledge and collaboration, all significant core competences when caring for patients and their relatives. 54 For faculty, organising formative peer assessment, can be cost beneficial. This was recently emphasised in high volume classes expressing the reduction of costs with students giving feedback to a peer instead of teachers. 55 Nevertheless, students express the importance of clarifying the aim of the peer assessment activity and the responsibility of the faculty. We recommend faculty to clearly define the activity and explain how it supports student learning and professionalism, especially when students are to provide feedback to each other on sensitive matters, such as unprofessional behaviour. A collaborative activity between students requires trust, and the real intention must be made transparent. 4 56–58 Moreover, to enable student development in line with the learning outcomes, the learning activity needs to be well designed and understood by students. 59–61 However, Casey et al 62 recommended further investigations of how to prepare students for the peer assessment activities.

The second phase concerns the organisation and structure of the formative peer assessment activity, for example, how to give and receive feedback and the complexity of peer collaboration as it affects students’ emotions concerning both themselves and their relationship with their peers. This coincides with earlier research emphasising the social factors of peer assessment and the importance for teachers to consider them. 4 Nevertheless, surprisingly, few studies highlight the collaborative part of peer assessment. 4 11 One reason might be that formative peer assessment is often presented as a ‘stand alone’ activity and not involved in a collaborative learning environment. 8 63 We agree with earlier research 64 65 arguing that peer assessment needs to be affiliated with practices of collaborative learning. Similar implications are presented by Tornwall, 12 who concluded the importance of integrating peer collaboration as a natural approach throughout education to support student development.

Limitations

Previous methodological concerns and discussions have been related to the systematic approach of handling grey literature. 66 67 We argue that the grey literature may contribute to a wider understanding of the research area. Nevertheless, when we conducted a critical appraisal of the included studies, the grey literature was excluded due to lack of methodological rigour. Therefore, we recommend considering this time-consuming phase of the methodology in scoping reviews. We further acknowledge that the last search was conducted in May 2019, studies may have been included if an additional search had been provided after this date and in other databases than the ones presented. Further, the current scoping review has not fully elucidated the perspective of teachers and faculty. Few of the included studies highlighted the teachers’ perspective why further research is required.

Conclusions and implications for further research

Some have argued that research on peer assessment is deficient in referring to exactly what peer assessment aims to achieve. 68 We conclude that within healthcare education the aim of formative peer assessment is to prepare students for the collaborative aspects crucial within the healthcare professions. However, healthcare education must consider preparing and introducing students to collaborative learning; therefore, well-designed learning activities aligned with the learning outcomes need to be developed. Based on this scoping review, formative peer assessment needs to be implemented in a collaborative learning environment throughout the education to be effective. However, since peer collaboration seems to affect students’ and teachers’ experience of formative peer assessment, empirical investigations exploring the collaboration between students are of utmost importance.

Supplementary Material

Acknowledgments.

Special thanks to the members in the expert group for their valuable contribution in the consultation.

Twitter: @Have none

Contributors: MS led the design, search strategy, and conceptualisation of this work and drafted the manuscript. EM, MB and EC were involved in the conceptualisation of the review design, inclusion and exclusion criteria, and critical appraisal and provided feedback on the methodology and the manuscript. All authors give their approval to the publishing of this scoping review manuscript.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Ethics statements, patient consent for publication.

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MINI REVIEW article

Career construction theory: tools, interventions, and future trends.

• School of Education, Huainan Normal University, Huainan, China

With the emergence of the borderless career era in the 21st century, career coaching has experienced a change from career guidance and career education to career counseling. Career construction theory has been widely used in career counseling and has substantial application value. Introducing career construct theory’s assessment tools and intervention strategies is necessary and meaningful. In this mini-review, the qualitative assessment tools and intervention approaches of career construct theory are introduced and analyzed; the qualitative assessment tools include the Career Construction Interview and “My Career Story” workbook, and the intervention approaches include the Computer-Assisted Career Counseling System, workshops, group counseling, and individual counseling. Finally, future research directions are proposed, including an analysis of what kinds of career construction interventions are most effective for which groups and under what conditions, career intervention in the digital age, and the standardization of assessment tools. The novelty of this paper lies in the fact that it purposefully proposes future directions for career construction theory from the perspectives of assessment tools and intervention approaches and that research on the assessment tools and intervention approaches of career construction theory still needs further attention.

Introduction

Career counseling has changed from career guidance and career education to career counseling. In the 19th century, career counseling was centered on the matching career guidance model, which is making rational decisions based on self and career information. After entering the 20th century, career counseling is based on career development theory, focusing on how individuals make decisions, a process-oriented career intervention. Furthermore, beginning in the 21st century, career counseling centers on career construction theory, focusing on vocational personality, career adaptability, and life theme, emphasizing constructing careers. These three theoretical models are the career guidance model to determine the person-job match, career education to promote career development, and career counseling to design work-life.

Career construction theory

Savickas (2005) proposed the career construction theory based on personal constructivism, social constructionism, and post-modernity. Career construction theory believes that the essence of individual career development is the dynamic construction process of pursuing mutual adaptation between the subjective self and the external objective world, and different people construct different stories. Career construction theory provides a dynamic perspective to give personal meaning to memories, present experiences, and plans, constructing careers through a sense of meaning and clarifying future directions. The theory includes three parts: vocational personality, career adaptability, and life theme. Occupational personality refers to an individual’s career-related abilities, needs, values, and interests. Career adaptability is described as “a psychosocial construct that denotes an individual’s resources for coping with current and imminent vocational development tasks, transitions, traumas” ( Savickas and Porfeli, 2012 , p. 662). The difference between occupational personality and career adaptability is that occupational personality emphasizes the content of a career, while career adaptability emphasizes the coping process of constructing a career. Career adaptability deals with how individuals construct careers, while occupational personality deals with what careers they construct. Career adaptability deals with how individuals construct their careers, while occupational personality deals with what careers they construct. Unlike vocational personality and career adaptability, life theme is a dynamical system that primarily explains why individuals make career choices and the significance of those choices and expresses the uniqueness of the individual in a particular context, which provides a way of looking at the world. Career counseling, developed from career construction theory, focuses on vocational personality, career adaptability, and constructing meaning in life themes ( Savickas, 2013 ). Vocational personality focuses on the “what,” career adaptability is about the “how,” and life theme responds to the “why” ( Guan and Li, 2015 ).

Compared to other career theories, career construction theory helps students adapt to the future’s complex and changing career world and inspires a richer perspective on career development ( Gao and Qiao, 2022 ). Meta-analysis has shown that social construction theory is more effective than individual-environmental matching theory ( Langher et al., 2018 ). Career construction theory seeks to explain the interpersonal process in which individuals construct the self, establish the direction of career behavior, and assign meaning to careers, providing a unique perspective on how to view the subject of career counseling ( Hou et al., 2014 ). Career construction theory provides specific ideas to help the case make career decisions and enhance work satisfaction ( Savickas, 2005 ). Therefore, this review aims to introduce the tools, interventions, and future directions of career construction theory to help individuals better adapt to the rapidly evolving situation.

To ensure the quality of the literature, the terms “career construction” and “intervention” were used as search terms in this study, both of which appeared in the title, abstract, or keywords. A comprehensive search was conducted on the “Web of Science, PsycINFO, and EBSCO.” The search was limited to English-language articles. Specifically, the literature was searched from 2013 to 2023. In addition, only standard research papers were included in this study, excluding review-type articles.

Life design counseling

Life design counseling is based on career construct theory, which gives meaning to life and supports adaptive responses by helping the individual to tell a career story, constructing the past, present, and future to form continuity and consistency. The five assumptions of the life design model of vocational intervention are contextual possibilities, dynamic processes, non-linear progression, multiple perspectives, and personal patterns. Life design counseling is lifelong, holistic, contextual, and preventive. It aims to increase the client’s adaptability, narratability, and activism ( Savickas et al., 2009 ).

The life design paradigm relies on story construction and action. The first stage of life design counseling is constructive, which involves clarifying the problem and what one hopes to achieve through counseling. The counselor encourages the client to find the life theme by describing the problem to be solved through a story. The second is deconstruction, which helps the client reflect on and shape the story by allowing them to clearly express experiences, expectations, actions, and expectations for the future. The third stage is reconstruction. The counselor and the client can interpret the story from different perspectives, thus enabling the client to rewrite his or her story. The fourth is the co-construction stage. The issues raised by the client are put into the rewritten story, and a new story is co-constructed as a solution. The fifth stage is action. Assign participation in some of the narrative’s possible self-relevant activities. It is necessary to specify what they will do and what this means to help the client make a plan ( Savickas et al., 2009 ).

Career construction interview

The Career Construction Interview is a structured process based on life design counseling designed to help clients tell, hear, and enact their life career stories. Counselors help them to coherently tell their career story, cope with changes in the environment, design a meaningful life, and take action by conducting a qualitative career assessment with a narrative model and methodology. The career construction interview comprises five questions, each leading to a thematic story. Role Models are to identify adjectives that describe self-constructs and concepts. Favorite magazines/TV/websites are to identify the types of environments and activities that interest the client. Favorite stories are understanding the stories or cultural scripts the client might use to envision transformational outcomes. Favorite mottos can give the client some advice. Early recollections can provide insight into how the client perceives the issues presented in the transition narrative ( Savickas, 2011 ).

At the beginning of the second phase, the counselor draws a portrait of life-occupation based on the client’s answers to CCI questions, combined with observation and reflection. By reviewing the story together and encouraging reflection and reflexivity in the conversation, the counselor and client construct a powerful new life-career identity that has coherent meaning for the client’s life. In the third phase, the client develops an action plan with the counselor. The career interest results obtained from the CCI correlate moderately with the quantitative Career Interest Inventory results, which suggests that the CCI agrees with traditional quantitative assessment tools ( Barclay and Wolff, 2012 ). Barclay (2018) provided three additional ways to use the CCI: written exercises, career collages, and career portfolios. Lindo and Ceballos (2019) developed the Child and Adolescent Career Construction, which includes the development of appropriate expressive arts to promote self-expression and career exploration in children ages nine and older. The CACCI includes a socio-emotional focus that encourages clients to explore self-concepts, life themes, and career awareness.

My Career Story

“My Career Story” is a career autobiographical workbook developed based on the Life Design Paradigm and contains written exercises and goal-setting activities essential to successful career planning ( Brown and Ryan Krane, 2000 ). It corresponds to the construction, deconstruction, reconstruction, co-construction, and action of life design counseling ( Hartung and Santilli, 2017 ).

MCS is designed to help clients tell, hear, and enact their life-career stories about who they are, who they want to be in the world of work, and how they can connect themselves to careers they might enjoy. Individuals, groups, and educators can use MCS to guide self-reflection to increase narrative identity, intentionality, and adaptability in career planning, career choice, and work adjustment. The MCS workbook consists of three sections to guide clients in telling their life stories. The first section, “Telling My Story,” begins by defining the participant’s problem, listing the careers they have considered pursuing and how they would like the workbook to benefit them. Next, participants answered questions related to life-career topics: (1) role models they admired while growing up, (2) favorite magazines and television shows, (3) stories from favorite books or movies, (4) favorite mottos. The second part is “Listening to My Story.” Portrait their lives by integrating smaller stories into a more cohesive career story. Including (1) Who will I be? (2) Where do I like to be? (3) The portrait summarizes (4) Rewrite my story. The third section, “Enacting My Story,” involves creating a realistic plan to implement the story ( Santilli et al., 2019 ). The MCS can be used by clients alone or with the counselor’s assistance. As an adjunct to career counseling, the MCS can be used in one-on-one individual and group counseling and career development learning activities in the classroom or other settings ( Hartung and Santilli, 2017 ).

Career intervention

Twenty-two studies published between 2013 and 2023 met all criteria and provided the necessary data for the systematic review. Databases included Web of Science, PsycINFO, and EBSCO. Two authors screened all titles and abstracts. In addition, they considered the eligibility of full-text articles. First, the databases were searched with the keywords “career construct theory” and “intervention.” Furthermore, a citation search was conducted for key papers, and reference checking was performed as suggested by Tuttle et al. (2009) . Thus, the search strategy was iterative and multi-stage, including computerized and manual searches. Therefore, it can be concluded that these searches were adequate for a systematic review. Finally, 22 studies were identified, including three qualitative and 19 quantitative studies. The two authors evaluated these studies against the selection criteria and agreed on the final 22 studies. Figure 1 depicts the process of selection.

Figure 1 . PRISMA flow chart.

These studies review intervention research on career construction theory, as shown in Table 1 .

Table 1 . Intervention studies.

Career group

Career Group is based on group counseling theory and can promote the cognitive, emotional, and behavioral aspects of an individual’s career development. Career group guidance and career group counseling are two forms of career groups. The difference is that career group guidance has more participants and focuses on transferring knowledge. Career counseling has fewer members and emphasizes interaction and communication between members ( Jin, 2007 ).

Researchers examined the effects of life design group guidance on 9th grade. Findings supported the effects of life design group guidance on career identity, career adaptability, and career decision-making self-efficacy ( Cardoso et al., 2022 ). Maree (2019) used quantitative and qualitative research methods to conduct group career construct counseling with 11th-grade students. The Career Adaptability Scale was used for quantitative analysis. Career interest analysis and Maree Career Matrix were used for qualitative intervention. The findings revealed that students significantly improved career adaptability. Maree et al. (2019) explored the impact of life design group counseling on unemployed young adults’ career adaptability. First, the Career Interest Profile was used to obtain information about career choices: work-related information, five most and least preferred career preferences, six career choice questions, and 15 career story narrative questions. Career counseling techniques such as career genealogy charts, interviews, and personal statements were used. Results indicated that life design group counseling increased participants’ career adaptability.

Recently, Gai et al. (2022) used career construct theory to develop a peer motivational interview that included engagement, focus, arousal, and planning. The research involved senior students conducting one-on-one career motivational interviews with junior students. Results indicated that the intervention increased students’ career control and career confidence. Cook and Maree (2016) compared the effects of career construction group counseling and a life-oriented curriculum on 11th-grade students in different educational settings. The group counseling included Collage, the Career Interest Profile, and the lifeline technique. Participants demonstrated higher career adaptability after participating in career construction group counseling. Maree et al. (2017) used career construction group counseling. The experimental group completed narrative questions in the Career Interest Profile. They created career collages depicting how they see their future. In addition, “My Lifeline” was drawn to mark essential themes in their lives. The quantitative study results indicated that life design group counseling did not increase participants’ career adaptability compared to the traditional program.

Seminar is another form of group counseling. Seminars are less frequent and intensive than group counseling, with more fixed topics and less interaction between members, making them an efficient method ( Jin, 2007 ).

Life design counseling can reduce indecision, anxiety, uncertainty, and insecurity among college students ( Obi, 2015 ). Maree and Symington (2015) designed eight life design workshops with five 11th-grade students in a private school. The students demonstrated increased effort to address issues related to career concern, control, curiosity, and confidence, suggesting that the intervention facilitated the development of their career adaptability. Cadaret and Hartung (2021) designed career construction group counseling using the workshop format combining individual reflection and group discussion. The workshops were based on the My Career Story (MCS) workbook. The first session was “Telling My Story,” which included role models, favorite magazines/TV shows/websites, favorite books/movies, and favorite mottos. The second was “Hearing My Story,” which included describing myself and my interests, scripting roles, making suggestions, and constructing a life portrait. The third session, “Enacting My Story,” included co-setting goals, seeking more information, and exploring pathways to select and identify career goals. Results indicated that the career construction intervention increased students’ career control and confidence. Ginevra et al. (2017) used a life design approach to develop resources that help cope with career transitions, encourage thinking about the future, identify one’s strengths, and plan future projects. It is divided into three phases. Participants were encouraged to tell, revise, and construct their career stories in the first phase. In the second phase, participants were administered an online questionnaire on hope, optimism, resilience, future direction, and career readiness. Consider their strengths in response to the career change in the third phase. Results indicated that the life design approach improved their career adaptability.

Peila-Shuster et al. (2021) used career construct theory to conduct career workshops with adults who had been unemployed for more than six months. Workshops included current status, describing role models, favorite mottos, rewriting stories, reflections, and action plans. The counseling utilizes the My Career Storybook to help participants cope with their problems and prepare for their job search by facilitating narratability, intentionality, and career adaptability. Da Silva et al. (2022) conducted career construct interviews with students. The interview consisted of three workshops that (1) discussed role models, television shows, books or movies, mottos, and early memories; (2) Exploring participants’ answers to career construct interview questions; (3) Discuss the steps needed to implement a new career plan. The study showed that the Career Construct Interview promotes the development of students’ career adaptability and remains stable 3 months after the intervention. This suggests that the intervention of the Career Construct Interview has a good latency. Santilli et al. (2019) compared the impact of life design and traditional career counseling on adolescents. Life design group counseling utilized the “My Career Story” workshop format. The results showed that the intervention promoted the development of career adaptability in the Life Design group. This suggests that “My Career Story” may be an effective means of developing career adaptability in adolescents.

However, the study yielded inconsistent results. Researchers examined the impact of the life design workshop on 9th and 12th-grade students. The intervention utilized the “My Career Story” life design methodology. The results showed that the life design intervention did not impact students’ career adaptability ( Cardoso et al., 2018 ).

Online career group

The advantage of online interventions is the availability of audiovisual materials, including videos, slideshows, and animations, which help students explore values, interests, and skills independently. Online career counseling is more accessible than traditional career guidance, and students can access various practical information ( Chen et al., 2022 ).

Nota et al. (2016) compared the validity of online life-based design and traditional test interpretations. All students received personalized feedback, including suggestions for future schools and jobs related to their interests, values, and motivation. Results indicated that the online life design group demonstrated higher career adaptability, life satisfaction, and future aspirations. The researchers compared online and face-to-face life design counseling on career development. The online interventions included an introduction to online books, bilingual career videos, short animations, access to a virtual library, an introduction to similar websites that promote career development, and online chats with career counselors. The results showed that online and face-to-face career interventions improved students’ career development ( Pordelan et al., 2018 ). Later, they compared life design digital storytelling and face-to-face storytelling, and the study found that the digital storytelling group had higher career decision self-efficacy than face-to-face storytelling ( Pordelan et al., 2021 ).

Zammitti et al. (2023) conducted a life design paradigm online career intervention with college students to enhance their psychological resources. The online intervention consisted of career workshops and 13 online activities. The study showed that an online group career intervention in the life design paradigm promotes the development of resilience, subjective risk intelligence, career adaptability, self-efficacy, optimism, hope, and life satisfaction. Camussi et al. (2023) foster the development of student’s skills to face complexity and unpredictability, transforming their time perspective into optimism to face the future. The intervention was based on the theoretical model of Life Design. The intervention themes were “My future, why?” and “Who am I and who do I want to be?.” The intervention consisted of two online workshops. It included reflections on conscious life design and current global contextual challenges. The study demonstrated that the Life Design online intervention facilitated the development of students’ levels of career adaptability, courage, time perspective, and resilience.

Individual career counseling

Individual career counseling is usually a one-on-one approach that assists with career confusion to enhance career adaptability. Individual counseling has the highest cost but significantly impacts the client and the counselor.

The value of individual career counseling is to help all those challenged by unemployment and poverty (especially emerging adults) to become employable, find decent work, and increase their sense of self, and in the process, promote the idea of a fair and just society ( Maree and Twigge, 2016 ). Maree and Gerryts (2014) conducted narrative counseling with a newly young male engineer based on career construct theory. Methods included collage, Career Interest Profile, life chapters, lifeline, early recollections technique, and Career Construction Interview. Participants demonstrated an increase in willingness to cope with challenges and adaptive strategies. This suggests that narrative counseling can facilitate the development of career adaptability. Maree (2016) conducted career construction counseling with a mid-career Black man to construct, deconstruct, reconstruct, and co-construct the client’s life story. The interview included role models, favorite magazines/TV/websites, favorite stories, early memories, and favorite mottos. The client demonstrated an improved self-awareness and a willingness to be more flexible in dealing with challenges related to the career.

Career assessment

The Career Construction Interview and MCS workbook are two qualitative assessment tools under the Career Construction Theory. The groups for which the tools are applicable may be different. The adult population may be more suitable for the Career Construction Interview, and most individual counseling uses the Career Construction Interview ( Maree and Gerryts, 2014 ; Maree, 2016 ; Maree and Twigge, 2016 ). Quantitative tools for career construction intervention mostly use a career adaptability scale ( Maree and Symington, 2015 ; Ginevra et al., 2017 ; Maree et al., 2019 ).

Quantitative assessment is a standardized and scientific measurement tool but has certain disadvantages. The advantage of qualitative assessment is that it facilitates the discussion of group career counseling and can improve the shortcomings of quantitative tools. The case study of self-narrative can help the researcher to sort out the main conflicts and critical variables in career development ( Guan and Li, 2015 ). Integrative Structured Interview, based on the system’s theoretical framework, is a method that combines qualitative and quantitative measures to advance storytelling. Using Hollander’s interests as the basis for quantitative assessment, integrating assessment results with storytelling, the integrative structured interview facilitates this integration through quantitative score-based career storytelling that focuses not on the scores but on facilitating participants’ understanding of their scores, career decisions, and transitions ( McMahon et al., 2020 ). Therefore, it is necessary to develop a hybrid standardized assessment method based on career construction theory.

Career construction theory has been widely used in the field of career counseling. Career group counseling is guided by the theory of career construction, and career intervention programs are designed for the career construction process of different groups, which can effectively solve the problems faced by different groups in career development. Individual career counseling can help cases to link their self-concept with their work through the self-construction of work so that individuals can become the creators of their work and actively construct the meaning of their careers to be prepared for the new changes in the work pattern.

Brown and Ryan Krane (2000) meta-analysis identified five critical elements of career counseling: written exercises and workbooks, individualized explanations and feedback, career world information, role modeling, and building support. The MCS workbook corresponds to the written exercises and workbooks among the key elements. Another meta-analysis indicated that the three critical elements of career counseling are counselor support, value clarification, and psycho-educational intervention ( Whiston et al., 2017 ). The career construction interview gained direct counselor support and clarification of specific values. Combining the MCS manual and supporting materials may effectively develop career adaptability in adolescents ( Santilli et al., 2019 ). However, some research suggests that ninth graders show more difficulty than twelfth graders in recounting their own experiences ( Cardoso et al., 2018 ). This may be because the career construction interview is more helpful for lower grades, which require direct support and clarification of specific values from the counselor.

Currently, the primary interventions of career construction theory are computer-assisted career counseling systems, workshops, group counseling, and individual counseling. Career courses are the most effective ( Oliver and Spokane, 1988 ). Therefore, converting life design counseling into a career course is warranted, and a career construction orientation curriculum needs to be developed to enrich the career construction intervention. A meta-analysis by Whiston et al. (2003) demonstrated that intervention effectiveness significantly increases using a computerized career guidance system in counseling. Various career intervention approaches are often integrated into practice, mainly using computerized career guidance with other modalities. The study found that a comprehensive intervention combining online life design and written exercises was more likely to increase students’ career adaptability and life satisfaction ( Nota et al., 2016 ).

Future research trends

Although the assessment tools for career construct interventions have been enriched in recent years, the stability, validity, and applicability of the assessment tools still need to be tested in the further. Career construction interventions focus on the reconstruction of life stories. Some studies have found that career construct interventions did not increase students’ career adaptability ( Maree et al., 2017 ; Cardoso et al., 2018 ). This suggests that relying on the Career Adaptability Scale as a quantitative study is insufficient, some questionnaires should be designed to measure whether students can articulate and identify what is important to them before and after the intervention. Assessment tools for career construction intervention mainly consist of qualitative or quantitative tool, but standardization still needs to be improved ( Di Fabio, 2016 ; Cardoso et al., 2022 ). Some studies utilize quantitative and qualitative assessment tools ( Maree, 2020 ), but they need more cross-cultural validation.

Therefore, future research in assessment tools can consider the following aspects: In terms of assessment content, special assessment tools must be prepared for different and unique groups. Savickas (2011) developed a complete set of guidelines for career construction counseling. Online guidelines and assessment tools could be developed in the future, incorporating technologies such as computer networks and multimedia. In particular, comprehensive assessment tools that include quantitative and qualitative aspects should be developed to meet the needs of large-scale research with different groups and achieve standardization and stability of assessment methods.

First, there is a question of what groups and career interventions are most effective under what conditions. The economic benefits of career interventions in different modalities, age groups, and various intervention goals are critical. The meta-analysis result indicated that the career course was the most effective but required the most intervention time. Individual counseling produced more benefits per session than other interventions ( Oliver and Spokane, 1988 ). Subsequently, meta-analysis yielded different results. Individual career counseling was the most effective, followed by group career counseling, with career courses coming in third. Computerized online systems were the most cost-effective ( Whiston et al., 1998 ). A recent meta-analysis indicated that individual counseling was the most effective, while group and individual counseling and computer-based interventions varied widely ( Whiston et al., 2017 ). Meta-analyses have not yet yielded consistent conclusions. In addition to the results, individual and group counseling are effective methods. However, at the same time, it is essential to consider the number of people and the economic benefits that professional interventions can bring ( Whiston, 2011 ).

Additionally, the results showed differences in intervention impact based on the participants’ grades. Ninth graders only improved at the level of career certainty, while twelfth graders showed more significant development on all measured variables. This may be because higher-graders can better understand what is important to them and what they strive for. Therefore, it is essential to consider the characteristics and needs of different groups to maximize the effectiveness of career construction interventions in future research. Different intervention modalities affect individuals’ career development, which is best for group counseling and which works best for individuals. These issues must be better understood, requiring meta-analysis or systematic review to explore in the further.

Second, digital technology is essential for career interventions. In particular, Online interventions allow alternative experiences and role modeling to be more readily available through websites where short videos of successful people can be viewed and inspired. Therefore, career construction theory may benefit career interventions in the digital age. Online career construction interventions are very efficient and likely to be used more and more. Online career construction can present stories in short films, slideshows, or photographs, allowing the client and the counselor to discover hidden stories and help the client gain new concepts. The advantage of online career construction intervention is convenience, where stories can be opened on a computer or other electronic device. In the storytelling process, information technology is utilized as a platform for digital storytelling, where one’s life story is expressed as a photo, movie, or audio ( Pordelan et al., 2021 ). In the future, personalized interpretation and feedback procedures can be added to the computer-based online intervention to maximize the usefulness of the career construction intervention.

Finally, developing new content and a short career construction interview are necessary. Using career construction theory, the researcher developed a peer motivational interview for at-risk students that included engaging, focusing, evoking, and planning ( Gai et al., 2022 ). Questions include “What do you want to obtain from your future occupation? Why?” “What occupations are you likely to pursue in the future? What occupations are you unlikely to pursue? What occupations are you not sure about whether to pursue? How can you become certain?” Future research needs to focus on particular groups as subjects, focusing on those severely hindered in their career development or career transition, and test the effectiveness of career interviews through group interventions to maximize the effects of career interventions.

However, completing the career construction interview typically requires two 90-min sessions, which hinders its practical use with many students in school. Therefore, Rehfuss and Sickinger (2015) developed a short form of the career construction interview. Only three initial career construction interview questions were used in the short form. “Who did you admire when you were growing up? What are your favorite magazines, TV shows, or websites? Tell me your favorite saying or motto.” These three questions were used to learn about the students’ role models, self-advice to help solve current problems, and preferences for the work environment. In addition, there is a need to develop a short form of the Life Design Group Counseling and MCS. Also, some form of screening is necessary to determine what questions of the career construction intervention will benefit the individual the most.

Career construction theory applies to the current borderless career era, and such a career theory perspective is more helpful for individuals to adapt to the complex and changing career world in the future. Currently, the tools of career construction theory mainly include the structured career construction interview and the qualitative assessment manual of MCS. The interventions of the theory mainly include workshops, group counseling, online group counseling, and individual interviews. This study identified several challenges to the career construction tools and interventions.

Therefore, it offers some suggestions on how to deal with these challenges: Future researchers need to pay attention to the development of comprehensive quantitative and qualitative assessments to standardize and stabilize assessment methods for the tools. For the interventions, there is a need to examine the question of what groups and under what conditions career interventions are most effective. Second, future research should develop personalized interpretation and feedback procedures for computerized online interventions in the digital age. Finally, developing new content and a short career construction interview are necessary.

Author contributions

DW: Writing – review & editing, Writing – original draft. YL: Writing – review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Acknowledgments

This study would like to thank and extend our sincere gratitude to the reviewers.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: career construction theory, My Career Story, career construction interview, career intervention, future trends

Citation: Wang D and Li Y (2024) Career construction theory: tools, interventions, and future trends. Front. Psychol . 15:1381233. doi: 10.3389/fpsyg.2024.1381233

Received: 03 February 2024; Accepted: 25 March 2024; Published: 05 April 2024.

Reviewed by:

Copyright © 2024 Wang and Li. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Yanling Li, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Open access
• Published: 10 April 2024

Cultural adaptation and validation of the caring behaviors assessment tool into Spanish

• Juan M. Leyva-Moral 1 ,
• Carolina Watson 1 ,
• Nina Granel 1 ,
• Cecilia Raij-Johansen 1 &
• Ricardo A. Ayala 2 , 3  

BMC Nursing volume  23 , Article number:  240 ( 2024 ) Cite this article

Metrics details

The aim of the research was to translate, culturally adapt and validate the Caring Behaviors Assessment (CBA) tool in Spain, ensuring its appropriateness in the Spanish cultural context.

Three-phase cross-cultural adaptation and validation study. Phase 1 involved the transculturation process, which included translation of the CBA tool from English to Spanish, back-translation, and refinement of the translated tool based on pilot testing and linguistic and cultural adjustments. Phase 2 involved training research assistants to ensure standardized administration of the instrument. Phase 3 involved administering the transculturally-adapted tool to a non-probabilistic sample of 402 adults who had been hospitalized within the previous 6 months. Statistical analyses were conducted to assess the consistency of the item-scale, demographic differences, validity of the tool, and the importance of various caring behaviors within the Spanish cultural context. R statistical software version 4.3.3 and psych package version 2.4.1 were used for statistical analyses.

The overall internal consistency of the CBA tool was high, indicating its reliability for assessing caring behaviors. The subscales within the instrument also demonstrated high internal consistency. Descriptive analysis revealed that Spanish participants prioritized technical and cognitive aspects of care over emotional and existential dimensions.

Conclusions

The new version of the tool proved to be valid, reliable and culturally situated, which will facilitate the provision of objective and reliable data on patients beliefs about what is essential in terms of care behaviors in Spain.

• This paper provides a culturally translated, adapted, and validated version of the Caring Behaviors Assessment tool in the Spanish context, which can be used to obtain reliable and culturally adapted data on essential aspects of patient care.

• The findings of this study contribute to the wider global clinical community by demonstrating the importance of considering cultural factors when assessing and evaluating patient care from patients’ own perspective, and also emphasizes the need for culturally sensitive approaches in healthcare settings.

• This validated instrument facilitates the measurement of caring behaviors in the Spanish context, allowing for objective evaluation and improvement. Use of the Caring Behaviors Assessment tool could thus serve as a valuable resource for both future research and clinical practice.

Peer Review reports

Caring,  as a complex culturally derived phenomenon, encompasses recognition of individuals’ uniqueness and includes moral, emotional, and cognitive dimensions [ 1 ]. Within the field of nursing, the professional act of caring is defined as an interpersonal process characterized by nurses’ expertise, competencies, personal maturity, and interpersonal sensitivity. The ultimate aim is to meet patients’ bio-psycho-social needs, ensuring their protection, emotional support, and overall satisfaction [ 2 ]. Furthermore, caring has been understood as the pivotal element that patients expect and should encounter to feel satisfied with nursing services [ 3 ]. Therefore, the concept of caring is dynamic, requiring adaptation to diverse sociocultural contexts.

Drawing on humanistic, transformative, integrative, and complex ontological and epistemological perspectives, various nursing theories have been developed that focus on promoting human-centred care [ 4 , 5 ]. One such perspective is the theory of human-to-human relationships proposed by Travelbee [ 6 ], which emphasizes the unique and irreplaceable nature of anyone who has lived or will live in this world. In this perspective, therapeutic human relationships evolve through a series of interactive steps, including the emergence of identities and the development of empathy (and later sympathy) until finally establishing rapport with persons receiving care [ 7 ].

Similarly, Watson [ 8 , 9 ] has elaborated a care process consisting of the following ten steps (caritas process): 1) consciously practising kindness and honesty while providing care; 2) being authentically present in a facilitative manner; 3) cultivating spirituality by transcending the self; 4) developing and maintaining a relationship of trust; 5) supporting the expression of both positive and negative feelings; 6) using creativity to obtain information during the care process; 7) engaging in genuine teaching and learning that take a global view of phenomena, while considering the perspective of the other; 8) creating healing environments that enhance integrity, comfort, dignity, and peace; 9) consciously and intentionally assisting with basic needs while enhancing the mind, body, and spirit; 10) remaining open to the experience of life and death, including care of both the professional and the patient’s soul. In short, caring is the essence of nursing and is a fundamental element for establishing effective nurse-patient relationships and achieving high-quality health outcomes.

The quality of nursing care is directly related to patients’ general experience and satisfaction. Evidence shows that patient experience with nursing care is a crucial predictor of patient satisfaction [ 10 , 11 ]. Studies indicate that providing expert and integrated care contributes to patients’ sense of safety and feeling embraced [ 12 ]. Conversely, professional nursing practice based on the biomedical model has been associated with low patient satisfaction and limited professional fulfilment among nurses [ 13 ].

Nevertheless, measuring nursing care plays an essential role in assessing its effectiveness and quality. By measuring nursing care, healthcare organisations and policymakers can identify areas for improvement and make evidence-based decisions to enhance patient outcomes. While caring cannot be reduced to a mere collection of actions and behaviours, this step is crucial in systematising the components of care that impact patients’ experiences [ 14 ] and in determining the contribution of nursing to health systems [ 15 ]. Watson [ 9 ] argues that, without engaging in philosophical contradictions, the use of quantitative instruments to assess care is necessary to provide scientific evidence. Such evidence helps managers and researchers to evaluate the complex and unique role of nursing and its effects on health.

The presence of an adequate number of well-trained nurses is known to reduce the risk of patient mortality, with outcomes similar to those achieved by physicians [ 16 ]. Nevertheless, nursing care extends beyond numerical values and clinical outcomes. It is well-established that discrepancies exist between the perceptions of nurses and patients regarding what constitutes care, primarily due to the uniqueness of each individual; hence the application of individualized care is promoted and takes into account the sociocultural context [ 17 ]. Moreover, humanised care is associated with high levels of patient and family satisfaction in various contexts [ 18 ].

One of the oldest and most widely used tools for assessing nursing care is the Caring Behaviours Assessment (CBA) tool, developed by Cronin and Harrison [ 19 ]. The authors were concerned about the exclusion of patients’ perspective in care settings and sought to identify which behaviours communicated care and how their effectiveness could be evaluated. Consequently, they created and validated the CBA, which comprises 63 items, grouped into seven subscales based on Watson’s ten carative factors. The instrument has been translated and validated in several languages, including Chilean Spanish [ 15 ]. However, the Spanish spoken in Spain exhibits distinct differences to the Chilean variety in word usage, meaning and cultural nuances, influenced by other languages spoken in the country such as Catalan or Galician. Consequently, despite extensive debate in recent years, there are currently no reliable assessment instruments available in the Spanish context that adequately consider cultural nuances in patients’ experiences. Therefore, using the CBA in an apparently similar but different language variety could lead to misinterpretation [ 20 ].

The aim of this study is to report the process of cultural translation, adaptation, and validation of the CBA in Spain, which to the best of our knowledge is the only culturally grounded version available. This new version of the CBA will provide a reliable means to obtain objective, tangible, and culturally adapted data on patients’ perceptions of the elements they deem to be essential in their care.

Approval was obtained from the relevant Ethics Committee on 2020 ( ethics committee name, hidden for blinding purposes ). Then, a study organised in three phases was undertaken on 2021–2022. The phases were as follows: 1. Transculturation. 2. Training. 3. Administration.

A previous publication reported the process of creating a version of the CBA in Latin-American Spanish, namely in Chile. The authors of that publication suggested several steps for obtaining a transculturally adapted version, which we used here. These steps were as follows:

Translating the CBA from English to Spanish : one translation (draft 1) was done by a non-nursing translator, and another one (draft 2) by two bilingual nurses, who were familiar with Watson’s theory. The two drafts were then contrasted, leading to an agreed translation (draft 3).

Back-translation from Spanish into English : A bilingual nurse who was familiar with the subject but unfamiliar with the CBA, back-translated draft 3 into English (draft 4).

Refining the Spanish draft prior to the pilot test : the authors reworked a refined version (draft 5) by contrasting the back-translation with the original CBA in English.

Pilot-testing the translated version : Once satisfactorily refined, the translated version was tested with 36 volunteers. This step included interviewing them to identify their understanding of each item.

Linguistic and cultural adjustment: draft 5 was further adjusted by analyzing the volunteers’ responses and using three linguistic criteria: semantic disambiguation, morpho-syntax, and language. This step aimed to ensure one of the key traits of the CBA: plain language. As in the Latin-American version by Ayala and Calvo [ 15 ], conjugation was adjusted (i.e., use of the subjunctive tense instead of the present tense), so that the items reflected hypothetical situations. Otherwise, it would be all too easy for patients to misconstrue that they were being asked to assess the actual care provided by specific nursing staff. Equally, the order of the Likert-type scale was maintained from 1 to 5, left to right. Lastly, grammatical structures and words that sounded natural in spoken Spanish were double-checked with a linguistic consultant. This process led to the preliminary version of the CBA in Spanish.

A team of research assistants was trained in the application of the instrument to ensure a standardised administration process. The training included, for example, that informed consent had to be obtained from all participants before they were given a copy of the questionnaire, that the instructions had to be read aloud to the participants clearly and calmly, that the instrument had to be completed privately, and that the assistants had to remain nearby and attend to participants’ queries. This phase was crucial to minimize the risk of inducing an observer effect on responses.

We administered the transculturally-adapted version of the CBA to a non-probability sample ( N  = 402). To test its psychometric properties [ 21 ], the preliminary version was applied to a sample of adults (between 5 and 10 per item; with a mean age of 39.5 years [SD = 16.5]), who had been hospitalised within the previous 6 months (mean = 2.75 times). This phase aimed to assess the CBA with users of similar characteristics and under similar conditions to those of the final intended users: the CBA is specifically designed to be used in hospital settings.

The procedure yielded 402 observations, providing a significant amount of data for the analysis of item/scale and subscale/scale consistency, as well as the overall reliability of the CBA in measuring a single construct. Of the 402 observations, 120 were excluded from the analysis as they were from health practitioners. As a result, the final sample size was for the analysis was N  = 282.

Statistical analysis

Our objective was to analyse the single items and item‐scale consistency, as well as explain potential differences in perceptions based on demographic data. In addition to assessing the validity of the scale, we also aimed to determine the relevance of diverse caring behaviours within the particular cultural setting of the study. To achieve this, we used correlation analyses to examine the associations between caring behaviors and relevant cultural factors.

Analyses were performed by examining mean and SD (± 1SD) values per item to identify the highest‐ and the lowest‐ranking behaviours. In addition, a Kaiser–Meyer–Olkin (KMO) factor adequacy and Bartlett’s test for sphericity were used to know if our dataset could be factored. Afterwards, Exploratory Factor Analysis (EFA) was used to find common structure in data. The final number of factors was obtained using a parallel analysis. The factorial method employed was minimum residual with Varimax rotation.

Finally, Cronbach’s alpha as well as McDonald’s omega were used to estimate internal consistency and reliability respectively. All statistical analyses were performed using R statistical software (v4.3.3) [ 22 ] and the package psych (v2.4.1) [ 23 ].

As previously mentioned, 120 out of the 402 participants were health professionals. Our initial intention was to retain them in the sample, but their responses made the items markedly redundant, likely due to their familiarity with philosophies of care or a self-validating effect. Therefore, these participants were excluded from the sample. The paragraphs below report the results of the validation tests.

Scores by items

As per descriptive statistics, we calculated mean scores ± 1SD for each of the 63 items of the CBA. The five highest‐ranking and five lowest‐ranking behaviours are listed below (Tables  1 and 2 ). The means ranged from a maximum of [4.87] (± 0.44) for item 3 “Know what they’re doing” to a minimum of [2.88] (± 1.06) for item 25 “Visit me if I move to another hospital unit.”

Cronbach’s alpha and MacDonald’s omega scores by subscales

To calculate the mean ± 1SD per subscale, the items were grouped into their respective subscales. Table 3 shows the scores by subscales alongside their reliability coefficients (ω). As expected, the subscale “Existential/phenomenological/spiritual forces” was the lowest-ranking subscale (3.76 ± 0.34), while “Human needs assistance” was the highest-ranking subscale (4.49 ± 0.23). Nevertheless, both Cronbach’s alpha and McDonald’s omega were 0.8 or higher in all subscales. Importantly, Cronbach’s alpha for the overall scale was 0.96, indicating that the instrument shows a high internal consistency, while McDonald’s omega showed high reliability (0, 97).

Consideration of scale purification

After running the statistical tests, we were dissatisfied with some of the results and deliberated on the need for scale purification [ 24 ]. We found that the items correlating less highly with the overall scale, typically those carrying some existential meaning, were not automatically associated by the respondents with nursing care, and some even considered they were not pertinent to nurses’ work.

Additionally, numerous participants informed us that some items were confusing or sounded redundant. This result had already been detected during the linguistic phase of the study (phase 1), when participants often pointed out that some questions were being asked twice, although differently, which they found somewhat tiresome or repetitive (see Table  4 ).

The decision to perform scale purification for the sake of simplicity required some debate among the listed researchers, as our aim was to have a very high correlation in all of the items. Naturally, this is not the aim of validating an instrument per se. More problematic still were the items that had relatively lower correlations but were meaningful from a theoretical perspective [ 25 ].

We thus aimed to combine personal judgement and statistical criteria, as keeping those items could allow changes in perception to be assessed across time. Furthermore, when removing the items in question, the overall Cronbach’s alpha increased only minimally (from 0.960 to 0.963). Therefore, we decided to keep all 63 items, as in the original CBA [ 19 ], resulting in the validated version of the CBA questionnaire in Spanish. The final version and the item-by-item translation are provided in the Supplementary material .

Exploratory factor analysis

Interestingly, EFA showed that while subscales 1, 2 and 5 are conceptually linked (Humanism/Faith-hope/Sensitivity, Helping/trust, Supportive/protective/corrective environment), these were also strongly associated in the dataset. Similarly, subscales 4 and 6 (Teaching/learning, Human needs assistance) and 3 and 7 (Expression of positive/negative feelings, Existential/phenomenological/spiritual forces) formed somewhat 4 separate groupings on their own. This was also highlighted by the parallel analysis, which showed that 5 factors were found. The latter was reassuring in terms of how well structured the CBA tool is. Additionally, EFA enabled us to identify that the highest loadings (L, see Table  5 ) were item 17 “Really listen to me when I talk” (L = 0.71); item 36 “Ask me what I want to know about my health/illness” (L = 0.70); item 37 “Help me set realistic goals for my health” (L = 0.69); item 06 “Encourage me to believe in myself” (L = 0.69); item 07 “Point out positive things about me and my condition” (L = 0.67); and item 28 “Encourage me to talk about how I feel” (L = 0.67).

KMO and Bartlett’s sphericity test showed that our data set was able to be factorized. KMO overall was 0.93, while Bartlett’s sphericity test (X 2  = 11126.8, p  < 0.05) also suggested that our dataset could be used in EFA. This analysis was done using 5 factors, as shown by the parallel analysis. Table 5 shows the item loadings higher than 0.5 for each factor, while the results for the EFA are shown on Table  6 . The first 3 factors explain 30% of observed variability, while adding factors 4 and 5, completed the 45% of variability explanation (see Table  6 ).

The variability explained after the EFA clearly demonstrates how complex the observed variability becomes following the application of the CBA tool.

How respondents answered the open‐ended question

Some carefully selected examples of the participants’ responses are shown in Table  7 . Additionally, in Phase 1 participants seemed surprised by the items relating to existential/phenomenological/spiritual dimensions. The participants disagreed that these dimensions pertained to nursing care (i.e., “What have nurses become now? Psychologists?”).

Discussion of cultural adaptation and validity of the CBA

The steps taken to ensure accurate cultural adaptation of the Spanish version of the CBA were essential to creating a version tailored to Spanish users, considering the specific features of a region influenced by several languages. Cronbach’s alpha for overall reliability was high (0.96), and all its subscales were 0.8 or higher. The overall Chronbach’s alpha is reassuring as it mirrors that of the Chilean Spanish CBA validated by Ayala and Calvo in 2017 [ 15 ], although in our study there was more dispersion across the subscales. Equally, McDonald’s omega showed high reliability.

Research studies conducted in different regions have also validated CBA versions for patients in the USA [ 26 ], Saudi Arabia [ 27 ] and Jordan [ 28 ]. These studies consistently reported overall Cronbach’s alpha values above 0.8, adding cumulative evidence in support of the CBA as a valid instrument to measure nurses’ caring behaviours.

Moreover, a descriptive analysis was conducted to identify the caring behaviours receiving the highest and lowest ranking. As expected, some items showed weaker correlations with the overall scale, and some participants even considered them “irrelevant” or unrelated to nurses’ duties. When we compared our study to that performed by Ayala and Calvo [ 15 ] and the original by Cronin and Harrison [ 19 ], similarities were found in the results for most of the items. However, differences were found in the item “consider my spiritual needs”, which was rated lower by the Spanish sample. This discrepancy may be related to cultural and contextual factors influencing perceptions and expectations regarding caring behaviours.

Emergence of a 5-dimensional factorial solution for the CBA scale in the Spanish context

Our study presents evidence for a 5-dimensional factorial solution for the CBA scale in the Spanish healthcare context. The convergence of findings suggests that the identified dimensions capture meaningful variance in the dataset and reflect underlying patterns of caring behaviors within the Spanish healthcare context.

Our findings suggest a strong theoretical coherence among certain dimensions within the CBA (Caring Behavior Assessment) scale, reflecting interconnected clusters of caring behaviors. For instance, subscales 1, 2, and 5 demonstrate conceptual linkage, forming a cohesive first dimension that encompasses ‘Humanism/Faith-hope/Sensitivity, Helping/Trust, and Supportive/Protective/Corrective Environment’. Specifically, our analysis reveals an expanded understanding within the first dimension, encompassing not only the initial three carative factors as in the original version but also incorporating two additional factors. These include the formation of a humanistic-altruistic system of values, the installation of faith-hope, the cultivation of sensitivity to oneself and others, the development of a helping-trust relationship, and the provision for a supportive, protective, and corrective environment. This expanded dimension highlights the interconnectedness of empathy, compassion, trust, and reliability within caregiving relationships, reinforcing the foundational principles outlined in Watson’s Theory of Transpersonal Care [ 8 ] and also supported by established theories of patient-centered care [ 29 ]. Additionally, this dimension highlights the importance of providing a supportive, protective, and corrective mental, physical, sociocultural, and spiritual environment, aligning closely with Watson’s emphasis on creating conducive environments for healing and growth. By recognizing this evolution in our analysis, we underscore the ongoing refinement and adaptation of theoretical frameworks to specific contexts better capture the complexities of caregiving dynamics and promote holistic patient care.

While subscales 1, 2, and 5 form a single cohesive dimension, subscales 3, 4, 6 and 7, form separate groupings, resulting in a total of five dimensions, each representing specific facets of caring behaviors. The second dimension, ‘Teaching/Learning’, focuses on the educational aspects of caregiving and skills training. This dimension aligns with the principles of transpersonal care, emphasizing the importance of nurturing the growth and development of both caregivers and recipients through shared learning experiences. The third dimension, ‘Human Needs Assistance,’ emphasizes the importance of fulfilling the fundamental needs of people receiving care, reflecting the humanistic approach to caregiving that prioritizes the preservation of dignity and autonomy. The subscale ‘Expression of Positive/Negative Feelings’ captures the acknowledgement and validation of the emotional experiences of patients receiving care, resonating with the empathetic and compassionate aspects of transpersonal care. Lastly, the dimension ‘Existential/Phenomenological/Spiritual Forces’ addresses the existential, phenomenological, and spiritual aspects of caregiving. This dimension emphasizes the interconnectedness of mind, body, and spirit, echoing the holistic perspective of transpersonal care, which acknowledges the spiritual essence and interconnectedness of all beings. This comprehensive framework illuminates the multifaceted nature of caregiving, addressing diverse aspects essential for holistic patient care and well-being.

Relevant findings and preferences of Spanish individuals

The highest-ranking items among the Spanish participants mainly related to technical and cognitive components, such as competence in clinical procedures and the handling of equipment. Conversely, the lowest-ranking behaviours related to emotional and existential dimensions, such as talking about life outside the hospital, understanding patients’ experiences, and considering spiritual needs. These results may indicate that, within the Spanish context, these components are perceived by patients as less important than technical competencies, thus highlighting their priorities in terms of their care, even though the respondents were not hospitalised. These results suggest that clinical skills and technical competencies play an important role in patients’ perceptions of the quality of nursing care in Spain [ 30 ]. This finding is supported by a prior study [ 31 ] comparing nursing practice in Spain with that in the UK.

The prioritization of technical competencies over emotional and existential dimensions in nursing care may be explained by people’s prioritizing. Individuals usually prioritize basic needs and gradually move to more complex ones after basic needs are met. The perception of care may follow a similar pattern. The primary focus may thus be on safety and meeting the standard of performance required to guarantee this basic need, with less emphasis on the overall experience of wellbeing and being looked after. This approach also tends to be used in healthcare delivery, where the main focus is usually placed on survival-related outcomes [ 32 ]. However, as healthcare evolves toward value-based and person-focused approaches, there is growing awareness of the need to expand services and prioritize broader aspects of care. Expectations may thus be informed by factors such as recovery and quality of life, and become aligned with patients’ priorities, expectations and desire for comprehensive care and enhanced overall quality of life. By understanding this dynamic, healthcare professionals can better navigate the complexities of patient expectations and ensure the delivery of care in accordance with diverse needs and preferences.

However, to ensure comprehensive nursing care aligned with the expectations of individuals in Spain, it is essential to have a deep understanding of their individual needs and priorities. Validation studies conducted for specific populations may shed light on the elements of healthcare that are highly valued and contribute to humanisation. For example, research focusing on transgender populations has shown that being asked about their preferred form of address is highly valued [ 33 ] but does not seem to be a priority for the general population in our setting. Similarly, individuals in end-of-life processes place great importance on the ability of nurses and clinicians to show compassion and empathise with their feelings, while these qualities were not prioritised in the participants in our sample [ 34 ]. Equally, women going through challenging experiences, such as miscarriage, stressed that a key element of the care they required was being helped to cope with the future and understand their feelings [ 35 ].

In a similar vein, another study focused on how the general population perceived the quality of nursing services. The findings of that study revealed that various dimensions of quality, such as psychological, physical, and communication components, were rated at a moderate level, suggesting that there was room for improvement in meeting patients’ expectations [ 36 ]. This finding emphasises the importance of tailoring nursing care to specific populations to address the complexity of individual preferences, and highlights the need to focus on the multidimensional aspects of care to enhance the overall quality of nursing activity.

An awareness of contemporary nursing training and the scope of nurses’ work in society could fruitfully contribute to shifting such expectations away from a focus on technical and knowledge-related issues. As stated by López-Verdugo et al. [ 37 ], society often relies on misinformation when referring to nursing work, which is also often based on widely disseminated myths and stereotypes. A stereotyped image of nursing work, and of nurses themselves, may well lie beneath the reaction of some of the Spanish participants in our study when asked about the importance of emotional and spiritual needs in nursing care. Participants may not always fully appreciate the importance of integrated care, just as contemporary nursing remains largely unknown in Spain [ 37 ]. Therefore, a change in perspective is needed to foster greater appreciation of the profession for more rewarding experiences during periods of health and illness, both for users and for healthcare providers.

Previous research has emphasised human care as a driving force in nursing practice, highlighting that quality care relies on a holistic view of care that extends beyond technical proficiency [ 38 ]. Several studies have underscored that human care, which encompasses emotional support, effective communication, and attention to patients’ psychosocial needs, is essential for promoting patient satisfaction and achieving favourable health care outcomes [ 39 ].

A drawback of the CBA is its relatively long length, leading to a risk of tiring respondents. This limitation has been acknowledged in previous literature [ 15 ]. In addition, during the cultural adaptation phase of the present study, participants reported that some items were somewhat repetitive. To address this concern, future research could focus on validating abbreviated versions of this and other instruments. This approach would allow more streamlined integration of theoretical perspectives into routine assessments in clinical practice. Similarly, exploring the perspectives of specific population groups could provide a more nuanced understanding of their unique expectations regarding healthcare.

As patient-centered care gains recognition as a fundamental aspect of quality healthcare, understanding and measuring caring behaviors become necessary for healthcare organizations and professionals, highlighting the importance of tools like the CBA scale.

The interplay between theory and practice has gained prominence in nursing care over the past two decades. This dynamic encompasses various dimensions, ranging from abstract concepts like human sensitivity and emotional engagement to more tangible factors such as clinical skills. In this context, the use of tools to assess and translate nursing care into workable data have gained importance in healthcare policy and management. Indeed, such objective data can be useful for decision-makers in higher-level management, as nurses’ work is key to user satisfaction and the transformation of the biomedical paradigm in health care. Adapting and validating instruments can thus contribute to these processes.

Similarly, implementing ‘tooling up’ strategies can be a useful way of rendering nurses’ often invisible work visible, which, in the process, could incentivise a humane approach, which is perceived to have been lost in the evolutionary loop of healthcare in the industrialised world.

To support this endeavour, this article provides a validated version of the CBA for users in Spain. This version remains true to the original CBA but incorporates certain modifications into the Spanish version for respondents’ ease of use. Through a process of translation, cultural adaptation and statistical analysis, this new version has been demonstrated be a valid and culturally-appropriate instrument, which provides reliable, objective, comparable and culturally-sensitive data on patients’ perceptions of the most essential elements of care during hospitalization.

All authors declare that they have no conflicts of interest. The individuals who participated in this study were research participants and were not involved in the design, conduct, or preparation of the manuscript.

Relevance for clinical practice

The study addressed the problem of the lack of a culturally translated, adapted and culturally validated version of the Caring Behaviors Assessment (CBA) tool in the Spanish context. This was a significant issue as it hindered the collection of objective and culturally sensitive data on essential aspects of care.

The research will have an impact on several groups. First, it will benefit healthcare professionals and providers, policymakers and managers by providing them with a reliable instrument to evaluate and improve patient care. This instrument could enhance their understanding of patient needs and preferences, enabling them to identify areas for improvement and promote person-centered care.

Second, the research could directly benefit the Spanish-speaking population. Through the CBA tool, individuals will be able to ask for care that aligns more closely with their personal values and preferences, thus promoting a shift towards person-centered care.

Availability of data and materials

The datasets used and/or analyzsed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Caring Behaviors Assessment

Exploratory Factor Analysis

Standard Deviation

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Acknowledgements

We would like to express our gratitude to all the participants who took part in the study. We also wish to thank Dr Pedro Hervé (U. Magallanes, Chile) for providing statistical support. Lastly, we would like to thank Dr Sherill N. Cronin (Bellarmine University, USA) for giving us permission to use and translate the CBA tool into Spanish.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Ghent University, Ghent, Belgium

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Contributions

JM.LM. and RA.A. made substantial contributions to the conception and design of the project. including the development of survey instruments and strategic planning for project dissemination. C.W. and N.G. played a key role in data acquisition, overseeing survey implementation and managing outreach efforts. JM.LM. and RA.A analyzed and interpreted data. C.W., C.RJ., and N.G. were involved in drafting and revising the manuscript. JM.LM and RA.A critically reviewed it for significant intellectual content. All authors read and approved the final manuscript.

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Correspondence to Carolina Watson .

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All ethical principles of biomedical research advocated in the Declaration of Helsinki were respected. This study has been reviewed and approved by the UAB Research Ethics Committee in accordance with ethical standards and guidelines. Approval reference number: (approval reference number CEEAH 5194). Participants were provided with a thorough explanation of the study procedures before accessing the questionnaire, ensuring their voluntary participation, with a commitment to maintaining the anonymity of the collected data. Informed consent was obtained from each participant before the completion of the questionnaires.

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Leyva-Moral, J.M., Watson, C., Granel, N. et al. Cultural adaptation and validation of the caring behaviors assessment tool into Spanish. BMC Nurs 23 , 240 (2024). https://doi.org/10.1186/s12912-024-01892-2

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Received : 17 December 2023

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DOI : https://doi.org/10.1186/s12912-024-01892-2

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