Nurturing Caring Characteristics on Nurse Candidate: A Character Learning Model in Nursing Education Nurse A Character Learning Model Nursing

The caring characteristics have been considered a fundamental element of nursing as it has been studied in a variety of patient care and educational contexts for many years. To teach and cultivate caring as a character value in nurse candidates, a character education model is required. To answer this issue, this study aims at developing caring characteristics learning model for nurse candidates through a basic human needs class. This study employs a 4D design reflecting its stages: defining, designing, developing, and disseminating by involving 168 participants consisting of 4 lecturers, 41 nurses, 3 experts, and 120 nurse candidates from one of universities in Sumedang, West Java. 18 characters were recognized as significant values for a nurse, and the I-CARE paradigm was used to include these values in the learning process. It was found that the I-CARE learning paradigm is efficient in instilling caring characteristics in nurse candidates. This study adds to the body of knowledge on how to develop human resources in the health care sector.


Introduction
Caring is considered a fundamental characteristic of a nurse. As a result, it has been explored in a range of patient care and educational contexts over the years [1]. Nurses' compassionate approach toward patients has a significant impact on hospital services since it leads to patient satisfaction [2], [3]. However, a negative stigma associated with nurses' attitudes and behavior in certain health care settings, particularly hospitals, is persisting [4]. According to the Ministry of Health of the Republic of Indonesia, in 2015, 14% of patient in different Jakarta hospitals were dissatisfied with the treatments due to insufficient caring characteristics [5]. The behaviors felt by the patient are the lack of touch, motivation, empathy, love and attention provisions, have became a benchmark to assess the nurse's caring characteristics. This reality contrasts with the nursing fundamental that caring is an important aspect of a nurse [6]. Caring characteristic is a central and a core element of nursing [7], [8]. Caring is the essence of a nurse [9]. This ambivalence is bolstered even further by Ranheim et al. who argue that nurses impulsively conveyed their experience of alienation from caring theory. However, when they explained their caring characteristics, the connection to theory became clear, thus confirming their practice. As a result, caring theory can still be developed for reflecting on and cultivating through practice [10].
The negative stigma associated with nurses' attitudes and behaviors that do not represent caring characteristics suggests an issue of a nurse [11]. In this context, the characteristic is a behavioral tendency that stems from psychological symptoms, such as desires, motives, attitudes, needs, and beliefs that are unique [12]- [15]. Of course, the only way to tackle the issue is through character education [16].
Values and moral education are sometimes used interchangeably in British literature, such as in Taylor, and other related studies from the Nordic countries such as Johansson and Thonberg or from Australia such as Lovat who use values education as an overarching concept including moral education, character education, ethics education, and citizenship education [17]- [20]. As a result, character education in nursing education institutions is necessary to grow, strengthen, and develop nurses' caring characteristics. The loss of the core character elements of a nurse is symbolized by their lack of care [11].
The crucial role of an educator is linked to the achievement of education as teachers are crucial to the success of education [21]. In its process, teachers must be able to develop a learning method that incorporates caring qualities in all nursing education courses. A teacher must be able to create a learning model based on the development of caring characteristics. To attain the goals of character education, according to Lickona [22], methods, strategies, and resources must be implemented to instill and promote values during the learning processes. Therefore, the goal of this study is to find a formulation for nursing candidates related to the caring characteristics learning model. This is critical to increase educational quality and to produce professional nurses. Ensuring nursing students are given a qualified education plays a key role in nursing education [23].
To achieve the goals, a search for studies on the caring characteristic in the context of nursing was conducted. Guo et al. [24], investigate the relationship between graduate nursing students' professional identities and caring personalities in China. They discovered that graduate nursing students had positive caring personalities despite their poor professional identities. In addition, the nursing caring characters evaluation instrument and the professional identity scale for nursing students were found to have a substantial positive relationship. The conclusion was that graduate nursing students' professional identities were unsatisfactory, and one method to change this is to incorporate caring characteristics into the learning process [24]. Firmansyah [5] stated that the nurse percentage with poor caring quality was in Ireland (11%) and Greece (47%). In addition, Greenfield (2018) affirmed that patients want nurses to have a friendly attitude, be dedicated to their work, have empathy for their patients, and respond quickly to their needs [4]. Patients will be extremely sensitive if they are treated badly by nurses. According to Keliat, Lee, and Suryani [25]- [27], caring characteristics are an asset that nurses must possess to improve the quality of nursing care. Nurse caring characteristics development through evidence-based practice (EVB) has been shown to increase their performance. This study, on the other hand, is motivated by a desire to develop caring characteristics learning design through basic human needs courses. This study yielded a learning model for nurturing the caring characteristics of nurse candidates. To support the production of professional nurses, the findings of this study help to improve the quality of nursing education.

Literature Review
Nursing is a profession that is concerned not only with the use of technical knowledge and abilities in clinical practice but also with the representation of human values [24]. Nurses aim at fulfilling their role in addressing basic human needs, including psychological, physical, and emotional demands, as well as love and affection, self-esteem, and actualization [28]. These efforts will fail if they are not founded on human values, and one of the most important human values for a nurse is compassion or caring [29].
Caring is defined as a means of nurturing valued persons toward whom one feels a personal feeling of commitment and obligation [30], [31] in this sense, caring is providing excellent nursing care to patients while maintaining a strong feeling of commitment and duty [32]. According to Richards and Morse caring as human nature, caring as a moral ideal, caring as an emotion, caring as interpersonal interaction, and caring as an intervention are the five key aspects of this caring [33].
According to Sitzman et al, [34] in Theory of Human Care, 10 carative factors can indicate a nurse's caring qualities. Those are forming a humanistic-altruistic value system, instilling beliefs and expectations, developing sensitivity for oneself and others, fostering a relationship of mutual trust and mutual assistance, increasing and accepting the expression of positive and negative feelings, using systematic problem-solving methods in decision making, improving interpersonal teaching and learning processes, providing an environment that supports, protects, and/or improves mental, socio-cultural and spiritual, assisting in meeting basic human needs, developing phenomenological existential power factors.
Comfort, attention, affection, caring, health care, encouragement, empathy, interest, love, trust, protection, presence, support, touch, and is available to help and visit patients are all behaviors that motivate patients for the betterment of their physical, psychological, spiritual, and social elements [34]. Appropriate caring behavior from nurses will reduce anxiety, which means that in providing caring behavior, nurses should comprehend the patient's feelings and requirements without restricting the patient's movement or health scope [35].
Other health professions regard caring to be an important aspect of knowledge and skills that must also be possessed. Therefore, caring cannot be claimed as a paradigm that is only owned by the nurse. Caring is a universal phenomenon that describes how a person thinks, 88 Nurturing Caring Characteristics on Nurse Candidate: A Character Learning Model in Nursing Education feels, and acts in interactions with others. Caring characteristics in nursing are examined from a range of philosophical and ethical viewpoints. Milton Mayeroff [36], in analyzing the phenomenon of the meaning of caring in human relationships, describes caring as a process that provides an opportunity for a person (either the caregiver or the recipient) for personal growth. As a result, caring characteristics must be enhanced, developed, and strengthened [24].
Character education is inextricably linked to the development of a caring attitude or characteristic. Character education is the process of establishing specific characteristics or ideals while also helping students to create their character in their daily lives [37]. It means that students not only see education as knowledge but also make it a part of their lives based on ethics [38]. Because nurse candidates are trained in school, the development of caring characteristics becomes critical. As a result, education plays a critical role in developing caring nurses. To be able to nurture caring in the learning process, knowledge alone is insufficient. It is required to modify values and habits to shape caring characteristics. In this case, education is more than just a transfer of information; it is also a transfer of values [39].
Of course, to implement character education, a learning model that develops nurse candidates is required. There have been various character learning models, for example:1) habituation and example; 2) Contextual Teaching and Learning (CTL); 3) role-playing; 4) participative instruction [40]- [43]. This study focuses on the development of contextual teaching-learning for the development of caring character based on these various models. CTL is taken into account as an effort to succeed in character education. Additionally, in its implementation, it emphasizes the relationship between learning materials and students' daily lives so that they can put the characters learned into practice every day [44]- [47]. In its most basic form, CTL is a method of introducing content utilizing a range of active learning approaches to help students connect what they currently know to what they are supposed to learn and generate new knowledge through the analysis and synthesis of the learning process [46], [48].

Research Design
This study employs a 4D model of Thiagarajan et al., [49] to create a learning paradigm based on caring characteristics development for basic human needs The 4D model depicts the four stages of this study. The 4 stages are defining, designing, developing, and disseminating. Furthermore, the 4D model was chosen because it has been widely employed by several studies concerning pedagogic development such as Kuswanto

Research Location
This study was done in a nursing study program at a well-known university in West Java. West Java was chosen because the province has the highest number of universities with nursing programs in Indonesia. The second highest is East Java with the most hospital facilities, including general and specialty hospitals based on the Indonesian Ministry of Health Online Hospital system in 2017.

Participants
In determining research participants, we distributed questionnaires using a Google Form to several nursing lecturers as academics and to nurses as practitioners. The Google Form contains the willingness of academics and practitioners to be involved in this research project to develop a caring learning model for nurse candidates. Before they filled out the consent form, we provided an explanation in the form regarding the aims and objectives of this project and the extent of their involvement. The willingness form was distributed to 12 lecturers and 112 nurses, and there were 4 lecturers and 41 nurses expressed their willingness to participate. In addition, we also involved three academics as experts of this research topic including 1 professor of character education, 1 professor of learning models and 1 nursing expert. Meanwhile, in conducting the product trials of caring character learning model, there were 120 nursing students involved and attended lectures on basic human needs. Demographically, the participants in this study are presented in the following table. there is a group of four lecturers, two men, and two women, who teach nursing courses. Second, there are 82 females and 38 males among the 120 students in the student group. They are students enrolled in level 1 nursing courses, who had been exposed to several courses about building their caring characters, such as: Basic human needs In addition, two other groups contributed to this study. The first group consists of 41 nurses. The second group consists of 3 academics as the expert team, consisting of 1 professor of character education, 1 professor of learning model development, and 1 expert of nursing.

Defining Stage
This is the beginning of the study and development process. This phase is also known as a preliminary study to assess the needs associated with the caring characteristics learning model [53], [54]. In this stage, documents about the curriculum, teaching materials, and literature were analyzed. This task was done to gather information about the topic. Field studies were also done to map the need for caring characteristics and to analyze the empirical conditions surrounding the character learning process. In basic human needs courses, the discovery of gaps in the field study becomes a factor in determining learning objectives. Several indicators of learning objectives were developed in the basic human needs course to fill in the gaps in field data.

Designing Stage
Based on the first stage, a conceptual design for the learning model was designed in this stage. The design aims at accomplishing the learning objectives while also addressing the demands of the field in terms of moral character and performance of the nurse's character. The instrument was created, the assessment format was selected, and the first version of the product was designed. The first product is a model for teaching basic human needs based on caring characteristics development, which is divided into three learning scenarios: planning, implementation, and assessment. This step results in a variety of deliverables, including teaching materials guidelines, student activities, and evaluation instruments.

Developing Stage
Two key tasks were done throughout this stage: validity testing and effectiveness testing. A validity test is an activity in which numerous validators are asked to provide expert judgments and recommendations to determine the level of product validity. Effectiveness testing is students were experienced an efficacy test to evaluate if they improved in affective elements after going through the learning process.

Disseminating Stage
This is the final phase where the product was disseminated through focus group discussions, seminars, and publications. This is done to make the results to be more relevant and useful.

Data Collection Technique
The steps include analysis of learning curriculum documents, interviews, and surveys. The purposive sampling technique was used to collect survey data. The survey consists of ten questions with open-ended responses. Google Forms was used to collect the survey data. The survey was administered to groups of nurses to gather information about their caring characteristics and their demands on the field. Research ethics are examined before they complete the survey. The nurses were explained about the goal and the extent of their participation. The confidentiality of their data was discussed, and they were asked to sign a form indicating their willingness to participate. To analyze the survey results further, interviews were performed. As a result, interview guidelines, and questionnaires were used as the instruments. The qualitative information data was obtained during this stage. It should be noted that there was no instrument used in the designing stage because it involved the activity of designing a product. Meanwhile, in the developing stage, the data was obtained from the assessment in the form of numbers and results. Quantitative data was obtained in this stage.

Data Analysis
Thematic inductive analysis with a content analysis approach was used to analyze qualitative data. So that the data would not overlap, coding and categorization were done. NVivo software was used to assist the coding and categorization while SPSS software was used to analyze quantitative data.

Defining Stage
A documentation study of the curriculum and teaching materials related to basic human needs was conducted at this stage. The findings of the study show that the caring character had not been strengthened. The focus of learning should be to deliver cognitive and psychomotor components of offering actions to patients. These actions are nurse authority including administering medication to a patient per a prescription from a medical professional or practicing medical action in accordance with their competence on the delegation of delegated authority or based on the delegation of authority from a doctor to carry out medical actions, such as administering medication to a patient following a prescription from a medical professional or in accordance with their competence [55]. 90 Nurturing Caring Characteristics on Nurse Candidate: A Character Learning Model in Nursing Education Some lecturers agreed that there was a lack of emphasis on developing a caring character in the learning process for nurse candidates. One of the main factors is learning methodology issues. This opinion was expressed by several lecturers.
The learning experience for prospective nurse students is still not ideal in terms of developing soft skills or character value, which presents a challenge for lecturers in terms of enhancing their pedagogic competence to help students develop character (Lecturer 1).
Because I never receive pedagogic information when I attend lectures, I am frequently perplexed about the best way to instill character in nurse candidates (Lecturer 2). Although I wrote the lesson to develop specific traits, I sometimes find it challenging to discover an effective approach to nurture particular characters in nurse candidates (Lecturer 3). The need for learning methods that focus on developing character is a must according to the interviews above because instilling and cultivating values in the learning process necessitates the use of methods, techniques, and resources to attain the goal of value or character education [22]. It shows that if a learning model that develops character values is used, the desired character values will be attained [56]- [59].
On a conceptual level, the learning model can be thought of as a conceptual framework that describes a systematic procedure for organizing learning experiences to achieve specific learning objectives. It also acts as a guide for education planners and teachers in planning and implementing learning activities [60]- [65].
The requirement for a learning model to develop caring characteristics has to be fulfilled as fast as possible given the demands of the sector that requires skilled nurses with great characters. A questionnaire about the requirement for character qualities for a nurse who exhibits caring characteristics was provided to 41 nurses at various hospitals in West Java. Based on Davidson's theory, the questionnaire responses connected to the need for values that express the caring characteristics mapped into two character components: performance character and moral character [66]. The concept map depicts the division as shown in Figure 1.
Based on the concept above, 18 characters reflecting the caring characteristic of a nurse are divided into two categories. The first category is moral characters, which include religious, compassionate, responsible, disciplined, empathetic, polite, friendly, honest, humanitarian, and patient. The second category is performance characters, which include communicative, educative, collaborative, responsive, loyal, creative, companionable, and kind. These 18 characters present a challenge for nursing education institutions since they must be formed in the learning process and to develop a methodological learning formulation to nurture these values to the nurse candidates.

Designing Stage
Glasser's learning model creation components, which are objective instructional, entering behavior, instructional procedures, and performance assessment, were utilized to construct a learning model fostering caring characteristics in nurse candidates [67]. Students are focused on knowing and applying caring characteristics as a learning goal in basic human needs courses in the instructional goal stage. On the other hand, the entering behavior component focuses on developing caring characteristics that include the 18 characters mentioned earlier. According to Suherman et.al. [68], an educator must be able to teach character values in all humane dimensions during the character learning process. In education, these dimensions include the spirit, mind, heart, desire, and body, which are the potential of humans. Character education in the learning process shown in the table 2.
In instructional procedures, learning steps were developed to promote caring characteristics. The learning steps consist of an introductory, core, and closing activities. The Introductory activities consist of apperception, explanation, and motivation. The learning method in this activity is focused on inspiring students to care about the values that are collected in moral character and performance character. It was done to motivate the caring characteristics. Lecturers can engage in one of three types of action inactivity, for example, spiritualization that demonstrates caring can be done through prayer recitation and prayer interpretation. For a Muslim, usually after praying, reciting Asma'ul Husna and understanding its meanings can also be done. Internalization of caring characteristics can be done by showing films or short stories that can inspire the behavior. Dissonance is an attempt to explore the consequences of caring characteristics. This activity can encourage students to adhere to caring character qualities and discourage them from disregarding them. The next step is the core activity. In this step, educators constantly offer all content on basic human needs conceptually, which is related to caring characteristics. It includes the process of knowing and actualizing the values in nursing. The last activity is the evaluation process, which is the fourth component of Glasser's model (performance assessment). The four components were combined to form I-CARE (Inspiring, Caring Value, Actuating, Reflecting, and Evaluating). The syntax is presented in table 3.
This stage produces a learning module draft that mostly comprises lesson plans and learning material content. In addition, evaluation instruments are also produced. These products would be tested in the next stage.  The lecturer looks at basic human needs and how they relate to nursing.

2.
Lecturer asks students to explain the character values that need to be grown related to the material.

3.
Lecturer asks students to show how to apply these values daily.

4.
Lecturer asks students to show how to apply these values in nursing.

5.
Reinforcing character values through value practice experience in nursing.

Conceptualization Actualization
Reflecting Values

1.
Lecturer confirms the importance of caring included the material.

2.
Lecturer and students reflect on these values as an internalization effort.

Developing Stage
There are two steps in this stage. First, three experts were asked to review the product. Second, after the product had been assessed, its validity and reliability were tested on non-sample students. The assessment result can be seen in the table 4 on the Likert scale.
Based on the recapitulation results, all components' mean is higher than 4.5 and it can be categorized as good. Thus, the model design can be used in the learning process. To strengthen this assessment, the validity and reliability of the instruments were also tested. First, question items that would be examined were formulated. Second, the experiment was conducted in non-sample classes. Third, the validation was tested. The results can be seen in the table 5.
Based on the validity and reliability tests given to 10 non-sample participants, the moral character indicators mean score of r count (0.737) > r table (0.632). Therefore, it can be considered valid [69], [70]. On the other hand, the performance character indicators mean value of r count (0.719) > r table (0.632). Thus, it can be considered valid [69], [70]. After the validity test, a reliability test was performed to determine the instrument's consistency. The reliability test score is 0.875 and it can be considered high [69], [70]. As a result, this instrument is suitable for assessing the effectiveness of the caring characteristic-based nursing care learning paradigm.
To determine students' characteristic diversity in a semester, the limited trial was done by assessing their caring characteristics that were divided into two groups. The first group was given a caring character-based nursing learning model (experimental) and the other was not (control). The trial was done twice before the students received the treatment (pretest) and after they had received the treatment (posttest). The trial results are presented in table 6.  The results of the diversity of student characteristics carried out during one semester next, an average difference test was done using a paired sample t-test with a significance level of α (0.05). to determine a significant average difference between the pretest and posttest scores.

Disseminating Stage
In the final stage, the product of developing caring character learning models through basic human needs courses was disseminated to nursing lecturers in universities and the Indonesian national nurse association through scientific forums in the form of seminars related to the implementation of the learning model. Furthermore, as a type of academic diplomacy, the results have been also disseminated through worldwide standard scientific publications.

Discussion
The findings above demonstrate that to strengthen, instill, and nurture caring characteristics in nurse candidates during the learning process, effective planning and an effective learning design are required. According to Lickona [22], to instill and nurture values in learning activities, correct approaches, strategies, and resources have to be implemented. Starting with a needs assessment and the identification of values that reflect caring characteristics, learning is more than providing students with knowledge and skills, but also on meeting the demands for value content as the primary goal in the nursing education process because education also involves the transfer of values [68]. Transfer value during a learning process requires lecturers' ability to identify the necessary values for a nurse because it is a conception of what is desired that influences the choice of means, intermediate goals, and ultimate goals of action [71].
The discovered values are required to be arranged and integrated into each learning material that is subsequently assembled into a learning plan. As part of the effort to instill values, the strategy needs to be applied in a pedagogic framework throughout teaching and learning activities. This is in line with Baier's assertion that value is a behavioral propensity that stems from psychological symptoms such as desires, intentions, attitudes, needs, and beliefs that are unique to each person [12]- [15]. The goal of establishing these principles is for the nurse candidates to understand, believe, and practice caring characteristics. Spiritualization, conceptualization, internalization, dissonance, and actualization are the five value acts that are used to cultivate values [68]. The five value acts were combined into a learning syntax as I-CARE (Inspiring, Character Value, Actualization, Reflection, and Evaluation), divided into three learning activities: introductory activities, core activities, and closing activities. In this case, I-CARE has become a brand name for caring characteristics learning models and a product of innovation in teaching caring characteristic values to nurse candidates. The I-CARE learning paradigm is extremely helpful in expanding and developing the caring characteristics of nurse candidates as the results of product-related trial reveal.
In this case, lecturers in the nursing environment should continue to reinvent learning by designing learning models developing both hard and soft skills because the essence of education is moral values development [72]. The referred learning innovation is the effort to develop a style of learning and teaching. Therefore, this necessitates that nursing instructors have pedagogic literacy [73]. Pedagogic literacy is important because it could influence students' interest in learning caring characteristics [74], [75].
In this case, lecturers can employ a 4D design to construct learning models promoting caring characteristics in all of the courses they teach as an alternative to boosting pedagogic skills. The emergence of issues relating to nurse characteristics that have been highlighted in various studies and reports regarding dissatisfaction with nurse services due to a lack of caring characteristics indicates a lack of focus on character education. This is purportedly due to a lack of methodological mastery of value learning rather than a lack of motivation or desire from the lecturer to nurture caring characteristics. Caring principles are taught, reinforced, and nurtured so they can be reflected in the nurses' behavior during their duty. This is undoubtedly a difficult task for educational institutions to produce professional nurses.

Conclusions
This study concludes that 18-character values are representing caring characteristics classified into moral characters and performance characters. The moral characters include religious, compassionate, responsible, disciplined, empathetic, polite, friendly, honest, humanitarian, and patient. The performance characters include communicative, educative, collaborative, responsive, loyal, creative, companionable, and kind. These 18-character values are integrated into the learning material. To instill these values, five value actions, which are spiritualization, conceptualization, internalization, dissonance, and actualization, are employed in five syntaxes, which are inspiring, character values, application values, reflection, and evaluation or I-CARE, a teaching model encourages caring characteristics. Therefore, the I-CARE learning paradigm may be a viable option for an educational setting to produce excellent students with great character values.

Suggestion
The I-CARE model can be implemented in nursing education and the development of nurses' character in various institutions as a means of developing human resources in the field of health care, including nurses, midwives, or doctors. Therefore, this model has a great possibility to be developed further.

Limitation
The study is limited to nurse candidates. Furthermore, this study only focuses on the development of caring characteristics through basic human needs courses. Therefore, the results can be developed further in other subjects. The findings of the study also might be used to develop a model for character development for medical personnel in various healthcare institutions.