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-East
Claire, Eau Claire, Wisconsin, USA

Accepted for publication 3 November 2004

Correspondence: / 8RILOWSKI G. A.llc WENDLER M. C. (200S) Journal of Advanced Nursing 50(6),

M Cealia Wendler, 641-650
Depamnenl of Nursing Systems, An evolutionary concept analysis of caring
College of Nursing and Health Sciences,
Aim. The aim of this paper is to identify rbe core, enduring attributes of nursing
Univers;ty of Wisronsi"...Eau Claire,
105 GarfUid,
caring in order to increase understanding of the concept and to identify its impli-
Eau Ciaire 55122, cations for research and practice.
Wisconsin, Background. Caring is considered a core concept in nursing as a practice discipline.
USA. During the past 20 years, research into nurse caring has been evolving. but the
E·mail: wtmdlern@Uwec.edw 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

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

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 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 lace
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
caring was identified as a separate term in the Cumulative
Index of Nursing and Allied Health (CINAHL), nursing's cote
database. Despite the growing bodyo£ 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 rime.
Concept analysis
Concepts are essential to theory development and have
often been referred to as the building blocks or structural

Q 2005 Blackwell Publishing Ltd 641

 CA Brlfowski and M.C. Wend/er
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 & Avanr 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
TIle purpose of the study was to examine the evolution of the
concept of caring within the nursing discipline.
·r Table 1 Evolutionary concept analysis processes (Rodgers 1989,
2000a, 2000W
• Identify of the concept of 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,using a
systematicapproach and a broad time frame
• Identify the attributes of the concept
• Identify the references,antecedents and consequencesof the
concept, jf possible
r: • Identify related concepts
, • Identify a model, 'real' case of the concept
.j
"The processesarc not numbered because they are iteratlu« 41U1
cyclical (Rodgers 1989).
642 e 2005
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
funher 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 tbe
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
Blackwell PublishingLtd, JOU1'1f4/ of Ad/Jonad NJlTsing, 50(6}, 641~
Nursing throry and concept development or analysis
clusions. Of the 68 articles selected, another seven did not
j any data relevant to the concept and were eliminated,
resulting in. a final total of 61 articles being formally
reviewed, wbich equated to a 21-6% 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 tbe 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.
'indings
Rodgers (2000b) asserted that 'identification of the attributes
of the concept represents the primary accomplishment of the
concept analysis' (p. 91) and constitutes a 'rea)' (Rodgers
2000a, p. 91) definition of the concept. By using the iterative
processes identified by Rodgers (1989, 200Oa, 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 eating 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
e 2005 Blackwell Publishing Ltd, Journal of Advanced Ntming, 50(6), 641-650
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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); the
state of being mutuallyor 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)
Attit1ide: 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 be.ing variable or subject to variation
(p. 2533}; vary, to malce an especiallyminor or partial change
in, malee different in some attribute or cllaracteristic (p. 2535).
importance of this relationship has been emphasized by
referring to the nurse as a companion on an illness journey
[Lindholm & Eriksson 1993, HaUdocsdottir & 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 eating 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,
Ha111993, 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, Halldorsdortir & 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'.
643
G.A. Brilowski and M.C. Wendler
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,
Guilo 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, Guilo 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, bur 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)1
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i
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. HaUdorsdottir 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.
of Advanced N.miHg, 50(6},641~50
J
 Nursing theory and concept developmentor analysis
~ptance
1_ ~ptance of another as a feilow 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 chat 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 recognizedas a person living,caring, and
glowing in caring. It is through undersranding, 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 bow a patient views
e world is fundamental to nursing {Oulton 1997}. Hartrick
197) notes:
a caring relationship embodies a concern for others in their own
terms. Inherent within this responsivenesswas 11 valuingof 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, 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 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 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 he
should have been treated by everyone, as a person with value,
with feelings'.
c[:) 200S Blackwcll Publishing Ltd.JOUJ7fQ/of Advanced Nursing, SO(6), 641~50
An euolutionary concept analysis of caring
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).
Identi.6cation of antecedents and consequences
of caring
The next iterative process of the evolutionary conceptual
analysis cycle (Rodgers 1989) is an examination of the
antecedents and consequences 01 the concept. Rodgers
(20oob) notes that; 'Exploring tbe 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 1000). In addition. trust and rapport (Ebersole
1996), as well as individual and organizational comrnitmenr
(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, Haltdorsdottir & Hamrin
1997, Hartrick 1997. Pearson et al. 1997, Gino 1998,
Hamnan 1998, Wing 1999). Danielson (1996) notes:
645
 G.A. Bri[owski and M.c' Wendler

I watched a once vibrant woman who had lootthe 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).
. nursing. Paradoxically, as complexity in the concept developed
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
J
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
s~udies defining and describing the characteristics of profes-
sional nurse caring. Of note is the (act that the earlier articles
reviewed often included a dearly-articulated definition of
~ver 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 coo-
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.
WiUiam (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 seep-down trauma unit, and unsuccessful
transfers to the rehabilitation unit and, later, to a nursing
borne, resulted in multiple readmissions to the inpatient, step-
down trauma unit. Some time during the first parr of his

~.
itI,",
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
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-
U its further development. In addition to the identification of
adherence to isolation requirements and occasional aggres-
attributes, antecedents, consequences, and related concepts,
sion, he became a possible permanent resident of the
Rodgers (2000a) specified that an analysis of the evolution of
. ~
.

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 Nursing theory and concept developmentor analysis
inpatient step-down trauma unit. His depression as his
rery slowed also affected his sense of well-being.
Ltlitially, 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 WiUiam'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
variaEnlity 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
WilIiam 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
isodes of agitation and aggressiveness subsided.
VilIiam'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, WilIiam was
able successfully to move to a nursing home.
----- This is an exemplar of caring because it demonstrates the
ve attributes described. There was a relationship between
Cl 2005 BlatkweU Publishing Lrd, Journal of Advanud Nursing, 50(6),641-650
An evo/utio1l42ry concept D1I42/ysis of caring
WilIiam, 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 Williamj when that was not enougb, 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 tbe 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 scay? Complications? Morbidity and mortality?
The findings of tbis 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.
647
G.A. Brilou/ski and M.C Wend/~r
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 the
nursing literature.
What this paper adds
• An evolutionary concept analysis of the significance,
use and application of the concept of caring since its
first use on the cumulated Index of Nursing and
Allied 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 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
~orks by certain authors, most notably Watson, for only two
of her important wor.lcs (Watson 1990a, 1~90b) 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, we
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
cuing 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.
648 Cl 2005 Blackwell Publishing Ltd. Journal of Adf/anced
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. MeW supervised and critically revised the
paper.
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