NURSING THEORY AND CONCEPT DEVELOPMENT OR ANALYSIS

An evolutionary concept analysis of caring

Gail A. Brilowski RN BSN MSN

Staff Nurse, St [osepb'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-EastClaire, Eau Claire, Wisconsin, USA

Accepted for publication 3 November 2004

8RILOWSKI G. A.llc WENDLER M. C. (200S) Journal of Advanced Nursing 50(6),641-650An evolutionary concept analysis of caringAim. The aim of this paper is to identify rbe core, enduring attributes of nursingcaring 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 theconcept of caring remains ambiguous.Methods. Using a rigorous evolutionary method of concept analysis, the conceptcaring was examined for its significance, use and application as it has unfolded overtime, between 1988 and 2002. After applying inclusion and exclusion criteria and asampling 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, allowsnurses to determine appropriate research questions, develop theory and identifypractice priorities at a time of increasing demands and constrained resources.

Correspondence: /M Cealia Wendler,Depamnenl of Nursing Systems,College of Nursing and Health Sciences,Univers;ty of Wisronsi"...Eau Claire,105 GarfUid,Eau Ciaire 55122,Wisconsin,USA.E·mail: wtmdlern@Uwec.edw

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 fOOlSof the discipline of nursing was'caring in the hwnan health experience' (p. 6). Caring firstemerged as a concept of interest to nurses during the 1950s(Leininger 1984), but several factors have hindered its furtherdevelopment. For example, lack of qualified researchers tostudy the phenomenon of caring resulted in minimal progressin understanding the essential features of the concept in theseearly years (Leininger 1984). Two decades later, in the lace1970s, research on the concept was stimulated by the firstNational Caring Research Conference and the seminal workof Watson (1988, 1999}, who published a theory of the

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science of human caring. It was, however, not until 1988 thatcaring was identified as a separate term in the CumulativeIndex of Nursing and Allied Health (CINAHL), nursing's cotedatabase. Despite the growing bodyo£ research and theorydevelopment since that time, the concept of caring remainsambiguous. The purpose of this paper is to clarify the conceptusing 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 rime.

Concept analysis

Concepts are essential to theory development and haveoften been referred to as the building blocks or structural

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CA Brlfowski and M.C. Wend/er

components of theory (Chinn & Kramer 1999). Clear,conceptual understandings are essential to the developmentof the scientific base of the discipline. Clarification of vagueor ambiguous concepts and identification and classification ofnursing phenomena may all be accomplished through conceptanalysis (Rodgers & Knafl 2000). In traditional conceptanalysis, a process of synthesizing existing views on aconcept results in the identification of the essence of theconcept (Walker & Avanr 1999), and is considered to be atheoretical snapshot in a moment in time: universal,unyielding, and, ultimately, restrictive (Knafl & Deatrick2000, Rodgers 2000a, 2000b), despite assertions to thecontrary (Walker & Avant 1999).

In contrast, Rodgers' evolutionary perspective (Rodgers1989, 2000a, 2000b) offers an inductive approach based onthe idea that concepts are constantly evolving and changing.Evolution of concepts, as a series of related changes in acertain direction (Gove 1986), can therefore be identified,assembled, and analysed. This theory development strategyallows a concept to be examined for its significance, use andapplication as it unfolds over time. The knowledge andunderstanding thus derived, although tentative, are gainedthrough 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 thisapproach increases understanding of phenomena, produces aclearer description of situations, and promotes effectivecommunication (Rodgers 2000b).

The study

Aim

TIle purpose of the study was to examine the evolution of theconcept of caring within the nursing discipline.

·r Table 1 Evolutionaryconcept analysis processes (Rodgers 1989,2000a, 2000W

r:

• Identifyof the conceptof interest• Identify surrogate terms and relevant uses of the concept• Identifyand select an appropriate sample, a minimum of 20%

of the identifiedliterature, from the relevant discipline,usingasystematicapproach and a broad time frame

• Identify the attributes of the concept• Identifythe references,antecedents and consequencesof the

concept, jf possible• Identify related concepts• Identifya model, 'real' case of the concept,

.j

"The processesarc not numbered because they are iteratlu« 41U1

cyclical (Rodgers 1989).

Method

The important first step in the rigorous and scholarlyidentification of an appropriate sample required by Rodgers(1989, 2000a) is to determine the boundaries. Rodgers(2000a) advocates, as a minimum, a random sample of atleast 20% over a broad timeframe of the identified literatureand asks theorists using this approach to be exact about howthe 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 databaseincludes materials published in nursing from 1982 to presentand consists of a comprehensive list of professional nursingjournals, books, book chapters, dissertations and selectedconference proceedings. both in many languages. Bothbibliographic information and abstracts are provided.

Using the CINAHL search feature, the keyword caring wasentered, and this revealed over 6000 articles with the wordcaring in the title or abstract. Further limiting the articles tothose written in English and identified by CINAHL asappearing in core journals reduced the number. The set wasfunher delimited by choosing articles published since 1988,the year that the concept caring appeared as a separatekeyword in the database as this was an appropriate bench-mark date for the emergence of the concept within thediscipline. A total of 670 articles was identified and all ofthese were read. Articles were eliminated if they containedany of the following headings as these were proceduralcategories focusing on nursing skills and fundamentals:nursing care, caregivers, caregiver burden, patient-centredcare. Similarly, articles emphasing work environment, nur-sing administration, organizational culture, and managementtheory, 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 theoreticaldata appropriate to the study aims. Anecdotes and individualcase descriptions of caring were specifically included, as thesegave important contextual information (Rodgers 2000a), avalued aspect of the process. A final total of 283 articles metthe 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. Forthe present analysis, a goal of 25% of the articles was initiallychosen for inclusion. The numbers 1--4 were written onseparate pieces of paper and placed in a container and tbenumber 4 was selected. Starting the selection with the fourtharticle, every fourth article on the list was chosen, resulting ina total of 68 articles. Each article was read and notes writtenbefore data analysis was initiated in order to avoid premature

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Nursing throry and concept development or analysis

clusions. Of the 68 articles selected, another seven did notj any data relevant to the concept and were eliminated,

resulting in. a final total of 61 articles being formallyreviewed, wbich equated to a 21-6% inclusion rate.

Data analysis

During the initial analysis, a coding system was created inwhich data pertaining to the attributes of the concept ofcaring, the contextual features of and related/surrogateconcepts were retrieved on individual coding sheets.

Each coding sheet was then reviewed for recurrent themes,which were identified as categories. Identification of thesignificance (prominence of the concept), use (commonmanner employing the concept; Rodgers & Knafl 2000),and application, range and scope of the concept of caring wasthe focus of this review. Word labels were then selected thatbest illuminated tbe nature of the data. A nursing scholarwith expertise in the area of concept analysis and familiarwith Rodgers' (2000a) approach also reviewed the raw dataand word labels Were agreed upon. The articles were thengrouped according to the emerging themes and collapsed intothe following synopsis.

'indings

Rodgers (2000b) asserted that 'identification of the attributesof the concept represents the primary accomplishment of theconcept analysis' (p. 91) and constitutes a 'rea)' (Rodgers2000a, p. 91) definition of the concept. By using the iterativeprocesses identified by Rodgers (1989, 200Oa, 2000b), thefindings of the present concept analysis suggested that thereare five attributes of caring within nursing. These attributesare: 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 toenter into a relationship with clients of nursing' (Hartman1998, 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 ofprofessional nurse eating when the other needs assistancebecause 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 withfriendship, in that both are relationships that develop fromaffection and concern for another (Olsen 1992). The

An evoiutiOlf4ry concept analysis of C4ring

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 (po 1916); thestate of being mutuallyor reciprocally interested (p. 1916); to havemeaningful social relationships (Gove 1986, p. 1916)

Action: A deliberative or authorized proceeding; a voluntary act ofwill that manifests itself externallyor that may be completedinternally; a thing done (p. 21)

Attit1ide: position or bearing as indicating action. feeling or mood;the feeling or mood itself; a persistent disposition to act, eitherpositively or negatively, toward a person, group, object, situationor value (p. 141)

Acceptance: Act of accepting (p. 11); to treat partially or withfavoritism; to regard as proper, suitable, normal (p. 10)

Variability: The quality of be.ing variable or subject to variation(p. 2533}; vary, to malce an especiallyminor or partial changein, malee different in some attribute or cllaracteristic (p. 2535).

importance of this relationship has been emphasized byreferring to the nurse as a companion on an illness journey[Lindholm & Eriksson 1993, HaUdocsdottir & Hamrin1997, Pearson et al. 1997).

Important characteristics on this caring relationship aretrust, intimacy, and responsibility (Moccia 1988). Trust andintimacy were essential in a professional eating relationship.Nurses attempt to create a trusting relationship characterizedby openness, sincerity, love, and patience. It is important tobe near, and not to abandon the patient (Fitzpatrick 1992,Ha111993, Lindholm & Eriksson 1993).

A professional caring relationship places responsibility onthe person who is providing the care. That person isresponsible for actions directed toward the well-being ofthe person being cared for. Therefore, it is imperative that theactions of professional carers are knowledgeable and current.Professional ethical codes provide a framework. for nurses tofacilitate decision-making and ensure a high standard ofconduct (Watson 1990a, Fealy 1995, Welch 1999).

Action

Action was the second attribute and was a dominant theme inthe conceptual analysis. Professional caring almost alwaysincludes some action, such as doing for the patient or beingwith the patient (Fealy 1995, Halldorsdortir & Hamrin 1997,Krebs 2001). These actions originate from the carer'sperception of another's needs, and result in motivation toact 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 caringactions. One student wrote, 'I don't grimace or flinch'.

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Another replied, 'Helping a patient through all of those awfulprocedures'. A third noted that a caring nurse 'looks at all theavailable resources the hospital has for a patient' (From1995, p. 330). These responses reflect four important actions:nursing care, touch, presence and competence.

Nursing careNursing care consists of the actions and interactions betweena nurse and patient (Fealy 1995), with physical care as aprimary focus (Garbett 1996, Shamansky & Graham 1997,Guilo 1998). For example, Hallock (1994) notes: 'It made mefeel good to do little things to try to make him more com-fortable like giving him a back rub or getting him a newsupper' (p, 88). Danielson (1996), describing her mother'scare in a nursing home, states that: 'From bathroom detail towhirlpool baths, from getting her in and out of chairs, in andout of bed. They dressed her and undressed her, made surethat her hair was done, and her makeup was perfect' (p. 28).These examples demonstrate the importance of the provisionof physical care as a primary focus of caring through nurseaction.

TouchCaring touch was identified as a second action of a caringnurse (Clapham 1992, Ebersole 1996, Guilo 1998). It is aform of non-verbal communication, and is influenced by anurse's intentionality and a patient's perceptions (Fredriksson1999). Mallory (1988, p. 63), writing of her brother's illness,records that: 'Joan wasn't afraid to touch him, to stroke hishair, or to hold his hand. She'd say and do things to makehim laugh. Most of all, she made him feel good through smallacts of concern, such as making sure the washcloth waswarm'. Ufema (1994) adds that: 'the little things really meanthe most to everyone involved' (p. 18).

PresenceA third action of the caring nurse was presence. This nurseuses self as a tool to be totally present (Pryds-jensenet al. 1993, Smith 1999). Being there is not only a physicalpresence, bur also specifically includes a giving of self(Fredriksson 1999). It consists of occupying the same spacewith 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 genuinelyengaging with another (Liehr 1989). As Welter (1989) asks,'How many nurses have charted at the bedside of a restless ordying patient ... patting his hand, stroking his forehead, andspeaking a few words to assure him that he is not alone'(p.45)1

iCompetenceA fourth action related to caring was clinical competence. Anunderstanding of how human and physical science interactswith the humanity of patients and their family members iscrucial to good care (Welch 1999, Sanford 2000). Indeed,Halldorsdottir and Hamrin (1997) assert that: 'Caringwithout competence is meaningless' (p. 123). As nursing carebecomes increasingly focused on technology, competence tocare has an increased urgency, with at times with life-threatening or life-saving consequences. The literature,however, suggests that competency alone is not considered tobe caring (Locsin 1995, Happ 1996, Thompson 1996).

Attitude

The third attribute of caring revealed in the analysis wasattitude. The literature revealed the importance of the nursepresenting a particular positive attitude in order to beconsidered caring. In fact, the concept of caring aboutrepresents a particular disposition. or attitude, towardanother. Caring is not simply a series of actions, but is alsoa way of acting (Fealy 1995}, a comportment, or ontology, ofthe nurse. Often it includes a positive approach to people andto life (Halldorsdottir & Hamrin 1997, Kearns 1999). Watson(1990b) wrote: 'If caring is to be sustained, those who caremust 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 ofattitude, is an indicator of caring. HaUdorsdottir and Hamrin(1997) interviewed nine health care recipients and askedthem to develop a description of a caring nurse. The findingsidentified a caring nurse as attentive, honest, genuine,involved, a good listener, genuinely concerned about thepatient's welfare, committed, understanding. respectful ofquestions and sensitive to the patient's needs. In anotherexample. Pryds-Jensen et al. (1993} asked 16 nurses todevelop a picture of the caring nurse, and discovered thatsuch a nurse demonstrates knowledge, practical skills,self-confidence, reflective self-knowledge, and knowledge ofothers. The caring nurse demonstrates empathy, timing basedon intuition, creativity, humour, and possessed the imagina-tion to facilitate the development of a new perspective forpatients. These nurses also demonstrate a love for humans,are deeply concerned, and act on the basis of ethical valuesand attitudes. They approach patients with a positive attitude .and are committed, interested, honest, and generous. Caringnurses demonstrate courage, acting calmly to control stressfulor threatening situations (Pryds-jensen et al. 1993). These:attributes all illuminate the idea that attitude is an importantattribute of nurse caring.

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~ptance

1_ ~ptance of another as a feilow human being is viewed ascritical to caring by many (Wurzbach 1990, Benner 1991,Schroeder 1995, Pearson et al. 1997, Smith 1999). The mostcompelling reason chat one cares for another is that the otheris a fellow human being worthy of dignity and respect (Fealy1995). A nurse is as concerned with a patient's spiritualwell-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 thenurse with another who is recognizedas a person living,caring, andglowing in caring. It is through undersranding, appreciating, andbeing open to the aestheticpathway that the fullnessof the nursingsituation is known. (p. 59)

This idea is conveyed in the literature as seeing the personbehind the patient (Halldorsdottir & Hamrin 1997), demon-strating a powerful acceptance.

Nurses attempt to confirm a patient's dignity and supportthe idea that those in their care are intrinsically valuable andprecious as human beings. This is accomplished by validatingwhat a patient has to say as important (Lindholm & Eriksson1993, Gullo 1998}. This concern about bow a patient views

e world is fundamental to nursing {Oulton 1997}. Hartrick197) notes:

a caring relationship embodies a concern for others in their ownterms. Inherent within this responsivenesswas 11 valuingof the powerof human contact and connectedness.Responsiveness is not focusedon problem identification and resolutionbut rather a responding in amanner which acknowledges, IUPpom the significance of people'.health.and healing as they are meaningfullyexperienced. (p. 526)

It is this taking on of the lived meaning of another that createsthe possibility of caring (Baker & Diekelmann 1994) in thecontext of nursing.

Interestingly, the concepts of caring and loving have beenconnected 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 iscapable of being is the greatest gift of caring (Brown 1993). Inthese situations, a person's complete human dignity is fullyacknowledged and they are helped on their own terms (Olsen1992). The example offered by MacInnis (1992) illuminatesthis: 'Somewhere in Hannah's milky blue eyes tucked in thesoft folds of her wrinlded skin, under her white cloud of hair,there was something worthwhile, wonh loving' (p. 96).Similarly, Mallory (1988, p. 63) says: 'She treated him as heshould have been treated by everyone, as a person with value,with feelings'.

An euolutionary concept analysis of caring

Variability

Variability was the fifth and final attribute identified throughthis conceptual analysis process and appeared frequently inthe included nursing literature. Cameron (1991) states that:'caring is personal, partial, intuitive, particular, contempla-tive, subjective and concrete' (p. 206). Caring has beenrepeatedly described as fluid, malleable, and changing,depending on the circumstances, environment, and the peopleinvolved (Schattsneider 1992. Brown 1993. Fealy 1995,Warelow 1996, McCance et al. 2001). Variability is also anaspect of care, and is a fluidity learned through experience.Therefore, the appearance of caring will change or evolve as anurse becomes more proficient in practice (Benner 1991,Young-Mason 1991).

Identi.6cation of antecedents and consequencesof caring

The next iterative process of the evolutionary conceptualanalysis cycle (Rodgers 1989) is an examination of theantecedents and consequences 01 the concept. Rodgers(20oob) notes that; 'Exploring tbe contextual aspects of theconcepts {facilitates} understanding of the situation in whichthe concept is used, the use of the concept in those varyingsituations, and its use by people with potentially diverseperspectives' (p. 91). While the literature gave ampledescriptions of the attributes of caring, the antecedents wereless well developed) and many antecedents focused on theembodied qualities of the nurse. For example, Watson(1990a) stated that: 'caring in nursing requires informedmoral action and passion' (p. 21). Further, caring is onlypossible when a nurse possesses an understanding of self andan appreciation of another's humanity (Hartrick 1997,Sanford 1000). In addition. trust and rapport (Ebersole1996), as well as individual and organizational comrnitmenr(Schroeder 1995), are important. Without these, factors suchas reduced nursing time at the bedside, prolonged nursingshortages, cost-containment efforts and decreasing lengths-of-stay may negatively affect nurse caring. Thus, time to careserves as a critical antecedent to nurse caring, but is assumedto be available.

The consequences of caring were clearer and the majorityof these consequences were positive for the patient/family,nurse, or for both (Hilt 1993, Fealy 1995). Most importantfor the patient, and strongly supported in the literature, is theoutcome that nurse caring results in increased health andhealing (Hinds 1988, Fowler 1989, Haltdorsdottir & Hamrin1997, Hartrick 1997. Pearson et al. 1997, Gino 1998,Hamnan 1998, Wing 1999). Danielson (1996) notes:

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I watched a once vibrant woman who had lootthe zest for lifewhenher husband died thrive under the attention and care of the staff atthe nursing home (p. 29).

Caring also results in a sense of solidarity, empowerment,hope, comfort, security, increased self-esteem, increasedreality orientation, personal growth, and lessening of fearand anxiety for patients (Francis 1988, Beck 1991, Funk1992, Pryds-jensen et al. 1993, Owen-Mills 1995, Halldors-dottir & Hamrin 1997, Gullo 1998, Fredriksson 1999).Mallory (1988) illustrates this as follows: 'How well Lloydknew suffering and how well I know that a nurse's kindnessand support can ease it' (p. 63). Caring also influences apatient's perception of a nurse. The nurse is now viewedas compassionate, competent, concerned, and respectful(Halldorsdottir & Hamrin 1997), but not in every case:Crigger (1997) notes that enmeshment and exploitation canalso occur as a consequence of nurse caring.

The nurse is also influenced by the caring experience,including an increasing ability to tolerate uncertainty and anincreasing sense of empowerment and choice (Hartrick1997}. Caring renews energy, feeds passion, and increases anurse'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 aposition of strength in the economy because caring is adesired product in health care (Tuck et al. 1998).

Related concepts

Related concepts are 'concepts that bear some relationship tothe concept of interest but do not seem to share the same setof attributes' (Rodgers 2000a, p, 92). Concepts related tocaring identified in this process included nurturing, compas-sion, concern and ministering (Young-Mason 1991, Boykinet al. 1994, Crigger 1997, Oulton 1997). All of the relatedconcepts 'were mentioned only once and were embeddedwithin a broader discussion of caring, thus demonstrating thisrelatedness.

Discussion

Rodgers (1989, 2000a, 2000b) determined that the overalloutcome of evolutionary concept analysis is a list of definingattributes, antecedents, and consequences. A definition is notoffered, as it unduly concretizes a concept, thereby hinderingits further development. In addition to the identification ofattributes, antecedents, consequences, and related concepts,Rodgers (2000a) specified that an analysis of the evolution of

the concept be included. In this review, which spanned14 years from the initiation of the keyword 'caring' inCINAHL to 2002, five attributes, antecedents, consequences,and related terms were identified. Descriptions of caring movedfrom simple stories of exquisitely orchestrated episodes ofphysical care between a patient and nurse to rigorous researchs~udies defining and describing the characteristics of profes-sional nurse caring. Of note is the (act that the earlier articlesreviewed often included a dearly-articulated definition of

. nursing. Paradoxically, as complexity in the concept developed~ver time, and the resulting need for conceptual understandingIncreased, there were actually fewer specific definitions of theconcept and this hindered understanding.

J

Exemplar case: William encounters nurse caring

An important completing process in evolutionary conceptanalysis is the development of the exemplar case. In Rodgers'approach (Rodgers 1989, 2000a, 2000b), because the coo-cept is seen as evolving over time, there is a focus on thesignificance, use, and application of the concept withinthe discipline (Rodgers 1989). This careful case descriptionof,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 aspecific practice situation. The exemplar case here describesthe experience of the first author (GB) in a caring situation inclinical practice, illuminating all the identified attributes andsome of the antecedents and consequences.

WiUiam (a pseudonym) was an older man hospitalizedafter being struck by a falling tree. He suffered massivetrauma, his many injuries including multiple intracranialhemorrhages, a cervical fracture, and many fractures to theright side of his body. Multiple operations and many weeks inthe hospital left him with chronic agitation and confusion,with occasional aggression. A tracheostomy, placed early inhis hospitalization to assist in mechanical ventilation, latermade swallowing impossible. His transfers from the intensivecare unit and seep-down trauma unit, and unsuccessfultransfers to the rehabilitation unit and, later, to a nursingborne, resulted in multiple readmissions to the inpatient, step-down trauma unit. Some time during the first parr of hishospitalization, William also acquired Methicillin-ResistantStaphylococcus Aureus (MRSA) infection, requiring contactisolation to prevent organism spread. Because of his multiplehealth management problems, including restlessness, non-adherence to isolation requirements and occasional aggres-sion, he became a possible permanent resident of the

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inpatient step-down trauma unit. His depression as hisrery slowed also affected his sense of well-being.

Ltlitially, William would frequently wander through thecorridors, ignoring the requirements for isolation. When staffattempted to redirect him, he was often physically aggressive.Restraints were not indicated [and are actively discouragedby law in the United States of America (USA)), and his nursesbecame increasingly frustrated as his care and his needsabsorbed enormous amounts of their time.

Realizing that transfer to another facility was unlikely, anurse began to assess measures to improve WiUiam's qualityof life. With a positive attitude, she actively created arelationship, focusing her concern on his quality of life.Planning a diversional activity that could be shared, she tookaction and purchased a few puzzles, an engaging activity thatcould be done in his isolation room. Thus, she providedvariaEnlity based on William's need for social interaction, anexpression of relationship. In the beginning. the nurse wouldwork alone on the puzzle, providing presence, in shortsections of time, silently offering acceptance of him as ahuman being worthy of nursing care and concern. EventuallyWilIiam began to work along with her. This was enormouslysuccessful, as he spent many hours attempting to completethe puzzles. As he was more engaged in diversion, the

isodes of agitation and aggressiveness subsided.VilIiam's depression became more prominent as the

agitation and confusion subsided, for he more clearlyunderstood that he could not leave his room. Further, hecould not enjoy the pleasure of eating food because of hisswallowing difficulty; and communication barriers persistedbecause of the continued need for the tracheostomy. Thenurse began to note that he spent many hours alone simplylying on his bed.

Again, the nurse took action. The family was asked tobring to the hospital a few precious belongings, includingphotographs and a treasured blanket. Although thesepersonal belongings added warmth, they did not alter theinstitutionalized environment of the hospital room. The nursefurther varied the environment with decorations purchasedfor the interior of the room, and, with these William's roomwas transformed from institutional to cozy and home-like.During the placement of decorations, he seemed bemused andWould respond with a shrug of his shoulders when he wasasked about the change. However, over time, nurses reportedthat he would smile when asked about his 'new room'. Hismood brightened and his symptoms decreased; approxi-mately 2 weeks after the room had been altered, WilIiam wasable successfully to move to a nursing home.

----- This is an exemplar of caring because it demonstrates theve attributes described. There was a relationship between

An evo/utio1l42ry concept D1I42/ysis of caring

WilIiam, who was a patient, and the nurse. The nurse used herpositive attitude to begin to envision possibility for him, evenas she accepted him for exactly who he was as a human being.She took action, first by purchasing the puzzles and byworking alongside Williamj when that was not enougb, shevaried her approach to modify the hospital room further tomake it more comfortable. The nurse took into the situationtrust, rapport and individual commitment; the positiveconsequences for William included an increase in self-esteemand reality orientation, a decrease in his anxiety as expressedby agitation and, in the end, a final and successful transitionfrom the hospital.

Implications for nursing

Important to concept development is the identification offurther areas of research (Rodgers 2000a), to assist indetermining the soundness of tbe findings of the analysis. Inthis case, there is an obvious need for additional theorydevelopment and research. The articles selected for thisstudy did not include a single concept analysis. This isimportant because a more detailed look at the sampleidentified a tendency for authors to discuss caring but not todefine it. The results of the present analysis may provideimportant markers for the development of a defini-tion through further research. Questions for researchinclude:• 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 scay? Complications? Morbidity and mortality?The findings of tbis Study suggest that caring is a valuable

aspect of clinical nursing practice. More specifically, theidentified attributes provide specific guidance for nurses, whomay reflect on their own clinical practices to determine howcaring can be more fully incorporated into their practice. Theidentified antecedents empower nurses to address personaland environmental factors that promote or hinder nursecaring. The consequences of caring provide outcome criteriafor the assessment of caring in practice.

The study could provide a practical method of studentevaluation, 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 nursecaring.

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What is already known about this topic

• Caring is a ubiquitous concept in nursing.• The terms care and caring axe often used in the nursing

literature as if the core attributes were already known,but the concepts remain ambiguous.

• There are no published concept analyses of caring in thenursing literature.

What this paper adds

• An evolutionary concept analysis of the significance,use and application of the concept of caring since itsfirst use on the cumulated Index of Nursing andAllied Health Literature in 1988 as a separate key-word.

• A list of defining attributes useful to nursing in educa-tion, research, theory development and practice.

Limitations

The evolutionary process adds rigor and scholarliness to theprocess of concept analysis (Rodgers 1989, 2000a, 2000b);however, there were limitations to the present study. Forexample, the sampling method may have excluded seminal~orks by certain authors, most notably Watson, for only twoof her important wor.lcs (Watson 1990a, 1~90b) wereincluded. Also, the important work of scholars who do notpublish in English led to an Anglophone bias. This conceptanalysis, then, may give an incomplete picture of theevolution of the state of the concept.

Conclusion

During the past 15 years, caring as a concept in nursing hasbecome increasingly important. The purpose of this evolu-tionary concept analysis was to focus on the significance, weand application of the concept in nursing. The findingssuggest that the core attributes of caring are relationship,action, attitude. acceptance, and variability. Factors such astrust, rapport, understanding of self and other, and commit-ment were identified as antecedents and need to be present forcuing to occur. The consequences of caring include anincreased ability to heal for patients and an increased sense ofpersonal and professional satisfaction for nurses. Thesefindings not only add to the body of knowledge but alsoserve as an important impetus for further theory developmentand research in nursing.

Author contributions

GB conceived the study, collected the data and drafted themanuscript. GB and MCW were involved in the study designand data analysis. MeW supervised and critically revised thepaper.

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1648 Cl 2005 Blackwell Publishing Ltd. Journal of Adf/anced Nursing, 50(6), 641~50