Evolutionary Concept Analysis of Caring

NURSING THEORY AND CONCEPT DEVELOPMENT OR ANALYSIS

An evolutionary concept analysis of caring

Gail A. Brilowski RN BSN MSN

Staff Nurse, St Joseph’s Hospital, Marshfield, Wisconsin, USA

M. Cecilia Wendler RN PhD CCRN

Associate Professor, Department of Nursing Systems, College of Nursing and Health Sciences, University of Wisconsin–Eau

Claire, Eau Claire, Wisconsin, USA

Accepted for publication 3 November 2004

Correspondence:

M Cecilia Wendler,

Department of Nursing Systems,

College of Nursing and Health Sciences,

University of Wisconsin–Eau Claire,

105 Garfield,

Eau Claire 55122,

Wisconsin,

USA.

E-mail: [email protected]

BRILOWSKI G. A. & WENDLER M. C. (2005)BRILOWSKI G. A. & WENDLER M. C. (2005) Journal of Advanced Nursing 50(6),

641–650

An evolutionary concept analysis of caring

Aim. The aim of this paper is to identify the core, enduring attributes of nursing

caring in order to increase understanding of the concept and to identify its impli-

cations for research and practice.

Background. Caring is considered a core concept in nursing as a practice discipline.

During the past 20 years, research into nurse caring has been evolving, but the

concept of caring remains ambiguous.

Methods. Using a rigorous evolutionary method of concept analysis, the concept

caring was examined for its significance, use and application as it has unfolded over

time, between 1988 and 2002. After applying inclusion and exclusion criteria and a

sampling method, a total of 61 articles was included in the final analysis.

Results. Defining attributes, antecedents, and consequences of caring were identi-

fied. Core attributes included relationship, action, attitude, acceptance and variab-

ility.

Conclusion. Identification of the core attributes of concepts, including caring, allows

nurses to determine appropriate research questions, develop theory and identify

practice priorities at a time of increasing demands and constrained resources.

Keywords: caring, concept analysis, evolutionary method, nursing

Introduction

Caring has been called fundamental to the practice of nursing

(Schattsneider 1992, Smith 1999). Indeed, Newman et al.

(1991) asserted that the focus of the discipline of nursing was

‘caring in the human health experience’ (p. 6). Caring first

emerged as a concept of interest to nurses during the 1950s

(Leininger 1984), but several factors have hindered its further

development. For example, lack of qualified researchers to

study the phenomenon of caring resulted in minimal progress

in understanding the essential features of the concept in these

early years (Leininger 1984). Two decades later, in the late

1970s, research on the concept was stimulated by the first

National Caring Research Conference and the seminal work

of Watson (1988, 1999), who published a theory of the

science of human caring. It was, however, not until 1988 that

caring was identified as a separate term in the Cumulative

Index of Nursing and Allied Health (CINAHL), nursing’s core

database. Despite the growing body of research and theory

development since that time, the concept of caring remains

ambiguous. The purpose of this paper is to clarify the concept

using Rodgers (1989, 2000a, 2000b) and Rodgers’ & Knafl’s

(2000) evolutionary approach, in order to increase under-

standing through identification of the attributes, antecedents,

and consequences of caring as they have changed over time.

Concept analysis

Concepts are essential to theory development and have

often been referred to as the building blocks or structural

� 2005 Blackwell Publishing Ltd 641

components of theory (Chinn & Kramer 1999). Clear,

conceptual understandings are essential to the development

of the scientific base of the discipline. Clarification of vague

or ambiguous concepts and identification and classification of

nursing phenomena may all be accomplished through concept

analysis (Rodgers & Knafl 2000). In traditional concept

analysis, a process of synthesizing existing views on a

concept results in the identification of the essence of the

concept (Walker & Avant 1999), and is considered to be a

theoretical snapshot in a moment in time: universal,

unyielding, and, ultimately, restrictive (Knafl & Deatrick

2000, Rodgers 2000a, 2000b), despite assertions to the

contrary (Walker & Avant 1999).

In contrast, Rodgers’ evolutionary perspective (Rodgers

1989, 2000a, 2000b) offers an inductive approach based on

the idea that concepts are constantly evolving and changing.

Evolution of concepts, as a series of related changes in a

certain direction (Gove 1986), can therefore be identified,

assembled, and analysed. This theory development strategy

allows a concept to be examined for its significance, use and

application as it unfolds over time. The knowledge and

understanding thus derived, although tentative, are gained

through scholarly examination of the evolution of a concept.

The iterative processes used are summarized in Table 1.

Clarification of the core attributes of concepts using this

approach increases understanding of phenomena, produces a

clearer description of situations, and promotes effective

communication (Rodgers 2000b).

The study

Aim

The purpose of the study was to examine the evolution of the

concept of caring within the nursing discipline.

Method

The important first step in the rigorous and scholarly

identification of an appropriate sample required by Rodgers

(1989, 2000a) is to determine the boundaries. Rodgers

(2000a) advocates, as a minimum, a random sample of at

least 20% over a broad timeframe of the identified literature

and asks theorists using this approach to be exact about how

the sample was obtained. CINAHL, as the most comprehen-

sive electronic database (Rodgers 1989, 2000a) for nursing,

was used to access literature in this study. This database

includes materials published in nursing from 1982 to present

and consists of a comprehensive list of professional nursing

journals, books, book chapters, dissertations and selected

conference proceedings, both in many languages. Both

bibliographic information and abstracts are provided.

Using the CINAHL search feature, the keyword caring was

entered, and this revealed over 6000 articles with the word

caring in the title or abstract. Further limiting the articles to

those written in English and identified by CINAHL as

appearing in core journals reduced the number. The set was

further delimited by choosing articles published since 1988,

the year that the concept caring appeared as a separate

keyword in the database as this was an appropriate bench-

mark date for the emergence of the concept within the

discipline. A total of 670 articles was identified and all of

these were read. Articles were eliminated if they contained

any of the following headings as these were procedural

categories focusing on nursing skills and fundamentals:

nursing care, caregivers, caregiver burden, patient-centred

care. Similarly, articles emphasing work environment, nur-

sing administration, organizational culture, and management

theory, in order to focus on the nursing experience of caring.

Articles involving survey research were also deemed inap-

propriate, as, on review, these did not offer any theoretical

data appropriate to the study aims. Anecdotes and individual

case descriptions of caring were specifically included, as these

gave important contextual information (Rodgers 2000a), a

valued aspect of the process. A final total of 283 articles met

the criteria for inclusion in the analysis.

Rodgers (1989, 2000a) asserted that a rigorous evolution-

ary conceptual analysis required random choice of a mini-

mum of 20% of the articles meeting the inclusion criteria. For

the present analysis, a goal of 25% of the articles was initially

chosen for inclusion. The numbers 1–4 were written on

separate pieces of paper and placed in a container and the

number 4 was selected. Starting the selection with the fourth

article, every fourth article on the list was chosen, resulting in

a total of 68 articles. Each article was read and notes written

before data analysis was initiated in order to avoid premature

Table 1 Evolutionary concept analysis processes (Rodgers 1989,

2000a, 2000b)*

• Identify of the concept of interest

• Identify surrogate terms and relevant uses of the concept

• Identify and select an appropriate sample, a minimum of 20%

of the identified literature, from the relevant discipline, using a

systematic approach and a broad time frame

• Identify the attributes of the concept

• Identify the references, antecedents and consequences of the

concept, if possible

• Identify related concepts

• Identify a model, ‘real’ case of the concept

*The processes are not numbered because they are iterative and

cyclical (Rodgers 1989).

G.A. Brilowski and M.C. Wendler

642 � 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 50(6), 641–650

conclusions. Of the 68 articles selected, another seven did not

yield any data relevant to the concept and were eliminated,

resulting in a final total of 61 articles being formally

reviewed, which equated to a 21Æ6% inclusion rate.

Data analysis

During the initial analysis, a coding system was created in

which data pertaining to the attributes of the concept of

caring, the contextual features of and related/surrogate

concepts were retrieved on individual coding sheets.

Each coding sheet was then reviewed for recurrent themes,

which were identified as categories. Identification of the

significance (prominence of the concept), use (common

manner employing the concept; Rodgers & Knafl 2000),

and application, range and scope of the concept of caring was

the focus of this review. Word labels were then selected that

best illuminated the nature of the data. A nursing scholar

with expertise in the area of concept analysis and familiar

with Rodgers’ (2000a) approach also reviewed the raw data

and word labels were agreed upon. The articles were then

grouped according to the emerging themes and collapsed into

the following synopsis.

Findings

Rodgers (2000b) asserted that ‘identification of the attributes

of the concept represents the primary accomplishment of the

concept analysis’ (p. 91) and constitutes a ‘real’ (Rodgers

2000a, p. 91) definition of the concept. By using the iterative

processes identified by Rodgers (1989, 2000a, 2000b), the

findings of the present concept analysis suggested that there

are five attributes of caring within nursing. These attributes

are: relationship, action, attitude, acceptance, and variability.

Definitions of these attributes are given in Table 2.

Relationship

Relationship has been called the ‘foundation of nursing’

(Hartrick 1997, p. 524) and even a ‘moral imperative to

enter into a relationship with clients of nursing’ (Hartman

1998, p. 18). This relationship is initiated when one person,

most often the nurse, identifies a need in another and is

motivated to act (Fealy 1995). This becomes a relationship of

professional nurse caring when the other needs assistance

because of disease, crisis, or inability to engage in self-care

(Balasco 1990, Schattsneider 1992, Boykin et al. 1994,

Fealy 1995). This relationship has also been compared with

friendship, in that both are relationships that develop from

affection and concern for another (Olsen 1992). The

importance of this relationship has been emphasized by

referring to the nurse as a companion on an illness journey

(Lindholm & Eriksson 1993, Halldorsdottir & Hamrin

1997, Pearson et al. 1997).

Important characteristics on this caring relationship are

trust, intimacy, and responsibility (Moccia 1988). Trust and

intimacy were essential in a professional caring relationship.

Nurses attempt to create a trusting relationship characterized

by openness, sincerity, love, and patience. It is important to

be near, and not to abandon the patient (Fitzpatrick 1992,

Hall 1993, Lindholm & Eriksson 1993).

A professional caring relationship places responsibility on

the person who is providing the care. That person is

responsible for actions directed toward the well-being of

the person being cared for. Therefore, it is imperative that the

actions of professional carers are knowledgeable and current.

Professional ethical codes provide a framework for nurses to

facilitate decision-making and ensure a high standard of

conduct (Watson 1990a, Fealy 1995, Welch 1999).

Action

Action was the second attribute and was a dominant theme in

the conceptual analysis. Professional caring almost always

includes some action, such as doing for the patient or being

with the patient (Fealy 1995, Halldorsdottir & Hamrin 1997,

Krebs 2001). These actions originate from the carer’s

perception of another’s needs, and result in motivation to

act to meet those needs (Fealy 1995).

From (1995), a nurse educator, discusses nursing students’

perception of caring. When asked to describe their percep-

tions of caring, students replied with a spectrum of caring

actions. One student wrote, ‘I don’t grimace or flinch’.

Table 2 Chosen definitions for identified attributes of caring (pre-

sented in order of appearance in the analysis; Gove 1986)

Relationship: The state or character of being related (p. 1916); the

state of being mutually or reciprocally interested (p. 1916); to have

meaningful social relationships (Gove 1986, p. 1916)

Action: A deliberative or authorized proceeding; a voluntary act of

will that manifests itself externally or that may be completed

internally; a thing done (p. 21)

Attitude: position or bearing as indicating action, feeling or mood;

the feeling or mood itself; a persistent disposition to act, either

positively or negatively, toward a person, group, object, situation

or value (p. 141)

Acceptance: Act of accepting (p. 11); to treat partially or with

favoritism; to regard as proper, suitable, normal (p. 10)

Variability: The quality of being variable or subject to variation

(p. 2533); vary, to make an especially minor or partial change

in, make different in some attribute or characteristic (p. 2535).

Nursing theory and concept development or analysis An evolutionary concept analysis of caring

� 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 50(6), 641–650 643

Another replied, ‘Helping a patient through all of those awful

procedures’. A third noted that a caring nurse ‘looks at all the

available resources the hospital has for a patient’ (From

1995, p. 330). These responses reflect four important actions:

nursing care, touch, presence and competence.

Nursing care

Nursing care consists of the actions and interactions between

a nurse and patient (Fealy 1995), with physical care as a

primary focus (Garbett 1996, Shamansky & Graham 1997,

Gullo 1998). For example, Hallock (1994) notes: ‘It made me

feel good to do little things to try to make him more com-

fortable like giving him a back rub or getting him a new

supper’ (p. 88). Danielson (1996), describing her mother’s

care in a nursing home, states that: ‘From bathroom detail to

whirlpool baths, from getting her in and out of chairs, in and

out of bed. They dressed her and undressed her, made sure

that her hair was done, and her makeup was perfect’ (p. 28).

These examples demonstrate the importance of the provision

of physical care as a primary focus of caring through nurse

action.

Touch

Caring touch was identified as a second action of a caring

nurse (Clapham 1992, Ebersole 1996, Gullo 1998). It is a

form of non-verbal communication, and is influenced by a

nurse’s intentionality and a patient’s perceptions (Fredriksson

1999). Mallory (1988, p. 63), writing of her brother’s illness,

records that: ‘Joan wasn’t afraid to touch him, to stroke his

hair, or to hold his hand. She’d say and do things to make

him laugh. Most of all, she made him feel good through small

acts of concern, such as making sure the washcloth was

warm’. Ufema (1994) adds that: ‘the little things really mean

the most to everyone involved’ (p. 18).

Presence

A third action of the caring nurse was presence. This nurse

uses self as a tool to be totally present (Pryds-Jensen

et al. 1993, Smith 1999). Being there is not only a physical

presence, but also specifically includes a giving of self

(Fredriksson 1999). It consists of occupying the same space

with the patient, listening carefully, allowing time to share

(Pryds-Jensen et al. 1993, Fredriksson 1999), and commu-

nicating to patients and families the nurse’s interest in them

(Stewart-Amidei 1988). Thus, presence is the act of genuinely

engaging with another (Liehr 1989). As Welter (1989) asks,

‘How many nurses have charted at the bedside of a restless or

dying patient…patting his hand, stroking his forehead, and

speaking a few words to assure him that he is not alone’

(p. 45)?

Competence

A fourth action related to caring was clinical competence. An

understanding of how human and physical science interacts

with the humanity of patients and their family members is

crucial to good care (Welch 1999, Sanford 2000). Indeed,

Halldorsdottir and Hamrin (1997) assert that: ‘Caring

without competence is meaningless’ (p. 123). As nursing care

becomes increasingly focused on technology, competence to

care has an increased urgency, with at times with life-

threatening or life-saving consequences. The literature,

however, suggests that competency alone is not considered to

be caring (Locsin 1995, Happ 1996, Thompson 1996).

Attitude

The third attribute of caring revealed in the analysis was

attitude. The literature revealed the importance of the nurse

presenting a particular positive attitude in order to be

considered caring. In fact, the concept of caring about

represents a particular disposition, or attitude, toward

another. Caring is not simply a series of actions, but is also

a way of acting (Fealy 1995), a comportment, or ontology, of

the nurse. Often it includes a positive approach to people and

to life (Halldorsdottir & Hamrin 1997, Kearns 1999). Watson

(1990b) wrote: ‘If caring is to be sustained, those who care

must be strong, courageous, and capable of inner love, peace,

and joy both in relation to themselves and others’ (p. 64).

Dyson (1996) suggests that work style, an expression of

attitude, is an indicator of caring. Halldorsdottir and Hamrin

(1997) interviewed nine health care recipients and asked

them to develop a description of a caring nurse. The findings

identified a caring nurse as attentive, honest, genuine,

involved, a good listener, genuinely concerned about the

patient’s welfare, committed, understanding, respectful of

questions and sensitive to the patient’s needs. In another

example, Pryds-Jensen et al. (1993) asked 16 nurses to

develop a picture of the caring nurse, and discovered that

such a nurse demonstrates knowledge, practical skills,

self-confidence, reflective self-knowledge, and knowledge of

others. The caring nurse demonstrates empathy, timing based

on intuition, creativity, humour, and possessed the imagina-

tion to facilitate the development of a new perspective for

patients. These nurses also demonstrate a love for humans,

are deeply concerned, and act on the basis of ethical values

and attitudes. They approach patients with a positive attitude

and are committed, interested, honest, and generous. Caring

nurses demonstrate courage, acting calmly to control stressful

or threatening situations (Pryds-Jensen et al. 1993). These

attributes all illuminate the idea that attitude is an important

attribute of nurse caring.



Acceptance

Acceptance of another as a fellow human being is viewed as

critical to caring by many (Wurzbach 1990, Benner 1991,

Schroeder 1995, Pearson et al. 1997, Smith 1999). The most

compelling reason that one cares for another is that the other

is a fellow human being worthy of dignity and respect (Fealy

1995). A nurse is as concerned with a patient’s spiritual

well-being as with their physical and emotional well-being

(Sanford 2000). Boykin et al. (1994) writes

Caring is viewed as the intentional and authentic presence of the

nurse with another who is recognized as a person living, caring, and

growing in caring. It is through understanding, appreciating, and

being open to the aesthetic pathway that the fullness of the nursing

situation is known. (p. 59)

This idea is conveyed in the literature as seeing the person

behind the patient (Halldorsdottir & Hamrin 1997), demon-

strating a powerful acceptance.

Nurses attempt to confirm a patient’s dignity and support

the idea that those in their care are intrinsically valuable and

precious as human beings. This is accomplished by validating

what a patient has to say as important (Lindholm & Eriksson

1993, Gullo 1998). This concern about how a patient views

the world is fundamental to nursing (Oulton 1997). Hartrick

(1997) notes:

a caring relationship embodies a concern for others in their own

terms. Inherent within this responsiveness was a valuing of the power

of human contact and connectedness. Responsiveness is not focused

on problem identification and resolution but rather a responding in a

manner which acknowledges, supports the significance of people’s

health and healing as they are meaningfully experienced. (p. 526)

It is this taking on of the lived meaning of another that creates

the possibility of caring (Baker & Diekelmann 1994) in the

context of nursing.

Interestingly, the concepts of caring and loving have been

connected to one another (Watson 1990b, Dyson 1996).

Jacono (1993) calls caring ‘a euphemism for loving’ (p. 193).

Enabling love of self and freedom to be whatever one is

capable of being is the greatest gift of caring (Brown 1993). In

these situations, a person’s complete human dignity is fully

acknowledged and they are helped on their own terms (Olsen

1992). The example offered by MacInnis (1992) illuminates

this: ‘Somewhere in Hannah’s milky blue eyes tucked in the

soft folds of her wrinkled skin, under her white cloud of hair,

there was something worthwhile, worth loving’ (p. 96).

Similarly, Mallory (1988, p. 63) says: ‘She treated him as he

should have been treated by everyone, as a person with value,

with feelings’.

Variability

Variability was the fifth and final attribute identified through

this conceptual analysis process and appeared frequently in

the included nursing literature. Cameron (1991) states that:

‘caring is personal, partial, intuitive, particular, contempla-

tive, subjective and concrete’ (p. 206). Caring has been

repeatedly described as fluid, malleable, and changing,

depending on the circumstances, environment, and the people

involved (Schattsneider 1992, Brown 1993, Fealy 1995,

Warelow 1996, McCance et al. 2001). Variability is also an

aspect of care, and is a fluidity learned through experience.

Therefore, the appearance of caring will change or evolve as a

nurse becomes more proficient in practice (Benner 1991,

Young-Mason 1991).

Identification of antecedents and consequencesof caring

The next iterative process of the evolutionary conceptual

analysis cycle (Rodgers 1989) is an examination of the

antecedents and consequences of the concept. Rodgers

(2000b) notes that; ‘Exploring the contextual aspects of the

concepts [facilitates] understanding of the situation in which

the concept is used, the use of the concept in those varying

situations, and its use by people with potentially diverse

perspectives’ (p. 91). While the literature gave ample

descriptions of the attributes of caring, the antecedents were

less well developed, and many antecedents focused on the

embodied qualities of the nurse. For example, Watson

(1990a) stated that: ‘caring in nursing requires informed

moral action and passion’ (p. 21). Further, caring is only

possible when a nurse possesses an understanding of self and

an appreciation of another’s humanity (Hartrick 1997,

Sanford 2000). In addition, trust and rapport (Ebersole

1996), as well as individual and organizational commitment

(Schroeder 1995), are important. Without these, factors such

as reduced nursing time at the bedside, prolonged nursing

shortages, cost-containment efforts and decreasing lengths-

of-stay may negatively affect nurse caring. Thus, time to care

serves as a critical antecedent to nurse caring, but is assumed

to be available.

The consequences of caring were clearer and the majority

of these consequences were positive for the patient/family,

nurse, or for both (Hilt 1993, Fealy 1995). Most important

for the patient, and strongly supported in the literature, is the

outcome that nurse caring results in increased health and

healing (Hinds 1988, Fowler 1989, Halldorsdottir & Hamrin

1997, Hartrick 1997, Pearson et al. 1997, Gino 1998,

Hartman 1998, Wing 1999). Danielson (1996) notes:



I watched a once vibrant woman who had lost the zest for life when

her husband died thrive under the attention and care of the staff at

the nursing home (p. 29).

Caring also results in a sense of solidarity, empowerment,

hope, comfort, security, increased self-esteem, increased

reality orientation, personal growth, and lessening of fear

and anxiety for patients (Francis 1988, Beck 1991, Funk

1992, Pryds-Jensen et al. 1993, Owen-Mills 1995, Halldors-

dottir & Hamrin 1997, Gullo 1998, Fredriksson 1999).

Mallory (1988) illustrates this as follows: ‘How well Lloyd

knew suffering and how well I know that a nurse’s kindness

and support can ease it’ (p. 63). Caring also influences a

patient’s perception of a nurse. The nurse is now viewed

as compassionate, competent, concerned, and respectful

(Halldorsdottir & Hamrin 1997), but not in every case:

Crigger (1997) notes that enmeshment and exploitation can

also occur as a consequence of nurse caring.

The nurse is also influenced by the caring experience,

including an increasing ability to tolerate uncertainty and an

increasing sense of empowerment and choice (Hartrick

1997). Caring renews energy, feeds passion, and increases a

nurse’s personal and professional satisfaction (Oulton 1997),

demonstrating reciprocity. Through caring, a nurse is bet-

ter able to understand the illness experience (Baker &

Diekelmann 1994). Caring also provides a nurse with a

position of strength in the economy because caring is a

desired product in health care (Tuck et al. 1998).

Related concepts

Related concepts are ‘concepts that bear some relationship to

the concept of interest but do not seem to share the same set

of attributes’ (Rodgers 2000a, p. 92). Concepts related to

caring identified in this process included nurturing, compas-

sion, concern and ministering (Young-Mason 1991, Boykin

et al. 1994, Crigger 1997, Oulton 1997). All of the related

concepts were mentioned only once and were embedded

within a broader discussion of caring, thus demonstrating this

relatedness.

Discussion

Rodgers (1989, 2000a, 2000b) determined that the overall

outcome of evolutionary concept analysis is a list of defining

attributes, antecedents, and consequences. A definition is not

offered, as it unduly concretizes a concept, thereby hindering

its further development. In addition to the identification of

attributes, antecedents, consequences, and related concepts,

Rodgers (2000a) specified that an analysis of the evolution of

the concept be included. In this review, which spanned

14 years from the initiation of the keyword ‘caring’ in

CINAHL to 2002, five attributes, antecedents, consequences,

and related terms were identified. Descriptions of caring moved

from simple stories of exquisitely orchestrated episodes of

physical care between a patient and nurse to rigorous research

studies defining and describing the characteristics of profes-

sional nurse caring. Of note is the fact that the earlier articles

reviewed often included a clearly-articulated definition of

nursing. Paradoxically, as complexity in the concept developed

over time, and the resulting need for conceptual understanding

increased, there were actually fewer specific definitions of the

concept and this hindered understanding.

Exemplar case: William encounters nurse caring

An important completing process in evolutionary concept

analysis is the development of the exemplar case. In Rodgers’

approach (Rodgers 1989, 2000a, 2000b), because the con-

cept is seen as evolving over time, there is a focus on the

significance, use, and application of the concept within

the discipline (Rodgers 1989). This careful case description

of the concept, if included in the analysis, must come from the

‘real world’ (Rodgers 1989, 2000a, 2000b). This ‘real world’

case may be illustrated through qualitative research or,

because nursing is a practice discipline, may emerge from a

specific practice situation. The exemplar case here describes

the experience of the first author (GB) in a caring situation in

clinical practice, illuminating all the identified attributes and

some of the antecedents and consequences.

William (a pseudonym) was an older man hospitalized

after being struck by a falling tree. He suffered massive

trauma, his many injuries including multiple intracranial

hemorrhages, a cervical fracture, and many fractures to the

right side of his body. Multiple operations and many weeks in

the hospital left him with chronic agitation and confusion,

with occasional aggression. A tracheostomy, placed early in

his hospitalization to assist in mechanical ventilation, later

made swallowing impossible. His transfers from the intensive

care unit and step-down trauma unit, and unsuccessful

transfers to the rehabilitation unit and, later, to a nursing

home, resulted in multiple readmissions to the inpatient, step-

down trauma unit. Some time during the first part of his

hospitalization, William also acquired Methicillin-Resistant

Staphylococcus Aureus (MRSA) infection, requiring contact

isolation to prevent organism spread. Because of his multiple

health management problems, including restlessness, non-

adherence to isolation requirements and occasional aggres-

sion, he became a possible permanent resident of the



inpatient step-down trauma unit. His depression as his

recovery slowed also affected his sense of well-being.

Initially, William would frequently wander through the

corridors, ignoring the requirements for isolation. When staff

attempted to redirect him, he was often physically aggressive.

Restraints were not indicated [and are actively discouraged

by law in the United States of America (USA)], and his nurses

became increasingly frustrated as his care and his needs

absorbed enormous amounts of their time.

Realizing that transfer to another facility was unlikely, a

nurse began to assess measures to improve William’s quality

of life. With a positive attitude, she actively created a

relationship, focusing her concern on his quality of life.

Planning a diversional activity that could be shared, she took

action and purchased a few puzzles, an engaging activity that

could be done in his isolation room. Thus, she provided

variability based on William’s need for social interaction, an

expression of relationship. In the beginning, the nurse would

work alone on the puzzle, providing presence, in short

sections of time, silently offering acceptance of him as a

human being worthy of nursing care and concern. Eventually

William began to work along with her. This was enormously

successful, as he spent many hours attempting to complete

the puzzles. As he was more engaged in diversion, the

episodes of agitation and aggressiveness subsided.

William’s depression became more prominent as the

agitation and confusion subsided, for he more clearly

understood that he could not leave his room. Further, he

could not enjoy the pleasure of eating food because of his

swallowing difficulty; and communication barriers persisted

because of the continued need for the tracheostomy. The

nurse began to note that he spent many hours alone simply

lying on his bed.

Again, the nurse took action. The family was asked to

bring to the hospital a few precious belongings, including

photographs and a treasured blanket. Although these

personal belongings added warmth, they did not alter the

institutionalized environment of the hospital room. The nurse

further varied the environment with decorations purchased

for the interior of the room, and, with these William’s room

was transformed from institutional to cozy and home-like.

During the placement of decorations, he seemed bemused and

would respond with a shrug of his shoulders when he was

asked about the change. However, over time, nurses reported

that he would smile when asked about his ‘new room’. His

mood brightened and his symptoms decreased; approxi-

mately 2 weeks after the room had been altered, William was

able successfully to move to a nursing home.

This is an exemplar of caring because it demonstrates the

five attributes described. There was a relationship between

William, who was a patient, and the nurse. The nurse used her

positive attitude to begin to envision possibility for him, even

as she accepted him for exactly who he was as a human being.

She took action, first by purchasing the puzzles and by

working alongside William; when that was not enough, she

varied her approach to modify the hospital room further to

make it more comfortable. The nurse took into the situation

trust, rapport and individual commitment; the positive

consequences for William included an increase in self-esteem

and reality orientation, a decrease in his anxiety as expressed

by agitation and, in the end, a final and successful transition

from the hospital.

Implications for nursing

Important to concept development is the identification of

further areas of research (Rodgers 2000a), to assist in

determining the soundness of the findings of the analysis. In

this case, there is an obvious need for additional theory

development and research. The articles selected for this

study did not include a single concept analysis. This is

important because a more detailed look at the sample

identified a tendency for authors to discuss caring but not to

define it. The results of the present analysis may provide

important markers for the development of a defini-

tion through further research. Questions for research

include:

• In what way are the core attributes of nurse caring related

to quality outcomes for hospitalized patients?

• What are the origins, or roots, of professional nurse

caring?

• What is the most effective way to teach students how to

care?

• Does nurse caring change outcome of hospitalization?

Length of stay? Complications? Morbidity and mortality?

The findings of this study suggest that caring is a valuable

aspect of clinical nursing practice. More specifically, the

identified attributes provide specific guidance for nurses, who

may reflect on their own clinical practices to determine how

caring can be more fully incorporated into their practice. The

identified antecedents empower nurses to address personal

and environmental factors that promote or hinder nurse

caring. The consequences of caring provide outcome criteria

for the assessment of caring in practice.

The study could provide a practical method of student

evaluation, through use of the identified attributes.

Additionally, the attributes, antecedents, consequences,

related concepts, and the exemplar could facilitate under-

standing by nursing students of the core features of nurse

caring.



Limitations

The evolutionary process adds rigor and scholarliness to the

process of concept analysis (Rodgers 1989, 2000a, 2000b);

however, there were limitations to the present study. For

example, the sampling method may have excluded seminal

works by certain authors, most notably Watson, for only two

of her important works (Watson 1990a, 1990b) were

included. Also, the important work of scholars who do not

publish in English led to an Anglophone bias. This concept

analysis, then, may give an incomplete picture of the

evolution of the state of the concept.

Conclusion

During the past 15 years, caring as a concept in nursing has

become increasingly important. The purpose of this evolu-

tionary concept analysis was to focus on the significance, use

and application of the concept in nursing. The findings

suggest that the core attributes of caring are relationship,

action, attitude, acceptance, and variability. Factors such as

trust, rapport, understanding of self and other, and commit-

ment were identified as antecedents and need to be present for

caring to occur. The consequences of caring include an

increased ability to heal for patients and an increased sense of

personal and professional satisfaction for nurses. These

findings not only add to the body of knowledge but also

serve as an important impetus for further theory development

and research in nursing.

Author contributions

GB conceived the study, collected the data and drafted the

manuscript. GB and MCW were involved in the study design

and data analysis. MCW supervised and critically revised the

paper.

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• A list of defining attributes useful to nursing in educa-

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Evolutionary Concept Analysis of Caring