Define and describe in detail your beliefs about each of the 4 concepts of nursing theory
Revisit Four Nursing metaparadigm concepts of nursing, environment, person and the health.
– Define and describe in detail your beliefs about each of the 4 concepts of nursing theory
– Address how the four concepts interrelate
– Propose an additional concept or concepts you feel may be appropriate to add to the metaparadigm of nursing
– Finally select one of the concepts ( it could be your additional concept if you choose) and provide a concept analysis using one of the methods outlined in your textbook book (chapter 3)
Support your ideas with literature and use appropriate 7th edition APA format
Articles
1.Systematic Review of Quality of Life in Nursing
2 . Development of Conceptual Framework
3. Concepts Development of “Nursing Presence
4.Development of a Theory of Wisdom-in- Action for Clinical Nursing.
Kindly note
– Avoid the excessive use of direct quotes
– Paragraphs or sentences should not be too long or short
– Avoid use of contractions, Colloquialisms and jargon
The paper must be APA format & must include Introduction, body and conclusion paragraphs.
– MCEWEN AND WILLS, THEORETICAL BASIS FOR NURSING, CHAPTERS 3 & 4
Requirements: 6 pages
AdvancesinNursingScienceVol.43,No.1,pp.28Ð41Copyrightc2020WoltersKluwerHealth,Inc.Allrightsreserved.DevelopmentofaTheoryofWisdom-in-ActionforClinicalNursingSusanA.Matney,PhD,RN;KayAvant,PhD,RN;LaurenClark,PhD,RN;NancyStaggers,PhD,RNNursespublisheddialoguesonwisdom;yet,aconceptualmodelisunavailable.Wepresentthedevelopmentprocessforatheoryofwisdom-in-actionforclinicalnursingdevelopedin3phases:(1)adeductivelyderivedmodelusingderivationandsynthesis;(2)inductively,aconstructivistgroundedtheorycapturedtheexperienceofwisdominnursingpractice;and(3)the2theoriesweresynthesizedintoanascenttheory.Thetheorydescribes2antecedentdimensions,person-relatedandsetting-relatedfactors,and2typesofwisdom,generalandpersonal.Thetheoryprovidesaframeworkfortranslatingwisdominnursingpractice,de-pictingboththescienceandartofnursing.Keywords:constructivistgroundedtheory,informatics,nursingtheory,wisdomASNURSES,weseektobetterunderstandhowtogainnursingwisdomandap-plyitintoourdailypractice.Wisdomisre-quiredforclinicalthinking,expertjudgment,andcompassionatecare.Yet,theconceptandexperienceofwisdominnursingprac-ticehavenotbeenwelldeÞned.Fundamen-taltonursingisanunderstandingofhowtocreate,locate,andusedata,information,andknowledgetoinformpatient-centered,cul-turallycompetent,compassionate,evidence-basedpractice.ThesefoundationalconceptsAuthorAfÞliations:IntermountainHealthcare,SaltLakeCity,UtahandCollegeofNursing,UniversityofUtah,SaltLakeCity,Utah(DrMatney);SchoolofNursing,UniversityofTexasHealthScienceCenter,SanAntonio(DrAvant);SchoolofNursing,UniversityofCaliforniaLosAngeles(DrClark);andCollegeofNursingandDepartmentofBiomedicalInformatics,UniversityofUtah,SaltLakeCity(DrStaggers).Theauthorshavedisclosedthattheyhavenosignif-icantrelationshipswith,orÞnancialinterestin,anycommercialcompaniespertainingtothisarticle.Correspondence:SusanA.Matney,PhD,RN,1148AliceLane,Farmington,UT84025([email protected]).DOI:10.1097/ANS.0000000000000304werefurtherelaboratedandtheconceptofwisdomwasaddedbytheAmericanNursesAssociation(ANA)inthe2008publication,ScopeandStandardsofNursingInformatics.1TheANAdeÞnedwisdomasÒtheappropri-ateuseofknowledgetomanageandsolvehumanproblems.Ó1(p5)However,thewisdomconceptwithintheANAÕsframework,whilerelevant,wastoobroadandlackedacleardeÞnitionfornursing.ThecriterionofÒappropriateuseÓsuggestsadomain-speciÞccomponenttowisdom,buttheuniquenessofwisdominanappliedhealthprofessionhasnotbeenaddressed.ItisdifÞculttodeterminehownursingknowledgeinßuencesnursingwisdom,howexperienceisreßectedinnursingwisdom,orhowwisdomrelatestoconceptssuchasclinicaljudgment,expertise,formsofnursingknowledge,empathy,andintuition.Thepurposeofthisarticleistodescribethedevelopmentofatheoryofwisdom-in-action(WIA)forclinicalnursinganddevelopbothadescriptiveconstructandgraphicrepresentation(ormodel)withinthecontextofclinicalnursingpractice.Wedescribethedevelopmentofanoveltheoryincludingasummaryofeachphase,aninterpretationCopyright©2020WoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited.28
DevelopmentofaTheoryofWisdom-in-ActionforClinicalNursing29StatementofSignificanceStatement1:Whatisknownoras-sumedtobetrueaboutthistopic:Thedisciplineofnursinghasmaintainedadialogueaboutwisdom,andsimilarconstructs,foryears.Forexample,BennerÕstheoryofnovicetoexpertaddressesthegrowthofexpertiseinclinicalnursingoveraperiodofprofessionaldevelopmentandCarperdescribesempirical,ethical,esthetic,andpersonalwaysofknowing.Yet,aunifyingconceptualmodeldepictingwisdomhasnotyetbeendeveloped.Thecomplementarybutdistincttheoriesofexpertise,waysofknowing,andlevelsofinformationwerenotharmonized.Statement1:Whatthisarticleadds:ThisarticlepresentsthedevelopmentofatheoryofWIAforclinicalnursingandincludesconstructandgraphicrepresen-tation(ormodel)withinthecontextofclinicalnursingpractice.Twotypesofwisdomareillustrated:generalwisdom,usedwhencaringforothers,andper-sonalwisdom,usedtounderstandyourownpractice.Wisenursingcarerequiresbothscienceandartthatareillustratedinthetheory.ThetheorymaysigniÞcantlyprovideaworkingframeworkfortrans-latingwisdominnursingpracticeintotheoreticalandpracticalterms,depictingboththescienceandartofnursing.ofstudyÞndings,anddiscussionsregardingsigniÞcance,limitations,andfutureresearch.METHODSANDINITIALTHEORETICALCONSTRUCTSThetheorywasdevelopedin3phases:Þrst,awisdomconstructwasdevelopedus-ingderivationandsynthesisprocesses.Next,apreliminaryWIAtheorywasdevelopedusingconstructivistgroundedtheory(CGT)methodology.Finally,the2theorieswerecompared,contrasted,andcombinedtopro-ducethetheoryofWIAforclinicalnursing.Phase1:DerivationandsynthesisTheÞrstphasewastodevelopaconstructfollowingWalkerandAvantÕs2derivationandsynthesisprocessesfortheoryconstruc-tion.Thesemethodswerechosenbecausetheyprovidedstructureandstep-by-stepapproachestotheorydevelopment.Themethodsusedinthisphasefollows.TheoryderivationTheoryderivationentailsthedevelopmentofanewconstructusingatheoryortheo-riesfromotherÞelds.Theprocessforderiva-tionincluded5steps.2TheÞrststepwastobeawareofothertheories.Threetheoreticalmodelsofwisdomfromotherdisciplinesandonefromthenursingliteraturewereevalu-ated.Thesecondstepwastogainanincreasedunderstandingbywidelyreadingwisdomlit-eraturepertinenttothetheoryincludingarangeofmultidisciplinaryresources,suchastheoreticalmodels,scientiÞcstudies,andpo-ems.Thesereadingshelpeddeterminetheconceptsandrelationshipspertinenttothenewtheory.Thethirdstepwastoselectaparenttheoryortheoriesfromwhichtheconstructcouldbedeveloped.The4theorieschosenforderiva-tionoftheWIAtheoryweredrawnfromtheBerlinWisdomParadigm(BWP),theModelofWisdomDevelopment,theModelofWis-dom,andtheData,Information,KnowledgeWisdom(DIKW)framework1,3,4asdescribedinapreviousarticle.5Thefourthstepwastoidentifywhichpartsoftheparenttheoriescouldbeusedtobuildthenewconstruct.2The4theorieswereanalyzedfortheirrespectiveconcepts,conceptualdeÞnitions,andtherelationshipsbetweentheconceptsacrossalltheories.TheBWPwaschosenasthemainparenttheorybecauseitdealswithexpertiseinthemattersofhumanlife.3Thecompo-nentsidentiÞedfromthese4theorieswereintegratedintoadiagramoftheemergingconstruct.Copyright©2020WoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited.
30ADVANCESINNURSINGSCIENCE/JANUARYÐMARCH2020TheÞnalstepofderivingtheconstructwastodeterminewhetheranyoftheconceptsin-cludedintheparenttheoriesneededtoberedeÞnedforanursingcontext.Inaddition,deÞnitionsforsimilarorsynonymouscon-ceptswerecomparedandreconciled.SynthesisTheorydevelopmentbysynthesisistheÒprocessoftransformingpractice-relatedre-searchaboutaphenomenonofinterestintoanintegratedwhole.Ó2(p140)The3stepswereasfollows:1.Identifytheconceptsofinterest.Initialconceptscamefromtheparenttheoriesandfocusedonbothknowledgeandwisdom.Ad-ditionalconceptswereincludedastheywereidentiÞedfromareviewofthenursinglitera-tureandtheories.2.Identifyrelatedfactors,anddeÞnere-lationshipsbetweentheconcepts,includingthedirectionandtypeofrelationship.Forexample,therelationshipbetweenknowl-edgeandwisdomdepictedintheDIKWÞgureintheANAScopeandStandardsisuni-directional,withknowledgeasanecessaryfactorenablingwisdomdevelopmentbuttherelationshipshouldbebidirectional,withtheconversehappeningaswell.3.Developanintegratedrepresentationormodel.Adiagramofconceptsillustratestherelationshipsamongthem.TheWIAcon-ceptsweregrouped,orputintofactors,ac-cordingtotheirsimilarity.Derivationandsynthesiswereperformedsynchronously,asÞndingsfromonestepin-ßuencedothers.Theconceptslocatedwithinthemodelsfromotherdisciplineswereusedassearchtermsforasynthesisliteraturere-view.Conversely,deÞnitionsfoundduringsynthesiswerecomparedwiththemodelsfromotherdisciplinesandinformedthedef-initionswithinanursingcontext.Thelitera-tureonwisdom,itsantecedents,attributes,andrelationshipstootherconceptswassys-tematicallycollatedandsynthesized.Figure1showstheÞrstWIAconstruct.TheinitialconstructwasacombinationoftheBWPandtheDIKWframework,withdef-initionstransformedintonursingdeÞnitions.Onhindsight,thisÞrstconstructwasinßu-encedbyaninformaticslensbecauseoftheFigure1.Firsttheoryofwisdom-in-actionconstruct.Copyright©2020WoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited.
DevelopmentofaTheoryofWisdom-in-ActionforClinicalNursing31largedata,information,andknowledgecir-cleswithintheconstruct.Theconstructwassharedinpresentationsnationallyandrevisedonthebasisofpeerfeedback.ThisinitialtheoryofWIAwasincludedasanemergingtheoryinthe2015ANANursingInformaticsScopeandStandardsofPractice.6Phase2:ConstructivistgroundedtheoryNext,agroundedtheorywasdevelopedusingCharmazÕs7CGTapproach.WechoseCGTbecausewealreadyhadinvolvementandinteractionswiththetopicofwisdom;CGTacknowledgesthissubjectivistperspective.8Incarryingoutthestudy,thetheoreticalformulationspreviouslyassembledduringderivationandsynthesiswerereßexivelyacknowledgedheldinabeyance.NursesÕlivedexperiencesandtheirembodimentofwisdomintheclinicalarenawerein-vestigatedwithinemergencydepartment(ED)nursingpractice.TheaimwastounderstandhowEDnursesconstructedthemeaningofwisdomwithintheirclinicalnursingpractice.TheEDsettingwaschosenbecauseitisafast-pacednexusofhumansufferingwithuncertaintythatmakestheapplicationofwiseclinicaldecision-makingexplicitinvaryingsituations,undertimepressure,andingreatervolumethanothersettings.Thirtystorieswereobtainedfrom10nurses.Thesubsequentgroundedtheorymodelfocusedon2separateprocesses:atechnicalpracticemodelandanaffectivepracticemodelsupportedwithexpertise.AllthestoriesthatincludedtechnicalÞndingsrequiredtopracticenursingweresimilartothederivedtheory.TheadditionalsigniÞcantÞndingswereaffectivecategoriesincludingemotionalintelligence,assertiveness,andcollaboration.ThesewerevisualizedwithinaCelticknotbecausetheyco-occurredsofrequentlythattheywerealmostinextricablefromoneanother(Figure2).Figure2.Groundedtheoryconstruct.FromMatneyetal.8Copyright2016bySagePublications.ReprintedbyPermissionofSAGEPublications,Inc.Copyright©2020WoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited.
32ADVANCESINNURSINGSCIENCE/JANUARYÐMARCH2020TheartofnursingisÒtheactofdoingÓortheactualprovidingofcare,aprocessinherentinwhichtheperformingofsomeactionisdesignedtoproducegoodforfel-lowhumans.9Thisrequiresusingbothtech-nicalandaffectiveprocesses.Emotionalintel-ligenceleveragestheabilitytoconnectwithpatientsusingempathy.Groundedtheoryanalysisoftemporalcauses,consequences,andconditionsgener-atedrelationshipsbetweenthedifferentprop-ertiesofaspectsofwisdom(technical,affec-tive,andexpertise)asexperiencedbytheEDnurses.Importantly,duringtheinterviews,andthroughoutanalyses,ourlensswitchedfromaninformaticsperspectivetoabroadernursingperspective.Phase3:ThetheoryofWAIforclinicalnursingTheÞnaltheoryofWIAforclinicalnursingisasynthesisoftheconstructfromphase1andthegroundedtheoryfromphase2.Theconstituentpartswereexaminedforsimilar-itiesanddifferencesandmergedintoonein-tegratedmodel.Atthispoint,theconstructcompletelychanged.TheÞrstconstructdidnotclearlydescribethetechnicalprocessanditsrelationshipstootherconcepts,nordiditincludeanaffectiveprocess.Toamendthis,thegroundedtheorybecamethecentralpor-tionofthecurrenttheory.Relationshipsandstructureswerechangedbecause,whenex-aminedfromthelensofapracticingnurse,werealizedtheimportanceofotherwaysofknowingbesidesempiricaldata,information,andknowledge.Theinitialconstructrepresenteddata,in-formation,andknowledgeaslargecircles.IntheÞnaltheory,wedeterminedthatdataincontextwereinformationandthusÒdataÓwerenotneededasaseparateconstruct.Informationandknowledgeweremovedtothetechnicalprocessasactions(Òinforma-tiongathering,ÓÒinformationprocessing,ÓandÒknowledgeidentiÞcationÓ).Generalwis-domandpersonalwisdomwereseparatedintodifferentprocesses.Aproviderconceptwasaddedtothepersonalfactorantecedentsbecauseineverystory,aproviderwasmen-tioned.ConceptsthatdidnotchangefromtheÞrsttotheÞnalconstructwerethosewithinthepersonalWIAportionanditsantecedents.Thesynthesizedtheorycomprised3parts:wisdomantecedents,generalWIA,andper-sonalWIA.The3partsoftheemergingthe-oryofWIAforclinicalnursingaredescribedasfollows.WisdomantecedentsAntecedentfactorsarepreexistingcondi-tionsthatinßuencewisdomdevelopment.Theantecedents,locatedontheleftsideofthemodel,wereaggregatedinto2dimen-sions:person-relatedandsetting-related.ThedimensionscontainfactorsgroupedtogetherbyconceptswithspeciÞcaspectsorfeaturesasgiveninTable1.Person-relateddimensionThreefactorsworkincombinationinthisdimension:(1)personalfactors,(2)knowl-edgefactors,and(3)clinicalfactors.Personalfactors.Personalfactorsin-cludeage,education,socialinteraction,cul-tureandreligion,values,relativism,andtoler-ance,cognition,lifeexperiences,opennesstolearning,assertiveness,andconÞdence(Table1).Theyaretheonlyfactorsthatper-taintothenurseandotherpeoplewithinasituation.ThisisbecausewisdomexempliÞedbyaclinicalnurseisadistributedact,tak-ingtheteam,patient,andfamilyintoconsid-eration.Wisdomappliestoeveryonewithinthesituation.Ageandeducationareself-explanatory.Socialintelligenceischaracter-izedbycommunicativeskills,ahighdegreeofempathy,andtheabilitytogiveadvice.12Socialinteraction,particularlyvaluedinhu-maninteractionsandrelationships,isavitalattributefornursing.13Cultureandreligionconceptsencompassvaluesandbeliefsystems,acquiredknowl-edge,behaviors,andunderstandingsthataresharedbycertaingroupsofpeople.14,15LeiningerdeÞnedcultureasÒ…thelearned,Copyright©2020WoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited.
DevelopmentofaTheoryofWisdom-in-ActionforClinicalNursing33Table1.Wisdom-in-ActionAntecedentDeÞnitionsWisdomPrecursorsandCharacteristicsNursingDefinitionPerson-relateddimensionPersonalfactorsAgeThelengthoftimeapersonhaslivedEducationInstructionreceivedincludingschoolandonthejobSocialinteractionThecapacitytoeffectivelyhandlecomplexsocialrelationshipsandenvironmentsCulture/religionAcquiredknowledge,behaviors,understandings,orbeliefssharedbycertaingroupsofpeopleValues,relativism,andtoleranceAnawarenessthatallclinicaljudgmentsareafunctionof,andarerelativeto,agivenculturalandpersonalvaluesystem.ToleranceisusedtoacknowledgeandcareforthehumanregardlessofthosedifferencesCognitionSpeedandaccuracyofbasicinformationprocessinginthebrainandskillssuchasreadingandwritingability4LifeexperiencesThingsthathavehappenedduringlifewhereknowledgeand/orskillsweregainedOpennesstolearningAwarenessthattherearemultipleperspectivesineveryexperienceandaninterestinlearningfromnewperspectivesandfromotherpeopleAssertivenessStandingupforoneselfandoneÕspatient,withouthurtingothers,throughhonestexpressionofthoughts,feelings,opinions,orneedsConÞdenceSelf-assuranceandrealizationofoneÕsownknowledgeandabilityKnowledgefactorsFundamentalknowledgeThepossessionofanextensiveknowledgebaseregardingthenursingprocessandcareofthepatientProceduralknowledgeKnowledgeregardingclinicalprocedures,processes,andinterventionsrequiredforcare10LifespancontextualismUnderstandingothersacrossthelifespaninordertoprovideage-appropriatecarePsychosocialknowledgeUnderstandingoforrelatingtotheinterrelationofsocialfactorsandindividualthoughtsandbehaviorsClinicalfactorsMentors/rolemodelsThosewholeadandguidestudentstobehaviorsthatpromoteself-awarenessandengagementwithclinicalsituationsClinicalexperiencesPastactsofclinicalcare11ClinicaltrainingThelevelofeducationanursehashadregardingclinicalcareandcompetenciesSetting-relateddimensionSettingtypeThelocationandclinicalspecialtyofthesituationSettingcultureAwayofthinking,working,andbehavinginaplacewherethesituationoccursNursefamiliaritywithsettingThedegreetowhichthelocationisknownwherethesituationtakesplaceCollaborativeteamNurses,physicians,andancillaryservicescooperativelyworkingtogetherandsharingresponsibilityforsolvingproblems,aswellasmakingdecisionstoformulateandcarryoutplansforpatientcareElectronicsysteminformationThetypeandformatofinformationprovidedbyanelectronichealthrecordDecisionsupportsystemComputerprogramsdesignedtoanalyzedataandassistwithdecisionmakingshared,andtransmittedvalues,beliefs,norms,andlifewaysofaparticularculturethatguidesthinking,decisions,andactionsinpatternedwaysandoftenintergenerationally.Ó16(p190)NursesneedtounderstandtheirownaswellasthepatientÕs/familyÕsreligiousorspiritualbeliefs,whichcontributetohowtheyexperiencetheprocessofcare,theirCopyright©2020WoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited.
34ADVANCESINNURSINGSCIENCE/JANUARYÐMARCH2020relationshipswithhealthprofessionals,andtheirlevelofinvolvement.17Somereligionshavehealthcareimplications,suchasthebe-lieftonotreceivebloodproducts.Values,relativism,andtolerancecanbecontributingfactorstowisdom.Anurseshouldconsiderthevariationsandlifepri-oritiesofthepatientwithinaparticularsituation.18Relativismrequiresanunder-standingofdifferentphilosophicalpositionsregardingwhatisgoodandright.Toleranceisacknowledgingandcaringforthehumanregardlessofthosedifferences.Cognition:Wisdomandcognitivedevelop-mentaretightlylinked.19Cognitivetheoristsdescribetheincreasinglevelsofcomplex-itythatindividualsdisplaywhentheymakemeaningoftheirexperiences,focusingspecif-icallyonhowmeaningisstructuredandnotonwhattheybelieveorknow.OpennesstolearningischaracterizedbyconÞdenceinknowledgeapersonhas,thehumilitytobelievethatheorshecannotknoweverything,andawillingnesstostumbleinthepursuitofknowledge.19Opennesstolearn-ingisrequiredforknowledgeacquisitionandinvolvesimagination,attentivenesstoinnerfeelings,andintellectualcuriosity.4Assertivenessistheabilitytostandupforyourselforyourpatientsbyexpressingthoughts,feelings,opinions,orneedswithoutbeingaggressiveorhurtingothers.20SeveralofthenursesÕstorieswerecaseswheretheytookcontrolofanemergentorhighlychargedsituation.Wealsosawassertivenesswhennursesstronglysuggesteddifferenttypesofinterventions,suchasalaboratorytest,toaprovider.ConÞdenceco-occurredinallthecasesofassertiveness.ThedataindicatedthatconÞdenceneededtoexistforthenursetobeassertive.AllthenursesinterviewedusedconÞdenceandassertivenesstospeakforthemselves.Acalm,conÞdent,demeanorsmoothedhigh-stakesdisturbancesduringEDencounters.Knowledgefactors.Wisdom-in-actioncannotoccurwithoutafoundationofknowl-edge,asdescribedin4factors:fundamentalknowledge,proceduralknowledge,lifespancontextualism,andpsychosocialknowledge.NursesusefundamentalknowledgetounderstandapatientÕssituation,andtheyhaveanexpertlevelofknowledgeregardingassessment,diagnosis,outcomesidentiÞca-tion,planning,implementation(includingcoordinationofcare),andevaluationwithinthespeciÞccontextofcare.21Proceduralknowledgeconcernsanyinter-ventionrequiredforcare.Examplesfromthestoriesincludededucatingaboutinvasivepro-cedures,performingprocedures,andmoni-toringpatients.11Lifespancontextualismisunderstandingothersfromconceptiontodeath,dependingonthecaresetting.TheJointCommissionintheUnitedStatesrequiresthatanyhealthcareproviderhavingpatientcontactbecom-petentinmeetingage-appropriateneedsin-cludingdevelopmentalneeds,cognitiveabil-ity,andage-appropriatesafetyguidelines,aswellasawarenessofsocialandindividualdifferences.22Patientsandfamiliesdonotjusthavephys-icalneedsbutalsopsychological,informa-tional,andeducationalneeds,aswellastheneedforsocialsupport.Thenurseswithpsy-chosocialknowledgetakeallthesefactorsintoconsiderationduringcareepisodes.Clinicalfactors.Clinicalfactorsareexperience-speciÞcconceptsanursehasen-counteredincludingmentors/rolemodels,clinicalexperience,andclinicaltraining.Nursesdrawontheexpertiseofmentors,combinedwiththeirclinicalexperience,asbuildingblocksofknowledgeforexpertisedevelopment.12Clinicaltrainingisanongo-ingprocessnecessarytodevelopandmain-tainknowledgeandexpertiseforpractice.Setting-relateddimensionSetting-relatedfactorspertaintothecon-textofcareandalignwithsituationaware-ness(SA)theory.23Situationawarenessistheperceptionofcomponentsintheenvi-ronment,theunderstandingoftheirmean-ing,andtheirprojectedfuturestatus.Nurses,workinginstressfulsituations,demonstrateSAwhentheyperceiveactivitiesintheCopyright©2020WoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited.
DevelopmentofaTheoryofWisdom-in-ActionforClinicalNursing35environment,understandwhattheymean,andprojecttheimplicationsofevent-drivendecisionsintothefuture.Theconceptswithinthisdimensionaresettingtype,settingcul-tureandpolicies,nursefamiliaritywiththesetting,andnurseexpertisewithsettingspecialty.Settingtype:Nursespracticewiselywhentheyhavetheclinicalknowledgethatper-tainstoaspeciÞcsetting,suchastheED,andarecomfortableintheirsetting.Nursefamiliaritywiththesetting:Be-yondfamiliarity,nursesexhibitexpertisewithinthespecialtysetting.Benner24de-scribesexpertiseaspracticalandtheoret-icalknowledge.Thismeansthatanursemusthavetechnicalaswellasnontechni-calexpertise(suchascommunicationandemotionalregulation).Electronicsysteminformationincludestheuseofcomputerizeddata,information,andknowledge.Whenprovidingcare,nursesusedata,information,andknowledgefromanelectronicrecordandvariousdevicestoassistindecisionmaking.Dataneedtobeprocessedintoinformationtoprovidecare.Informationisdatainthecontextofcaregroupedtoprovidemeaning.25Thesystemmayalsoincludedecisionsupportsystems,whicharecomputerprogramsdesignedtoanalyzedataandassistwithdecisionmaking.Wisdom-in-actionTheselectionofthetermÒwisdom-in-actionÓwasmotivatedbyBennerÕs26useofÒthinking-in-actionÓandSch¬onÕs27useofÒreßection-in-action.ÓÒIn-actionÓimpliesthattheprocessisoccurringduringtheactofprac-tice.Thetheoryillustrates2typesofWIA,gen-eralandpersonal.GeneralWIAoccursduringasituation,aswisdomisappliedtothepar-ticularpatientsituation.Itincludesatechni-calaspect,aligningwiththenursingprocess,andanaffectiveaspect.Expertiseunderpinsbothtechnicalandaffectiveaspects.PersonalWIAtakesplaceduringorafterthesituationandisspeciÞctothenurse.Thereßection-feedbackloopispersonal,allowingthenursetoreview,analyze,andevaluatetheeventthathasoccurred,ponderwhathappened,anddiscovermeaning.Sch¬oncallsthisÒreßection-on-action.ÓTable2containsalistofwisdomattributeswithassociateddeÞnitions.ÒStressfuloruncertainsituationÓisapre-cursortoWIAbecauseduringthattime,nursesaredealingwithmattersofhumanlife(derivedfromtheinitialparenttheory).3ThedeÞnitionsconceptsinthetheoryofWIAcanbeseeninTable2.Readerscanalignthenarrativewiththemodelbystart-ingwiththestressfuloruncertainsituationinthemiddleandfollowingthearrows:generalWIAoccurswhenthenurseisdealingwithstressfuloruncertainsituations.Whenthesit-uationoccurs,informationgatheringtakesplaceandinformationprocessingoccurs.Expertiseimpactsandinsightandintuitioninßuencetheclinicaljudgmentincontext.Judgmentleadstoadecisionandanintervention(Figure3).ThetechnicalaspectofgeneralWIAin-cludestheactionsofinformationgathering,informationprocessing,knowledgeidentiÞ-cation,criticalthinking,andclinicaljudgmentformulation,whichareinßuencedbyinsightandintuition,leadingtoadecision,interven-tions,andevaluation.Informationgatheringoccursassoonasanurseentersthesituationandreoccursaf-terinterventions.Duringthisprocess,anurseobtainsinformationaboutthepatientandthesituation.Informationprocessingcanbedonemen-tallyorininformationsystem.ThisisthepointwheninformationisanalyzedandknowledgeidentiÞcationoccurs.CriticalthinkingisthelinkbetweenknowledgeidentiÞcationandjudgmentfor-mulation.Whenpracticingwithwisdom,crit-icalthinkingisusedtodeÞneandunderstandthesituation(physicalormental)andestab-lishadesiredgoal.Clinicaljudgmentincontextisahumanskillthatrequirestheabilitytoinßuencesitua-tions,perception,skilledknow-how,andrea-soningaboutparticularclinicalsituations.29Copyright©2020WoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited.
36ADVANCESINNURSINGSCIENCE/JANUARYÐMARCH2020Table2.WisdomAttributeDeÞnitionsGeneralWIADefinitionStressfulsituationormanagementofuncertaintyAneventwherethenursefeelsworried,oranxious,regardingcareofthepatientordoesnothaveclearknowledgeastohowtoaddresstheproblemTechnicalprocessInformationgatheringDataincontextofcaregroupedtogethertoprovidemeaning25InformationprocessingInterpretingandtransformingincominginformationintoknowledgeKnowledgeidentiÞcationAnunderstandingofthesituationandthestepsrequiredtocareforthepatientduringtheparticularsituationattheexpertlevelCriticalthinkingTheuseofcognitiveskillsandlogicalreasoningtoanalyze,predict,andtransformknowledge28ClinicaljudgmentformulationincontextTheprocessofdatacollectionandinterpretationtoderiveaplanofaction26InsightandintuitionIntuitionisagutfeelingorhunchaboutsomethingthatmaybebasedonexperiencebutdoesnothaveconcretefactstosupportitThisfeelingguidesthenursetoperformsometypeofinterventionDecisionMakingachoiceregardingcareInterventionPuttingthedecisionintoactionEvaluationJudgingtheeffectivenessoftheinterventionAffectiveprocessEmotionalintelligenceEmotionalintelligenceistheinnatepotentialtofeel,use,communicate,recognize,remember,describe,identify,learnfrom,manage,understand,andexplainemotions;includessubcategories,self-awareness,managingnegativeemotions,self-regulation,andempathyAdvocacyPreservinghumandignity,patientequality,andalleviatingsufferingCollaborationWillinglyworkingjointlywiththeteamExpertiseAnexpertlevelofpracticalandtheoreticalknowledgewithintuitiveabilitytoefÞcientlymakecriticalclinicaldecisionswhilegraspingthewholenatureofasituation23PersonalWIAReßectionTakingtimetoponderandthinkaboutthecriticalthinking,judgments,anddecisionsusedafterdealingwithuncertainty27LearningGainingknowledgeDiscoveryofmeaningSelf-awareness,motivation,self-regulation,empathyAbbreviation:WIA,wisdom-in-action.Informationsystemscandisplayknowledgebutcannotprocessjudgment.Contextdeter-minesthetypeofknowledgeandjudgmentused,theactionsapplied,andtheknow-how.Insightandintuitioninßuenceclinicaljudgmentincontext.Insightandintuitionaregroupedbecauseintuitionisaninsight-fulsenseofknowingandunderstandingwith-outtheconscioususeofreason.30,31Thecon-ceptofintuitionhasbeenassociatedwiththeÒartÓofnursingbecauseitistheuseofthenonquantiÞablecharacteristicsofthenursingprocess.Smith32describesthisasÒresonantrelating,Óthatis,tuningintothepatientÕsen-ergyÞeldandgaininginsightastowheretoplacetheattentionorfocus.WisenurseshaveanintuitivegraspofclinicalsituationswithhighlyproÞcientperformance.33Acaredecisionfollowsclinicaljudgment.Caredecisionistheconclusionreachedre-gardingwhatisnecessarytothehealthandwelfareofthepatient.OncethedecisionCopyright©2020WoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited.
DevelopmentofaTheoryofWisdom-in-ActionforClinicalNursing37Figure3.Theoryofwisdom-in-actionforclinicalnursing.ismade,interventionoccurs.WithinthenursesÕstories,typesofinterventionsin-cludedmedicationoroxygenadministration,providingemotionalsupportoreducation,andperformingaproceduresuchasmoni-toringorstartinganintravenousline.TheÞnallinkinthecareprocessdescribedbythenursesisevaluationdonetode-terminetheresultsofinterventions.Typesofnurseevaluationsincludedreviewinglaboratoryresults,assessingvitalsignsorequipment,andmonitoringthepatientforinterventioneffects.Evaluationleadsbacktoinformationgathering,andactionscontinuetoloopthroughthetechnicalprocess.Evaluationisdonetodetermineresultsofproceduresorinterventions.Affectiveprocesscategories(theCelticknotofnursingcare)Theaffectiveprocessconsistsofemotionandhumaninteractioncharacteristicsthatarewoventhroughtheentiresituation,visual-izedwithinaCelticknot.Conceptsincludeemotionalintelligence,collaboration,andadvocacy.Emotionalintelligenceencompasses4subcategories:self-awareness,self-regulation,motivation,andempathy.34,35Toindicatesubcategories,thefontforthiscategoryislargerwithintheCelticknotofnursingcare.•Self-awarenessoccurswhenthenurserecognizedtheirownstrengthsandabil-ities.•Managingnegativeemotions:Wisenursesaremotivatedtorecognizeneg-ativeemotionsandlearntoovercomethem.Emergencydepartmentnursesde-scribedemotionstheyfeltduringstress-fulsituationssuchasfrustration,anger,orgrief.•Self-regulationisakeycomponentofemotionalintelligence.Wisenursesman-agetheiremotionsandreactionstobemosteffective.•Empathy:EmpathyistheabilitytosenseandunderstandotherpeopleÕsemotionsfromtheirperspective.EmpathywasCopyright©2020WoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited.
38ADVANCESINNURSINGSCIENCE/JANUARYÐMARCH2020evidentwhenthenursesthoughtofeachpersonasanindividualandtreatedeventhemostminorinjuryasimportanttothatspeciÞcperson.36,37Advocacy:TheANAaddressestheimpor-tanceofadvocacyinitsCodeofEthics.38NursesdescribedtheethicaldimensionofWIAbypointingtoadvocacy(supportingandenablingpeopletorepresenttheirviews)asanelementofwisepractice.Teamcollaborationispresentwhennurses,physicians,andallancillarymembersworkcooperativelytogether,sharingprob-lems,andcreatingaplanforthepatient.Col-laborationrequiressocialskillsandtheabilitytocommunicateeffectivelywithothers.Inastressfulsituation,collaborationiscrucialforbasicpatientsafetyandimplementationofef-fectivecareplans.Expertiseunderpinsboththetechnicalandaffectiveprocesses.HowthenurseshandledemergenciesandusedavailablesystemsisalearnedskillthatdemonstratedproÞciencyorexpertise.24Personalwisdom-in-ActionThereßection-feedbackloop(bottomleft4conceptsinthemodel)followsacaredeci-sionandcanoccurduringorafterasituation.Thediagramiscreatedasacontinualcircleindicatingthatthenurseentersintoandex-itsoutoftheloopanywhere.Theconceptsincludereßection,learning,anddiscoveryofmeaning.Whennewknowledgeisgained,itisintegratedbackintotheknowledgefactors.Reßectioncanbeaccomplishedthroughmindfulness,journaling,meditation,exer-cise,andothermethods.Throughreßectiononanexperience,newinsightsandmeaningarediscovered.NursesevaluatefaultylogicorinaccuratejudgmentsandgainwisdombyreßectingontheirownorothersÕmistakes,orsuccesses,anddetermininghowtoimprove.LearningtakesplacethroughreßectionandgainedknowledgeisfedintonursesÕclin-icalknowledge,thusincreasingthelevelofexpertiseavailablewhenthenextuncertainsituationarises.BeingopentolearningandlearningareimportantcharacteristicsofWIA.Wisdom-in-actionisnotadestinationbutaprocessthatoccursmultipletimesoveranurseÕscareer:nursingpracticeisacontinualprocessoflearningandgainingexpertise.KnowledgeisincludedduringtheuseofWIAtomakeanursingjudgment.Reßectionandlearningareanintegralpartoftheprocess.WedevelopedanewtheoreticalperspectivecharacterizinggeneralWIAastheexpertabilitytousebothtechnicalandaffectiveprocesseswithexpertiseduringstressfuloruncertainsituations.Duringorfollowingasituation,nursesapplypersonalWIAtoreßect,discovermeaning,learn,andintegrateknowledgebackintopractice.DISCUSSIONAdialogueaboutwisdomandsimilarconstructsoccurredforyears.BennerÕs24novicetoexperttheoryaddressedthegrowthofexpertiseinclinicalnursingduringape-riodofprofessionaldevelopment.Carper39describesempirical,ethical,esthetic,andpersonalwaysofknowing.Thedata-information-knowledge-wisdomhierarchydepictedmetastructuresunderlyingnursinginformaticspractice.6Despitetheseefforts,aunifyingconceptualmodelofnursingwisdomhasnotpreviouslybeendeveloped.Thecomplementarybutdistincttheoriesofexpertise,waysofknowing,andlevelsofinformationwerenotharmonized.OuremergingtheoryofWIAforclinicalnursingisanattempttoaccomplishharmonization.ThegoaloftheemergingtheoryofWIAistoprovideaworkingframeworkfortrans-latingwisdominclinicalnursingpracticeintotheoreticalandpracticalterms.Thethe-oryillustrateshowknowledgemasteryal-lowsnursestounderstandwhatisneededinastressfuloruncertainsituationandhowemotional,affective,andsubjectiveaspects(theartofnursing)helpnursesmakeap-propriatedecisionsaboutcareforapatient.Wisdom-in-actiondepictshownursesreßectonthosedecisions,discovermeaning,andlearnhowtheirdecisionsaffectpatientcare;applyingthatlearningimprovesnursesÕfuturepractice.Copyright©2020WoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited.
DevelopmentofaTheoryofWisdom-in-ActionforClinicalNursing39Wisdomisacomplexandmultifacetedphenomenonrequiringanintenseprocessoflearning,practice,andmotivationasnursesstrivetowardexcellence.Giventhecomplex-ityofthephenomenon,therearelimitationsandstrengthstothistheory.Wehaveattemptedtodiscerntheantecedentsandattributesofwisdomusing2methods.How-ever,thisisanascenttheoryandneedsfurthertesting,reÞnement,andsimpliÞcation.Itisourhopethatpublishingthisinitialworkwillstimulateresearchwithinthenursingcommunity.Thecriteriaforahigh-qualitytheoryareinternalconsistency,parsimony,testability,empiricaladequacy,andpracticaladequacyandsigniÞcance.40Contextandthecontentofthepreliminarytheorieswereexaminedtosupportinternalconsistency.Theconceptswithinthederivedtheorywereobtainedfromotherdisciplinesandhadpreviouslybeenvali-dated.Thisgivescredibilitytotheinitialsetofconceptsandrelationships.AlltheconceptsandrelationshipsaredeÞnedwithinanursingcontext.ThedeÞnitionsusedthroughoutthemanuscriptsanddiscussionswereconsistentunlessweindicatedwhytheyweremodiÞed.Thetechnicalprocessreplicatesthenursingprocess,asoundsetofrelationships.ThedeÞ-nitionsandrelationshipswithintheconstructcouldbeanareaforfutureresearch.ParsimonyisdifÞculttoevaluate.Themodelappearscomplexbutreßectsthecom-plexityofthephenomenonofwisdomitself.Thederivedtheoryhasbeenpresentedanddiscussedwithnursesacrossthecountry.ThetheoryresonateswithnurseswhoconÞrmthatitdeÞnesnursingpractice,butgiventheabstractconceptofwisdom,doesthetheoryactuallyillustratewisdom?Thatwillneedtobeevaluatedinthefutureasthetheoryma-turesandistested.Researchmethodologyisonedetermina-tionoftestabilityofmid-rangetheory.ThetheoryÕsstrengthisthatthedevelopmentwasapproachedbothinductivelyanddeductively.Anothermeanstodeterminetestabilityistodeterminewhethertheconceptsareobserv-ableusinginstruments.Manyoftheconceptshaveinstrumentsavailabletotestthem,suchasconÞdenceandassertiveness.Thisareaisripeforfutureresearch.EmpiricaladequacycanbedeterminedbyevaluatingwhethertheassertionsmadebythetheoryarecongruentwithscientiÞcev-idence.Thiscanbetentativelyacceptedasreasonablebyexternalevaluation.However,alternativetheoriesshouldbetakenintoac-countaswell.Forexample,thistheoryhassomesimilaritytoSAtheory.41Thetwohavebeencomparedtodeterminewhetherthistheoryisindeednewknowledge.Thesim-ilarityisthatSAhasindividualfactorsandincludesadecisionandtheperformanceofactions.However,SAislikelyacomponentofwisdomdevelopmentbutwisdomincludesadditionalconcepts.Finally,pragmaticadequacyexaminestheutilityofatheoryfornursingpractice.DoestheWIAtheoryrepresentnursingactionscompatiblewithexpectationsforpractice?Thepreliminaryevidenceofutilityisthatthe30EDnursesÕstoriesarerepresentedwithinthetheory.SignificanceThetheoryofWIAforclinicalnursinghassigniÞcanceforpatients,practicingnurses,nurseleaders,nurseeducators,nurseresearchers,andnurseinformaticists.Firstandforemost,thistheoryissigniÞcantforpa-tients.Whentheyarecaredforbyanursewhounderstandsandpracticesusingwisdom,theywillreceivethemostbeneÞt.Patientsmightunderstandthetypeofcaretheyshouldbere-ceivingfromawisenurse.ThetheoryofWIAforclinicalnursingcouldbeusedbynurseleadersasacriterionstandardmodel.Admin-istratorscanincludetheaffectiveprocess,aswellasthetechnicalprocess,inperformancecriteria.Couldnursesbeevaluatedusingthismodelbymorewisenurses?Coulditbeusedtotargetprofessionaldevelop-ment?Educatorscoulddevelopfoundationalnursingcurriculausingthetechnicalandaffectiveprocesses.Nursingstudentsmaybeencouragedtoseeexamplesofwisdomintheirclinicalrotations,learningthetechnicalandaffectiveskillsthatcontributetoanoverallconstellationofwiseactions.TheCopyright©2020WoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited.
40ADVANCESINNURSINGSCIENCE/JANUARYÐMARCH2020processofreßectioncouldbeemphasized.In-formaticistscancontinuetoconductresearchonhowinformationisobtainedandhowknowledgeisdevelopedandappliedduringastressfulsituationtofacilitateWIA.Userex-perienceinformaticistscantestdesignsthatpromoteknowledgedevelopmentandsup-portthedevelopmentofwisdominelectronicsystems.CONCLUSIONNursingisadistributedactthatrequiresgeneralwisdomregardingthelifeandsitua-tionofthepatientorfamilyandteamaroundthenurse.Nursingisalsoanindividualactasnursesneedtobeattunedtotheirbeliefsandvaluesystemsaswellashaveanunder-standingoftheirknowledgeandabilities.ThetheoryofWIAdescribestheconceptsandre-lationshipsofgeneralandpersonalwisdomusedduringnursingpractice.Wisdomisnotanendpoint.Rather,usingwisdominprac-ticeisajourneywe,asnurses,canachieveanddemonstrateoverourcareers.TheemergingtheoryÕsgreatestcontributionistoprovideanewperspectiveandworkingframeworkfortranslatingwisdominclinicalnursingpracticeintotheoreticalandpracticalterms.REFERENCES1.AmericanNursesAssociation.NursingInformatics:ScopeandStandardsofPractice.SilverSpring,MD:nursesbooks.org;2008.2.WalkerLO,AvantKC.StrategiesforTheoryCon-structioninNursing.5thed.UpperSaddleRiver,NJ:PrenticeHall;2011.3.BaltesPB,StaudingerUM.Wisdom.Ametaheuristic(pragmatic)toorchestratemindandvirtuetowardexcellence.AmPsychol.2000;55(1):122-136.4.Gl¬uckJ,BluckS.MOREWisdom:Adevelopmentaltheoryofpersonalwisdom:fromcontemplativetra-ditionstoneuroscienceIn:FerrariN,WeststrateN,eds.TheScientiÞcStudyofPersonalWisdom.NewYork,NY:Springer;2013:75-98.5.MatneySA,AvantK,StaggersN.Towardanunder-standingofwisdominnursing.OnlineJIssuesNurs.2015;21(1):9.6.AmericanNursesAssociation.NursingInformatics:ScopeandStandardsofPractice.2nded.SilverSpring,MD:nursesbooks.org;2015.7.CharmazK.ConstructingGroundedTheory:APrac-ticalGuideThroughQualitativeAnalysis.Thou-sandOaks,CA:Sage;2006.8.MatneySA,StaggersN,ClarkL.NursesÕwisdominac-tionintheemergencydepartment.GlobQualNursRes.2016;3:2333393616650081.9.JohnsonJL.Adialecticalexaminationofnursingart.ANSAdvNursSci.1994;17(1):1-14.10.CarperBA.ResponsetoÒPerspectivesonknowing:amodelofnursingknowledge.ÓSchInqNursPract.1988;2(2):141-144.11.HaggertyLA,GraceP.Clinicalwisdom:theessen-tialfoundationofÒgoodÓnursingcare.JProfNurs.2008;24(4):235-240.12.StaudingerUM,LopezDF,BaltesPB.Thepsychome-triclocationofwisdom-relatedperformance:intelli-gence,personality,andmore?PersSocPsycholBull.1997;23(11):1200-1214.13.McQueenACH.Emotionalintelligenceinnursingwork.JAdvNurs.2004;47(1):101-108.14.MorseJM,RichardsL.ReadmeFirstforaUserÕsGuidetoQualitativeMethods.ThousandOaks,CA:Sage;2002.15.RoperJM,ShapiraJ.EthnographyinNursingRe-search.Vol1.ThousandOaks,CA:Sage;1999.16.LeiningerM.Culturecaretheory:amajorcontribu-tiontoadvancetransculturalnursingknowledgeandpractices.JTranscultNurs.2002;13(3):189-192;dis-cussion200-181.17.SeaburnDB,McDanielSH,KimS,BassenD.Theroleofthefamilyinresolvingbioethicaldilemmas:clini-calinsightsfromafamilysystemsperspective.JClinEthics.2004;15(2):123-134;discussion135-128.18.PasupathiM,StaudingerUM.Doadvancedmoralrea-sonersalsoshowwisdom?Linkingmoralreasoningandwisdom-relatedknowledgeandjudgement.IntJBehavDev.2001;25(5):401-415.19.BrownSC.Learningacrossthecampus:howcollegefacilitatesthedevelopmentofwisdom.JCollStudDev.2004;45(2):134-148.20.HodgettsS.BeingassertivebeneÞtseveryone.NursTimes.2011;107(47):41.21.AmericanNursesAssociation.Nursing:ScopeandStandardsofPractice.3rded.SilverSpring,MD:nursesbooks.org;2015.22.Wilson-StronksA,LeeKK,CorderoCL,KoppAL,GalvezE.OneSizeDoesNotFitAll:MeetingtheHealthCareNeedsofDiversePopulations.Oak-brookTerrace,IL:TheJointCommission;2008.23.EndsleyMR.Theoreticalunderpinningsofsituationawareness:acriticalreview.In:EndsleyMR,Gar-landDJ,eds.SituationAwarenessAnalysisandCopyright©2020WoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited.
DevelopmentofaTheoryofWisdom-in-ActionforClinicalNursing41Measurement.Mahwah,NJ:LawrenceErlbaumAs-sociates;2000:3-32.24.BennerP.FromNovicetoExpert:ExcellenceandPowerinClinicalNursingPractice.MenloPark,CA:Addison-Wesley;1984.25.MatneySA,BrewsterPJ,SwardKA,CloyesKG,StaggersN.Philosophicalapproachestothenurs-inginformaticsdata-information-knowledge-wisdomframework.AdvNursSci.2011;34(1):6-18.26.BennerPE,Hooper-KyriakidisPL,StannardD.Clini-calWisdomandInterventionsinAcuteandCriticalCare:AThinking-in-ActionApproach.NewYork,NY:SpringerPublishingCompany;2011.27.Sch¬onDA.TheReßectivePractitioner:HowProfes-sionalsThinkinAction.Vol5126.NewYork,NY:Basicbooks;1983.28.SchefferBK,RubenfeldMG.Aconsensusstate-mentoncriticalthinkinginnursing.JNursEduc.2000;39(8):352-359.29.BennerP.Thewisdomofourpractice.AmJNurs.2000;100(10):99-105.30.BennerP,TannerC.Clinicaljudgment:howexpertnursesuseintuition.AmJNurs.1987;87(1):23-31.31.RewL,BarrowEM.Intuition:aneglectedhallmarkofnursingknowledge.AdvNursSci.1987;10(1):49-62.32.SmithMC.Holisticknowing.In:LocsinRC,PurnellMJ,eds.AContemporaryNursingProcess:The(un)BearableWeightofKnowinginNursing.Vol135-152.NewYork,NY:SpringerPublishingCompany;2009.33.BennerP.UsingtheDreyfusmodelofskillacquisitiontodescribeandinterpretskillacquisitionandclinicaljudgmentinnursingpracticeandeducation.BullSciTechnolSoc.2004;24(3):188.34.KookerBM,ShoultzJ,CodierEE.Identifyingemo-tionalintelligenceinprofessionalnursingpractice.JProfNurs.2007;23(1):30-36.35.CodierE.Emotionalintelligence:enhancingvalue-basedpracticeandcompassionatecareinnursing.EvidBasedNurs.2015;18(1):8.36.GoetzJL,KeltnerD,Simon-ThomasE.Compassion:anevolutionaryanalysisandempiricalreview.Psy-cholBull.2010;136(3):351.37.VonDietzeE,OrbA.Compassionatecare:amoraldimensionofnursing*.NursInq.2000;7(3):166-174.38.AmericanNursesAssociation.CodeofEthicsforNursesWithInterpretiveStatements.SilverSpring,MD:Nursesbooks.org;2015.39.CarperB.Fundamentalpatternsofknowinginnurs-ing.ANSAdvNursSci.1978;1(1):13-23.40.FawcettJ,WatsonJ,NeumanB,WalkerPH,Fitz-patrickJJ.Onnursingtheoriesandevidence.JNursScholarsh.2001;33(2):115-119.41.EndsleyMR.Towardatheoryofsituationawarenessindynamicsystems.HumFact.1995;37(1):32-64.Copyright©2020WoltersKluwerHealth,Inc.Unauthorizedreproductionofthisarticleisprohibited.
ANS200133April26,201219:14AdvancesinNursingScienceVol.35,No.2,pp.E1ÐE12Copyrightc2012WoltersKluwerHealth|LippincottWilliams&WilkinsASystematicReviewofAnalysesoftheConceptofQualityofLifeinNursingExploringHowFormofAnalysisAffectsUnderstandingJanetS.Fulton,PhD,RN,ACNS-BC,FAAN;WendyR.Miller,PhD,RN,CCRN;JulieL.Otte,PhD,RN,OCNQualityoflifeiscentraltonursingandcommonlyaimedatthepreservationofhealth-relatedqualityoflife.Fewrigorousstudiesaddressconceptdevelopmentofhealth-relatedqualityoflife.Thepurposeofthisarticlewastoexplorequalityoflifeasitisusedinnursingbysystematicallyreviewingpublishedconceptdevelopment.TheresultsfoundtheneedforamorerobustandrigorousstudyoftheconceptandsuggestthatformsofanalysisbeusedthatexplicitlyexploretheconceptincontextusingempiricaldataalongwithabroadandclearlydeÞnedliterature.Keywords:conceptanalysis,health-relatedqualityoflife,qualityoflifeQUALITYOFLIFE,aphenomenoncentraltonursingandfundamentaltothehu-manhealthexperience,isafrequentlycitedoutcomeofnursingresearchandpracticeaimedatthepreservationandrestorationofanindividualÕsoverallsenseofwell-being.DeÞnitionsofqualityoflifehaveincludedsub-jectiveperspectivesandobjectiveindicatorsandhaveincorporatedphysical,social,andenvironmentaldomains.Personalvalues,liv-AuthorAfÞliations:IndianaUniversitySchoolofNursing,Indianapolis,Indiana.ThisstudywassupportedbytheCenterforEnhancingQualityofLifeinChronicIllnessandIndianaUniver-sitySchoolofNursingResearchInvestmentFunds.TheauthorsthanktoTamilynBakas,PhD,RN,FAHA,FAAN,andKimHader,MSN,APRN,BC,fortheirsup-portwithmanuscriptpreparation.Theauthorshavenoconßictofinterest.Correspondence:JanetS.Fulton,PhD,RN,ACNS-BC,FAAN,IndianaUniversitySchoolofNursing,1111Mid-dleDr,Indianapolis,IN46202([email protected]).DOI:10.1097/ANS.0b013e318253728cingarrangements,economicconditions,andculturehavebeencitedasinßuencingqualityoflife,whichhasbeenmeasuredashappi-ness,lifesatisfaction,functioning,andotherindicators.Giventhewidespreaduse,varyingdeÞnitions,andmultipleoutcomeindicators,theconceptofqualityoflife,includingthemorespeciÞchealth-relatedqualityoflife,isanimportantfocusofinquiryfornursing.Conceptsarediscretecognitiveunitsofmeaning.1TheyarerepresentedinlanguageasawordortermthatservesasasymbolforanindividualÒunitofknowledge.ÓLinkedtogether,conceptshelptointegrateobserva-tionsandphenomena,sometimesapparentlyunrelated,intoviablehypothesesandtheoriesthatformthebasicingredientsofscience.1,2ItwouldbedifÞculttostudychemistrywith-outlanguageforbasicconceptssuchasel-ement,molecule,reaction,andequilibrium;likewise,itisdifÞculttostudynursingwith-outconceptsdesignatingnursingÕsessentialsubjectmatter.Frequentlyreferredtoasthebuildingblocksoftheory,conceptsarecriti-caltothedevelopmentofnursingknowledge,Copyright©2012LippincottWilliams&Wilkins.Unauthorizedreproductionofthisarticleisprohibited.E1
ANS200133April26,201219:14E2ADVANCESINNURSINGSCIENCE/APRILÐJUNE2012thought,andcommunication.3Somenursingconceptsarebroadandcentral,suchasper-son,health,andenvironment,whereasothersarenarrowerandfocusedonspeciÞcgroupsoractivities,suchaschronicsorrow,familycaregiving,andinfantfeedingresponsiveness.Conceptsaredevelopedusinglanguage,andconceptdevelopmentistheattempttodescribeorexplainphenomenathroughlan-guage.Methodsforconceptdevelopmentin-clude(1)conceptsynthesis,usefulfordis-coveringconceptsrelevanttoaphenomenonofconcern;(2)conceptderivation,appro-priateforgeneratingnewwaysofthinkingaboutaphenomenon;and(3)conceptanal-ysis,whichexaminesthestructureandfunc-tionofaconcept,includingattributesorchar-acteristicsthatmakeoneconceptdifferentfromanother.4Conceptsareessentialtothedevelopmentoftheoriesand,therefore,ex-aminationofconceptsiscritical.Qualityoflifeisabroadconceptusedinnursingscience.Despitetheinterestinqual-ityofliferesearchamongnursescientists,evidenceacrosstimesuggeststhatthecon-ceptitselfhasnotbeenwelldevelopedwithinthecontextofnursing.FerransandPowers5statedthatqualityoflifeisacomplexcon-ceptthathasnotbeenfullydeveloped.Mast6describedqualityoflifeasaprimitiveterm,andHaaseandBraden7notedthateffortstoclarifytheconcepthavebeenlikenedtotheTowerofBabel.Qualityofliferesearchhasproceededwithindividualresearchersselect-ingdeÞnitionsandmeasuringdesignatedin-dicators.Macduff8notedthatqualityofliferemainsanabstractideaattractinglegitimatephilosophicalquestionsastowhetheritex-istsatallbeyondtherealmofatheoreticalconstruct.Bergner9notedthatclariÞcationoftheconceptisavoidedinresearch,and,inef-fect,theconceptiswhatdifferentinvestiga-torsmeanittobe.Thislackofconceptualclar-ityleadstovaryingscientiÞcapproachesandinconsistentresearchÞndings.Matchingmea-surementtodeÞnitionsfacilitatesinterpre-tationofÞndings;however,aninvestigator-speciÞcconceptdeÞnitionhindersscientiÞcunderstandingandadvancement.Nursingscienceincludesmanybehavioralconceptsthatarerelativelyabstractanddonoteasilylendthemselvestoempiricaltesting.3Whatconstitutesqualityoflifeisnotaquestionthatcanyetbeeasilyanswered;however,itcanbeaddressedthroughcon-ceptdevelopment.QualityoflifeissofoundationaltonursingthatithasbeensuggestedthatqualityoflifereplacehealthinnursingÕsmetaparadigmÑhealth(qualityoflife),person,environment,andnursing.10Inpractice,qualityoflifeisfrequentlyatargetoutcomefornursinginterventions.11-13Eveninthefaceofagree-mentontheconceptÕsimportance,therehasbeenlittlescientiÞcallyrigorousworkad-dressingdevelopmentoftheconcept.Thepurposeofthisarticleistoexploreourcur-rentunderstandingoftheconceptofqualityoflifeasitisusedinnursingbysystemati-callyreviewingpublishedconceptdevelop-mentworksandconsideringÞndingsinthecontextoftheformofanalysisused.Thisarticleaimsto:1.examinetheconceptofqualityoflifethroughasystematicreviewofconceptdevelopmentworksinclud-ingderivation,synthesis,andanalysisstudiespublishedinnursing;2.exploretheinßuenceoftheformsofanalysisonunderstandingtheconceptofqualityoflife;and3.identifygapsinourunderstandingoftheconceptofqualityoflifefornurs-ingtheory,research,andpractice.METHODSMethodshavenotbeendescribedforre-viewingabodyofworkdealingwithdevel-opmentofasingleconcept.Followingtheprinciplesusedforintegrativeandsystematicreviews,theauthorscreatedaprocedureforreviewingandsynthesizingpublishedworksdealingwithconceptdevelopmentandimple-mentedtheproceduretoconductasystem-aticreviewoftheconceptofqualityoflife.Theproceduralstepsincluded(1)writingaCopyright©2012LippincottWilliams&Wilkins.Unauthorizedreproductionofthisarticleisprohibited.
ANS200133April26,201219:14AnalysesoftheConceptofQualityofLifeinNursingE3focusedquestion,(2)determiningcriteriaforliteratureinclusion/exclusion,(3)decidingonthesearchstrategy,(4)selectingarticles,(5)conductingindependentreviews(extractingthedata),and(6)analyzingresults.14-16Thequestionstobeansweredbythissys-tematicreviewareasfollows:Whatisourcurrentunderstandingoftheconceptofqual-ityoflifeasitisusedinnursingandhowdotheformsofanalysisusedforconceptdevel-opmentinßuenceourunderstanding?MED-LINE,CINAHL,andNursingOVIDdatabaseswerepreliminarysearchedbetween1960and1980usingthetermqualityoflife.TheÞrstappearanceofaquality-of-lifeÐrelatedpubli-cationwasa1970editorial.17Throughthe1970s,qualityoflifearticleswereanecdotalandeditorial,manyaddressingagingandend-of-lifecareissues.ScientiÞcarticlesonqualityoflifebegantoappearinthe1980s,thusoursearchperiodrangedfrom1980topresent(fall2011)andincludedthesearchtermsnurs-ing,qualityoflife,health-relatedqualityoflife,conceptdevelopment,derivation,synthesis,andanalysis.BothtermsÑqualityoflifeandhealth-relatedqualityoflifeÑwereincludedinthesearchbecausetheconceptofqualityoflifehasevolvedinnursingacrosstimeasevidencedinthepreliminarysearch.Articleswereselectedforevaluationif(1)theconceptofqualityoflifeorhealth-relatedqualityoflifewastheidentiÞedphenomenonofinterest;(2)thearticlewasanoriginalworkexploringqualityoflifeorhealth-relatedqualityoflifeconceptderivation,synthesis,oranalysisfornursing;and(3)adescriptionofconceptde-velopment(derivation,synthesis,oranalysis)wasidentiÞed.Fifty-eightarticleswereinitiallyidentiÞed.Ofthe58identiÞed,45didnotmeetthecrite-riaforthepurposeofthisreview.Ofthe45ar-ticlesthatdidnotmeetthecriteria,19articleswerereviewarticlesregardingconceptanaly-sis,9weredescriptivereportsbutdidnotin-cludeasystematicprocessorformofanalysis,and17wereconceptanalysisontopicsotherthanqualityoflifeorhealth-relatedqualityoflife.Thirteenarticlesmetthecriteriaandwereselectedforreview.10,18-29Becausenoarti-cleswereidentiÞedunderthesearchtermsÒconceptderivationÓorÒsynthesis,Óthisre-viewincludedonlyarticlesreportingconceptanalysis.Aninvestigator-designedreviewinstru-mentwascreatedtoguidedataanalysis.Theauthorsconductedindependentreviewsofeacharticleandabstractedinformationontotheinstrument,includingauthor,title,coun-tryoforigin,purposeoftheanalysis,formofanalysis,descriptionofproceduresorsteps,datasourcesfortheanalysis,authormajorÞndings,authorconclusions,andoverallcom-mentsregardingacritiqueoftheadequacyandrigoroftheanalysis.Forexample,theauthorsnotedthedegreetowhichauthorsofthearticlesunderreviewadheredtotheirstatedconceptanalysismethods,congruencybetweenpurposeoftheanalysesandÞndings,andthecomprehensivenessofliteraturere-viewed.Dataabstractedfromthearticlesbyeachauthorwerereviewedandplacedinta-blesforcomparisonacrossreviewers.The3reviewersmettodiscusstheirÞndings.IntheeventthattherewerediscrepanciesinÞnd-ings,suchÞndingswerediscusseduntilcon-sensuswasreached.Thisprocessinvolvedeachauthorrereviewingthearticleinvolvedandthenthe3authorsreviewingthearti-cleinvolvedtogether.DifferencesinÞndingswerethoroughlydiscussed,andthearticlere-visited,untilconsensuswasachieved.Datawerethenanalyzedonthebasisofthecriteriaforconceptanalysis.30Evaluationwasdividedinto2maincategoriesÑtheanatomyandlevelofmaturity.AconceptÕsanatomyallowsittobeoperationalized,measured,andmanipulatedforapplicationtoresearchandpractice.Anatomyincludesthestructuralfeaturesthatcanbemappedand,inthisreview,includeddeÞnitions,charac-teristics(attributes),boundaries(examplecases),preconditions(antecedents),andoutcomes(consequences).Maturityreferstoconsistencyandconsensusinuseamongtheorists,researchers,andclinicians.Con-sensusaroundasharedmeaninginnursingwouldindicatethattheconceptismatureenoughtosupportapplicationinnursing.Copyright©2012LippincottWilliams&Wilkins.Unauthorizedreproductionofthisarticleisprohibited.
ANS200133April26,201219:14E4ADVANCESINNURSINGSCIENCE/APRILÐJUNE2012Forthisreview,thestructuralelementsoftheconceptweredeterminedandplacedinatable.Maturitywasdiscussedaslevelofagreementregardingthestructuralelements.Inaddition,weexploredtheinßuenceoftheformofanalysisonoverallÞndings.FINDINGSPublicationdatesforthe13articlesmeet-inginclusioncriteriarangedfrom1990to2010.Eight(62%)articleswerefromtheUnitedStates,18-23,26,283(23%)articleswerefromCanada,10,24,251(7%)articlewasfromtheUnitedKingdom29;and1(7%)wasfromWestAfrica,27althoughtheauthorÕsafÞlia-tionwaswiththeUnitedStates.Health-relatedqualityoflifewasthefocusof3publications(23%)19,20,29andglobalqualityoflifeintheremainingarticles.10,18,21-28TheWalkerandAvant4formofanalysiswasusedin10articles(86%)18,20-29;RodgersandKnaß31evolution-aryformwasusedin1article(7%),andMorseetal30formofanalysisin1article(7%).SpeciÞcandnarrowpopulationsweread-dressedin3articles.Tayloretalexploredhealth-relatedqualityoflifeforadolescents,29Dugger20examinedhealth-relatedqualityoflifeamongnursinghomeresidentswithuri-naryincontinence,andCooleyanalyzedqual-ityoflifeinpersonswithnonÐsmall-celllungcancer.19PlummerandMolzhan10examinedqualityoflifeontheperspectiveof5nursetheoristsÑPeplau,Rogers,King,Leininger,andParse,selectedbecauseeachtheoristhadenoughsubstantiveliteratureusingtheconcept.Six(46%)articleswerejudgedtohaveanadequatedescriptionoftheprocessusedtoidentifyandselectliterature.10,19-21,24,29Theremaining7articleswerejudgedinade-quatelybecauseofmissinginformationaboutdatabasessearched,searchterms,yearscov-ered,totalarticlesfound,numberofarticlesmeetinginclusioncriteria,orotherdetailsofthesearchandselectionprocess.Oneauthorincludedanoteaboutthedecisiontoelimi-nateliteratureidentiÞedindatabasesbutnotavailablethroughheruniversityÕslibrarysys-tem,callingtheresultingliteratureaconve-niencesample.Thelevelofinterdisciplinaryappraisalincludedcouldnotbedeterminedbecauseoftheoverallpoordescriptionsoftheliteraturereviewprocessusedforeachanalysis.DefinitionTheconceptofqualityoflifewasde-Þnedin8articles(62%).10,18,19,21,25,27,29Sevenofthe8deÞnitionsviewedqualityoflifeasasubjectiveperception.10,18,21,25,27,29WiththeexceptionofPlummerÕsunidimensionaldeÞnitionÑÒqualityoflifeisanintangi-blesubjectiveperceptionofoneÕslivedexperienceÓ10(p139)ÑallotherdeÞnitionsin-cludedsubdimensions,mostfrequentlysatis-factionandwell-being,orincludedthedo-mainsofphysical,psychological,andsocial.OtherdeÞnitionsincludeduniqueelements:Haasincludedcultureandvalues21,22;Tay-loretalincludeddevelopmentalstage,ill-nesstrajectory,aspirations,andconstraints29;andBondandHahn18includedobjectivephysicalperformance.Haas,22MandzukandMcMillan,24andMeeberg25assertedthatob-jectiveparametersjudgedbyanothercouldbeusedasaproxyincasesinwhichindi-vidualsareunabletosubjectivelyperceive.MeebergÕs25deÞnitionspeciÞedthatotherpeopleshouldcorroboratetheindividualÕsperceptionoflivingconditions.Cooley19de-ÞnedqualityoflifeasÒtheimpactÓofdiseaseandtreatmentinselecteddomains.CriticalattributesForthisanalysis,attributesweredeÞnedasaquality,property,orcharacteristicoftheconcept.Allarticlesreportedcriticalattributes.Welistedandreviewedtheat-tributes,comparedandcontrastedtheitems,andidentiÞedacommontermtorepresentsimilarnotions.The8criticalattributesofqualityoflifeemergingfromthe13re-viewedarticlesweresubjective(arisingfromindividualperception),dynamic(amenableCopyright©2012LippincottWilliams&Wilkins.Unauthorizedreproductionofthisarticleisprohibited.
ANS200133April26,201219:14AnalysesoftheConceptofQualityofLifeinNursingE5tochange),multidimensional(havingplural-ityofelements),valuebased(groundedinindividualsigniÞcance),interactive(abletobecommunicatedandshared),contextual(groundedincircumstance),intangible(lack-ingphysicalindicators),andhealthrelated(belongingtopersonalhealthstatus).IncludedamongattributesidentiÞedinthearticlesweretermsthatcouldmoreaptlybecalleddomains.Forthisanalysis,wedeÞnedadomainasacircumscribedareaofknowledge,experience,oractivityinwhichanattributewouldrevealitself.Fivecoredomainsofqual-ityoflifeemerged:physical,psychological,social,economic,andenvironmental.AntecedentsTheoverarchingantecedentidentiÞedinallthearticlesreviewedwasapersonÕsabil-itytoperformself-evaluation.Thisantecedentpresumesthatlifeispresent,astateofcon-sciousnessexists,andthecognitiveabilitytoperceiveandevaluateisintact.ConsequencesTheconsequenceofbeingabletoself-evaluateisapersonaljudgmentofoneÕsqualityoflife.ThebroaddimensionsofapersonÕsjudgmentincludedsatisfaction,hap-piness,andwell-being.OthermorespeciÞcareasofjudgmentidentiÞedincludedself-esteem,dignity,independence,self-control,harmony,andpotentialforself-actualization.LevelofmaturityWewereabletoidentifysomeagreementsregardingstructuralelementsintheconceptanalysesreviewed,particularlytheareasofat-tributesandantecedents.Areasofdisagree-mentalsowereidentiÞed.Althoughallau-thorsassertedthatqualityoflifehadasub-jectiveelement,fewincludedobjectiveel-ementsandsuggestedthatobjectivevalida-tionofself-evaluationshouldbeincludedindeterminingqualityoflife.Therewasconfu-sionbetweencriticalattributesanddomains,withsomeauthorsreportingdomainsasat-tributes.Therewaslimitedagreementonthedimensionsorscopeofqualityoflife.Satis-faction,happiness,andwell-beingwerefre-quentlycitedasdimensionsinconceptdeÞ-nitionsaswellasbeinglistedasdimensionsofconsequences.Itisnotclearfromthisreviewwhetherthesubjectivenotionofqualityoflifereferstoaseamless,integratedwholepercep-tionorwhetheritisanadditivesumacrossdomains,witheachdomainindependentlyevaluated.INFLUENCEOFFORMSOFANALYSISFourformsofanalysisforconceptshavebeendescribedinnursingandaresumma-rizedintheTablealongwiththeformde-scribedbyWilson.32Theformofanalysisde-scribedbyWalkerandAvant,4basedontheformofanalysisbyWilson,32wasthedom-inantformusedforanalysesoftheconceptofqualityoflife.Thisanalysisformathas8steps:selectaconcept,determineaimsorpurposeoftheanalysis,identifyallusesoftheconceptthatcanbediscovered,deter-minethedeÞningattributes,identifyamodelcase,andidentifyborderline,related,con-trary,inventedandillegitimatecases,iden-tifyantecedentsandconsequences,andde-Þneempiricalreferents.Wilson,32atutorandlectureratOxfordUniversity,designedtech-niquesofanalysisasstudentexercisesaimedatclarifyingdistinctionsamongquestionsofconcept,questionsofmeaning,andotherquestionssuchasthoseoffactversusopin-ion.HeregardedthetechniquesassimpliÞedcomparedwithmorerigoroustechniquesoflinguisticphilosophy,butservingthepurposeofheighteningstudentawarenessintheuseofwordsineverydayuse.Forthepurposeofusingconceptstobuildtheorywithinadiscipline,webelievethatahigherlevelofanalysisrigorisneeded.Conceptsarecontex-tuallybound,suggestingtheneedtoincludeanempiricaldataforgroundingaconceptincontext.Whenconceptsareusedintheory,theyshouldbeanalyzedthroughtheoreticalCopyright©2012LippincottWilliams&Wilkins.Unauthorizedreproductionofthisarticleisprohibited.
ANS200133April26,201219:14E6ADVANCESINNURSINGSCIENCE/APRILÐJUNE2012Table.ConceptAnalysisFormsUsedinNursingbyPhilosophicalUnderpinningsandStepsMethodofConceptAnalysis/AuthorPhilosophicalUnderpinningsConceptAnalysisStepsWilson32Basedonlinguisticphilosophy:Conceptanalysisisnecessaryforeffectivecommunication;methoddevelopedtoidentifyconceptsastheyareusedincommonspeech.Conceptsarecommunicationtoolswithnouniversalmeaning;conceptmeaningsvarybycontext.11-stepprocesstouncoveressentialfeaturesofaconcept:IsolatingquestionsofconceptFindingrightanswersModelcasesContrarycasesRelatedcasesBorderlinecasesInventedcasesSocialcontextUnderlyinganxietyPracticalresultsResultsinlanguageThemodelaswellascontrary,related,borderline,andinventedcasesareusedasevidencetosupporttheessentialfeaturesofaconceptinaparticularcontext.WalkerandAvant4BasedonWilsonÕsmethod32:modiÞedtoassistwiththeoryconstructionratherthantoclarifyconceptsasusedineverydaylanguage.Addedliteraturereview;reducedstepsto8from11;rearrangedorderofsteps.Asaresult,incontrasttoWilsonÕsmethod32inwhichcasesprovideevidenceforthedeÞningattributesoftheconcept,thedeÞningattributesarelistedÞrstandthecaseslast.CasesdonotprovideevidenceofdeÞningattributes,butareillustrations.8-stepprocess.SelectaconceptDeterminethepurposeoftheanalysisIdentifyallusesoftheconceptviabroadliteraturereviewDeterminedeÞningattributesIdentifythemodelcaseIdentifyborderline,related,contrary,andillegitimatecasesIdentifyantecedentsandconsequencesDeÞneempiricalreferentsEvolutionarymethod1Thismethodisdatadrivenandemphasizesaßuidapproachtoconceptanalysis;conceptmeaningschangedependingoncontext.Rejectsphilosophyofessentialismwithitsbeliefthatcertaincontext-independentpropertiesareuniversallypossessedbyagroupÑpeople,things,andideas.Analysesareconsideredinitialandformabasisforfurtherinquiryinacontinuingcycleofconceptdevelopment.Eachanalysisservesasastartingpointforfurtherconceptdevelopment.Thecycleofconceptdevelopmentincludesconceptuse,signiÞcance,andapplication;thiscycleisboundtotimeandcontext.Activitiesarecarriedoutsimultaneously,andthusdonotrepresentspeciÞcsteps.IdentifyingconceptofinterestandassociatedexpressionsIdentifyingandselectinganappropriaterealm(settingandsample)fordatacollectionCollectingdataregardingconceptattributes,alongwithsurrogateterms,references,antecedents,andconsequences(continues)Copyright©2012LippincottWilliams&Wilkins.Unauthorizedreproductionofthisarticleisprohibited.
ANS200133April26,201219:14AnalysesoftheConceptofQualityofLifeinNursingE7Table.ConceptAnalysisFormsUsedinNursingbyPhilosophicalUnderpinningsandSteps(Continued)MethodofConceptAnalysis/AuthorPhilosophicalUnderpinningsConceptAnalysisStepsIdentifyingconceptsrelatedtotheconceptofinterestAnalyzingdataConductinginterdisciplinaryortemporalcomparisons,ifdesiredIdentifyingamodelcaseIdentifyinghypothesesandimplicationsforfurtherdevelopmentPragmaticUnityMethod30Thisdata-derivedmethodisusedtodeterminetheusefulnessofanabstractconcepttosciencebyclarifyingthepurposeoftheinquiry,ensuringvalidity,maintainingbibliographicrecords,identifyingsigniÞcantanalyticalquestions,andsynthesizingresults.Researchersusingthismethodrelyonqualitativedatainpresentingcasesinwhichtheconceptispresent/occurring.Thismethodcommenceswithacomprehensivereviewoftheliterature.IfthedeÞnitionoftheconceptremainsunclearafterthisreview,thenanalysisisundertakenin3phases:IdentifyingconceptattributesVerifyingtheattributesIdentifyingmanifestationsoftheconceptIneachphase,theresearcherusesqualitativedatathatdepictreal-lifeoccurrencesoftheconcept.HybridMethod35Thisdata-derivedmethodisusedtodeÞneaconceptbasedonitsuseinliteratureandinpractice.Usesmethodsthatarebasedonknowledgefrom3domains:sociologytheory,philosophyofscience,andresearchmethods.TheoreticalandempiricalperspectivesofaconceptaresynthesizedtoidentifycoreaspectsofdeÞnitionandmeasurement.Methodinvolves3phases:TheoreticalPhase:Selectaconcept,searchtheliterature,reviewmeaningandmeasurementoftheconcept,andchooseaworkingdeÞnition.FieldworkPhase:SelectaÞeldworksite,negotiateentryintothesite,selectcasesinwhichtheconceptexists,andcollectdata(usuallyviainterviews),andanalyzedata.FinalAnalyticalPhase:SynthesizeÞndingsfromtheprevious2phasesintoadeÞnitionoftheconcept.literature.Noneofthepublishedanalyseswereforthepurposeofclarifyingaconceptwithinatheory,andthususingtheWalkerandAvantformofanalysiswithnoempir-icalgroundingofthestructuralfeaturesoftheconceptappearedinadequate.Themodelandothercasespresentedinthearticlesre-viewedwerecreatedbythearticleÕsauthorsand,givennootherevidence,weconcludedthatasillustrationsthecasesreßectedeachauthorÕsknowledge,clinicalexperiences,andpersonalbiasesÑdescriptionsofwhattheau-thorsimaginedtheconcepttobe,nothowitwasreßectedincontext.Thisobservationsuggestedtousthatresultsofeachconceptanalysisrepresentedwhattheconceptmeanttotheindividualauthorratherthanwhattheconceptmeansinnursing.Ten(77%)Copyright©2012LippincottWilliams&Wilkins.Unauthorizedreproductionofthisarticleisprohibited.
ANS200133April26,201219:14E8ADVANCESINNURSINGSCIENCE/APRILÐJUNE2012publicationsincludedinthisreviewaresingle-authoranalyses.18-23,25-28WalkerandAvantÕsformofanalysisbeginswithlocatingdeÞnitionsoftheconcept,in-cludingdictionarydeÞnitions.4Thetermqual-ityoflifeisnotindictionaries,butseveralofthereviewedpublicationsbeganwithabriefhistoryoftheconcept.Historically,theideaofqualityoflifebeganafterWorldWarII,whenthegovernmentwasinterestedinmonitoringstandardoflivingandusedhousing,income,andotherdemographicdatatodeÞnequalityoflife.10,18,21,23Thisworkwasinßuencedbytheeconomicandsocialsciences,inwhichindicatorsofqualityoflifeincludedmeasuresofsatisfactionandhappiness.Theinßuenceofthisearlyworkcanbeseenintheresultsofthisconceptanalysisreview.In1990,OlesonmodiÞedWalkerandAvantÕsformat.26UsingHusserlÕsphe-nomenologicalmethodasaguide33Ñwithitsassumptionsofpersonsaswholebeings,contextuallysituated,andrealityassubjec-tivelyperceivedÑshenarrowedherlitera-turesearchbyincludingliteratureaddressingonlyqualityoflifeasasubjectiveperceptionandrejectingliteratureaboutobjectivesocialandeconomicindicators.Itbecomesappar-entthatbynarrowingselectionofliterature,theanalysisproceededinapredetermineddirection.BondandHahn18wereconcernedwiththevalue-ladennatureofqualityoflife.Tohelpisolatevalueconßicts,theyaddedavaluesclariÞcationstepthatincluded4questions:(1)Whatisthelogicalnatureoftheconcept?(2)Bywhosestandardsisqualityameasureoflife?(3)HowdoesthetermÒqualityÓrelatetoquantitywhenusedtoevaluatelife?(4)Doqualityandquantityoflifedeterminehealthcaredecision?Questionsaboutthenatureoftheconceptareontological,questionsofmea-surementaremethodological,andquestionsaboutapplicationdecisionsareethical.TheconßictthatBondandHahn18notedreßectsdifferencesinphilosophicalperspectivesrel-ativetoaconcept,notcontradictionsintheconceptitself.TayloretalnotedthatqualityoflifehasbeendeÞnedfrom5perspectives:(1)philosophicalperspectiverelatedtothenatureofhumanexistence;(2)ethicalper-spectivefocusingonthesanctityoflife;(3)aneconomicperspectiverelatedtoeconomicgrowth;(4)asociologicalperspectiveempha-sizingsocialrelationshipsbetweenindividualcircumstancesandculture;and(5)aphysi-ologicalperspectivefromwhichindividualsappraiselifeandfulÞllmentofgoalsinthecontextofphysicalhealth.29Incontrast,theRodgersandKnaß31evo-lutionaryformofconceptanalysisincludesdatacollectionandanalysisinthesteps.Thisformatemphasizesaßuidapproachtoconceptanalysis;conceptmeaningsareas-sumedtochangedependingoncontext.Coo-leyreportedusingRodgerÕsformattoana-lyzequalityoflifeforpatientswithnonÐsmall-celllungcancer,whichwouldappeartobeagoodchoiceforacircumscribedcon-textsuchaslungcancer.19However,theau-thordidnotfollowthestepsoutlinedbyRodgers,mostnotably,relyingsolelyontheliteratureandnotcollectingempiricaldata.TheauthorconcededthatnonÐsmall-celllungdisproportionatelyaffectsAfricanAmericansandolderadults,butthattheliteratureusedinthereview(theonlyliteratureavailable)waspredominatelyaboutwhiteandmiddle-agedadults.19FailuretouseduediligenceregardingtheanalysisformatresultedinÞnd-ingsbasedentirelyonaliteraturethatadmit-tedlydidnotadequatelyreßectthetargetedcontext.TheMorseformofanalysis30wasusedbyPlummerandMolzahn10toanalyzequalityoflifeasitwashistoricallyimbeddedinnursingtheory.Areviewof57yearsofnursingliter-aturelocated26articlespublishedinEnglishbynursetheoristsandincludingqualityoflife.ThetheoristswereParse,Peplau,Leininger,Rogers,andKing.Thiswastheonlyanaly-sisweidentiÞedthatwasgroundedsolelyinnursingtheory.DISCUSSIONAreviewoftheliteraturerevealed13con-ceptanalysesarticlespublishedinEnglishCopyright©2012LippincottWilliams&Wilkins.Unauthorizedreproductionofthisarticleisprohibited.
ANS200133April26,201219:14AnalysesoftheConceptofQualityofLifeinNursingE9between1990and2010onqualityoflifeandhealth-relatedqualityoflifeinnursing.ThereviewidentiÞedacoresetofattributesanddomainsassociatedwiththeconceptofqual-ityoflifeasusedinnursing.Therewasuni-versalagreementthattheprimaryantecedentforqualityoflifewasanindividualÕsabilitytoself-evaluate.Theseresultsoffermuch-neededinsightsintotheconceptofqualityoflifeasitisusedinnursing;however,additionalworkisneededtomorefullyunderstandthecon-ceptinthediscipline.Theexistingworkonqualityoflifeconceptdevelopmentdemonstratedalackofdepth.AsigniÞcantnumberofpublicationsweresingle-authoredbymasterÕs-anddoctoral-levelgraduatestudents,withlittleevidencesuggestingtheauthorscontinuedtopursuequalityoflifewithadditionalresearchorclin-icalworkinthearea.WalkerandAvantÕsformofconceptanalysisprovidesstudentswithanintroductiontotheimportantcon-ceptualworkofbuildingandtestingtheory,anditgivesstudentsaplacetobeginanalyt-icalworkinconceptdevelopment.Singular,student-authoredpublicationsprovidedsnap-shotsofinformationoftenoflimiteddepthortheoreticallinkage.Evenamongmorese-niorauthors,thereappearedtobelittleev-idenceofcontinuedworkinthedevelop-mentofqualityoflifeasaconceptinnursing.Whatisneededaresustainedworksprovidinggreaterdepthofunderstanding.Researchersinvolvedinqualityoflifeworkshouldrevisitthetheoreticalunderpinningsoftheirworkjustastheydowithmethodsandinstrumentsandadjustforanytheoreticaldriftinthecon-ceptofqualityoflife,thus,assuringthattheconceptremainscongruentwiththeresearchtrajectory.ThelevelofmaturityofqualityoflifeinnursingwasdifÞculttojudge.Wheretherewerecommonelements,thecriteriausedforselectingtheliteratureincludedinpublishedanalyseswerenotwelldescribed.Oneau-thorpurposefullylimitedtheliteraturetoin-cludeonlysubjectiveperceptions.25Anotherauthorlimitedtheliteratureusedinthear-ticletowhatwasconvenientlyavailableinherlibrary.20Asaresult,qualityoflifeisde-pictedasaconceptwithwide-rangingmean-ingatthetheoretical,metaparadigmlevel,assuggestedbyPlummerandMolzahn,10andatcontextuallevels,asseeninthemorelim-itedcontextsoflungcancer,urinaryinconti-nence,andadolescentswithchronicillnesses.Matureconceptsarewellunderstood,havecleardeÞnitions,andarewelldifferentiatedfromotherconcepts.3UsingthisdeÞnition,thematurityoftheconceptofqualityoflifeinnursingcanbequestioned.Thelackofduediligenceindiscoveringandgroundingtheconceptofqualityoflifewithinnursinghasresultedinalackofclarityabouthowtheconceptispositionedinnurs-ingrelativetootherdisciplines.Noconceptderivationorsynthesisworkswerelocated,suggestingthatasnursinggainedinterestintheconcept,littletonodevelopmentworkwasdonetoarriveatauniquedisciplinaryperspective.Conceptderivationandsynthe-sismethodsarehelpfulwhenaconceptmustbeinvented,discovered,orobtainedrelativetoaphenomenonofconcern.4TheÞndingsofthisreviewsuggestthatnursingmovedtooquicklytoconceptanalysis,whichinvolvesacriticalappraisalofconceptualizationsaboutaphenomenonthatalreadyexists.3Althoughtruethattheconcepthasexistedsincepost-WorldWarII,itexistedinotherdis-ciplines.Amongthenursingconceptanal-ysisworks,only1analysiswasgroundedinnursingtheoryliterature.10Withnoevi-denceoffundamentalconceptdevelopmentworkattendingtothediscoveryandshap-ingoftheconceptinnursing,itappearsthatourunderstandingofqualityoflifeasaphe-nomenonofconcernfornursingreliesheav-ilyonconceptualizationsfromotherdisci-plines.ThisÞndingsuggeststhatqualityoflifelackssharedmeaninginthedisciplineamongtheorists,researchers,andclinicians.Lackofsharedmeaningiscontributingtothecriticismsofqualityoflifeasundeveloped,5primitive,6andaTowerofBabel.7Whatisneededareworksaddressingconceptsynthe-sisandderivationÑworkgroundedinthedis-ciplinaryperspectivethatshouldbepreludeCopyright©2012LippincottWilliams&Wilkins.Unauthorizedreproductionofthisarticleisprohibited.
ANS200133April26,201219:14E10ADVANCESINNURSINGSCIENCE/APRILÐJUNE2012toconceptanalysis,theorybuilding,andmea-surement.Theboundariesofqualityoflifeinnursingarenotwellagreedon.PublishedanalysesworksreliedheavilyonWalkerandAvantÕsformofanalysisinwhichtheauthorillustratesboundarieswithinventedcasesforwhichnosupportingempiricaldataarepresented.Inconductingthereview,itappearedtousthattheinventedcasesintheWalkerandAvantanalysesreßectedeachauthorÕslevelofknowledgeandinterpretationofthephe-nomenon,asitismanifestinnursing.ThestatedpurposeofmanyoftheconceptanalysesworkswasconceptclariÞcation.Al-thoughsomeanalysesaddressedspeciÞcpa-tientgroups,17-19,28nonewerelinkedtospe-ciÞctheories.Risjord2notedthatthemean-ingofaconceptisthedifferenceitmakesincontextandidentiÞed2formsofconceptanalysis,eachwithitsownpurposeandkindsofevidence.TheaimoftheoreticalconceptanalysisistorepresentconceptsastheyareinscientiÞcliterature(thebodyofrelevantdataisthescientiÞcliterature),andtoanswerquestionsabouthowthetermisdeÞnedinatheory,theinßuenceofthedeÞnitiononotherconceptsinthetheory,andtheabilityoftheconcepttomakepredictionspossible.2Theaimofcolloquialconceptanalysisistorepresenttheconceptasitisforagroupofpeople(therelevantdataarewhatpeoplesayanddo)andtoanswerquestionsabouthowatargetgroupusestheterm.TheunderlyingphilosophicalprinciplesofcolloquialanalysisarethesameasWilsonÕs.32WalkerandAvantÕsformofconceptanalysis,althoughmodeledafterWilson,lackedarich,textureddescrip-tionbecauseitreliedonpublisheddeÞnitionsanduses,notdataderiveddirectlyfromthetargetgroup.Noneoftheanalysesinthisre-viewinvolvingspeciÞcpopulationsincludedevidencedrawnfromcontextsuchasinter-viewswithmembersofthetargetgroup.OnlyDuggerÕsanalysisofqualityoflifeinthecon-textofurinaryincontinenceincludedempiri-calreferentsrelatedtourinaryincontinence;however,theinformationwasalldrawnfromtheliteratureandnotfromthosepersonsex-periencingthecondition.19OtherformsofanalysisÑevolutionarymethod,28pragmaticunitymethod,27andhybridmethod32Ñallcallforempiricevidencesupportingdevel-opmentoftheconcept,yetauthorswhore-portedusinganyoftheseformsofanalysisdidnotincludetargetgroupinterviewdata.ThepredominanceofWalkerandAvantformofanalysiscontributestoagapinunderstandingoftheconceptasitisusedincontext.Conceptsdescribeaphenomenonandaredevelopedusinglanguage.Conceptdevelop-mentisaformofknowledgedevelopment;knowledgeislanguageboundandlanguageisculturebound.Disciplinesserveasatypeofculturalboundaryforcreatingsharedmean-ingwithinadiscipline.Forexample,thecon-ceptofÒreactionÓhasadifferentmeaninginchemistrythanitdoesinnursing.Uniquedis-ciplinarymeaningsofconceptsarerequiredbecausesharedmeaningwithinadisciplinefacilitatesthedevelopmentandadvancementofknowledgeinthediscipline.Manyoftheanalysesworksshowedtheinßuenceofsoci-ology,psychology,publichealth,andmed-icalsciencesonqualityoflife.Qualityoflifeemergedastheworkofsocialscien-tistsinthe1960sevaluatingpublicwelfareandtheimpactofsocialconditionsofhous-ing,healthcare,theeconomy,andotherfactors.18,21,24Nursingwasintroducedtothenotionofqualityoflifethroughthestudyofthesesciences.OurscientiÞcworkrelatedtoqualityoflifehasdependedonadoptingprevailingparadigmsasopposedtodevel-opingdiscipline-speciÞcsharedmeaning.Adisciplineisauniquebranchofknowledge,anddiscipline-basedconceptclarityfacilitatesuniqueknowledgedevelopment.Thisispar-ticularlyimportantinapracticedisciplinelikenursing,inwhichtheultimatepurposeofsci-entiÞcknowledgeistoguidepractice.AnadditionalobservationiswarrantedabouttheWalkerandAvantformofanaly-sissodominantamongthearticlesreviewed.Thereappearstobeaparallelbetweennurs-ingÕsembraceofWilsonÕs32methodofcon-ceptanalysisandourearlieradoptionoftheÒreceivedview,Óaphilosophicalperspectiveofsciencebasedonlogicalpositivism.Web-steretal34arguedthatundueadherencetoCopyright©2012LippincottWilliams&Wilkins.Unauthorizedreproductionofthisarticleisprohibited.
ANS200133April26,201219:14AnalysesoftheConceptofQualityofLifeinNursingE11thepositionsandideasoftheÒreceivedviewÓstiltedthedevelopmentofnursingtheory.Asaphilosophy,itdominatedsciencethroughthe1940stoearly1960s,afterwhich,itwaslargelyrejectedinsidemainstreamphiloso-phy.Atthissametime,nursingwasbeginningitsquestforknowledgegenerationandearlynursescientistspickeduponthephilosophyandbeganshapingnursingsciencealongitsphilosophicaltenets.Withitsrelianceonsim-pledichotomies,itwasnotwellsuitedforstudyingphenomenaofconcerninnursing.Thecoreoftheproblem,however,layinnewnursescientistsbeingoutsidetheÞeldofphi-losophyandnotknowingthattheveryideastheywerestrugglingtoimplementhadbeendiscredited.Themoraleofthestory:Whenworkingwithknowledgegeneratedbyotherdisciplines,itisimperativethatscientistshaveanunderstandingofdisciplinarycon-text.Doeshistoryrepeat?Itappearsthatnurs-ingÕseagerembraceofWilsonÕsformofcon-ceptanalysis,intendedtobeacontributiontoteachingstudentstobetterexplorecommonuseoflanguage,becameapillarofconceptdevelopmentandtheorybuildinginnursingwithoutaclearunderstandingofitspurposeorscope.Thismethodmaybetoolimitedtoclarifycriticalphenomenainthecontextofnursingpracticeandfortheorytesting.CONCLUSIONTheÞndingsofthisreviewsuggestthatcommonbroadattributes,antecedents,andconsequencesofqualityoflifeexistacrosspublishedconceptanalysisarticles.However,theÞndingsmaybesobroadastobeun-helpfulinunderstandingqualityoflifeinnu-ancedpatientgroupsandpopulations.Themajorityofconceptanalysesweresingleau-thoredarticlesusingtheWalkerandAvantformofanalysis,whichdoesnotprovideade-quateempiricalgroundingforidentifyingtheconceptincontext.TheresultthisformofanalysistendstoreßectauthorÕsunderstand-ingoftheconceptasexpressedinmade-upcaseillustrations.Severalanalyseswerelim-itedtonarrowcontextsandtheÞndingssug-gestthatqualityoflifemaynothaveauni-formstructureinallcontexts.Thereisnoagreementonwhetherqualityoflifeisasubjectiveperception,anobjectiveÞnding,orboth.Inconclusion,thissystematicreviewfoundtheneedforamorerobustandrigorousstudyoftheconceptofqualityoflifeincludingallthephasesofconceptdevelopment-Ðconceptsynthesis,derivation,andanalysis.Conceptdevelopmentshouldbeanintegralpartoftheorydevelopment;researchersshouldat-tendtothedevelopment,andmaturationofconceptswithinatheoryasscientiÞcknowl-edgeadvances.Inaddition,thecontextualel-ementsofqualityoflifeÑhowitisexperi-encedbydifferentgroupsofpeopleÑshouldbeexploredandidentiÞed.Itmaybepossi-blefornursingtoarriveatoneoverarchingdisciplinarydeÞnitionofqualityoflife,butthiswilllikelynotbepossibleuntilthereisagreaterin-depthunderstandsfrommultiplecontextsofdiversepatientgroupsservedbynursingpracticeonwhichtodraw.REFERENCES1.RodgersBL.Philosophicalfoundationsofconceptdevelopment.In:RodgersBL,KnaßKA,eds.Con-ceptDevelopmentinNursing:Foundations,Tech-niquesandApplications.Philadelphia,PA:Saun-ders;1993:7-33.2.RisjordM.Rethinkingconceptanalysis.JAdvNurs.2009;65(3):684-691.3.WaltzCF,StricklandPA,LenzER.MeasurementinNursingandHealthResearch.NewYork,NY:Springer;2010.4.WalkerLO,AvantKC.StrategiesforTheoryCon-structioninNursing.4thed.UpperSaddleRiver,NJ:PrenticeHall;2005.5.FerransCE,PowersMJ.PsychometricassessmentoftheQualityofLifeIndex.ResNursHealth.1992;15(1):29-38.6.MastME.DeÞnitionandmeasurementofqual-ityoflifeinoncologynursingresearch:reviewandtheoreticalimplications.OncolNursForum.1995;22(6):957-964.Copyright©2012LippincottWilliams&Wilkins.Unauthorizedreproductionofthisarticleisprohibited.
ANS200133April26,201219:14E12ADVANCESINNURSINGSCIENCE/APRILÐJUNE20127.HaaseJE,BradenCJ.Conceptualizationandmeasure-mentofqualityoflifeandrelatedconcepts:guide-linesforclarity.In:KingPS,HindsCR,eds.QualityofLifefromNursingandPatientPerspective.2nded.Sudbury:Jones&Bartlett;2003:65-91.8.MacduffC.Respondent-generatedqualityoflifemea-sures:usefultoolsfornursingormorefoolÕsgold?JAdvNurs.2000;32(2):375-382.9.BergnerM.Qualityoflife,healthstatus,andclinicalresearch.MedCare.1989;27(3)(suppl):S148-S156.10.PlummerM,MolzahnAE.Qualityoflifeincontem-porarynursingtheory.NursSciQ.2009;22(2):134.11.MalmD,KarlssonJE,FridlundB.Effectsofaself-careprogramonthehealth-relatedqualityoflifeofpace-makerpatients:anursinginterventionstudy.CanJCardiovascNurs.2007;17(1):15-26.12.EdwardsH,CourtneyM,FinlaysonK,ShuterP,Lind-sayE.Arandomisedcontrolledtrialofacommunitynursingintervention:improvedqualityoflifeandhealingforclientswithchroniclegulcers.JClinNurs.2009;18(11):1541-1549.13.McCorkleR,DowdM,ErcolanoE,etal.Effectsofanursinginterventiononqualityoflifeoutcomesinpost-surgicalwomenwithgynecologicalcancers.Psychooncology.2009;18(1):62-70.14.OxmanAD.Checklistsforreviewarticles.BMJ.1994;309(6955):648-651.15.CrowtherM,LimW,CrowtherMA.System-aticreviewandmeta-analysismethodology.Blood.2010;116(17):3140-3146.16.WhittemoreR,KnaßK.Theintegrativereview:up-datedmethodology.JAdvNurs.2005;52(5):546-553.17.CallahanCL.Thequalityoflife.NursOutlook.1970;18(8):19.18.BondAE,HahnPY.Qualityoflifeforcriticalcarepatients:aconceptanalysis.AmJCritCare.1996;5(4):309-313.19.CooleyME.Qualityoflifeinpersonswithnon-smallcelllungcancer:aconceptanalysis.CancerNurs.1998;21(3):151-161.20.DuggerBR.Conceptanalysisofhealth-relatedqualityoflifeinnursinghomeresidentswithurinaryincon-tinence.UrolNurs.2010;30(2):112-118;119.21.HaasBK.Amultidisciplinaryconceptanalysisofqualityoflife.WestJNursRes.1999;21(6):728-742.22.HaasBK.ClariÞcationandintegrationofsimi-larqualityoflifeconcepts.ImageJNursSch.1999;31(3):215-220.23.KleinpellRM.Conceptanalysisofqualityoflife.Di-mensCritCareNurs.1991;10(4):223-229.24.MandzukL,McMillanD.Aconceptanalysisofqualityoflife.JOrthopNurs.2005;9(1):12-18.25.MeebergGA.Qualityoflife:aconceptanalysis.JAdvNurs.1993;18(1):32-38.26.OlesonM.Subjectivelyperceivedqualityoflife.Im-ageJNursSch.1990;22(3):187-190.27.SredlD.Healthrelatedqualityoflife:aconceptanal-ysis.WestAfrJNurs.2004;15(1):9-19.28.McDanielR,BachC.Qualityoflife:aconceptanaly-sis.RehabilNurs.1994;3(1):18-22.29.TaylorRM,GibsonF,FranckLS.Aconceptanal-ysisofhealth-relatedqualityoflifeinyoungpeo-plewithchronicillness.JClinNurs.2008;17(14):1823-1833.30.MorseJM,MitchamC,HupceyJE,TasonMC.Criteriaforconceptevaluation.JAdvNurs.1996;24(2):385-390.31.RodgersBL,KnaßKA.ConceptDevelopmentinNursing:Foundations,Techniques,andApplica-tions.2nded.Philadelphia,PA:Saunders;2000.32.WilsonJ.ThinkingwithConcepts.NewYork,NY:CambridgeUniversityPress;1963.33.KockelmansJJ,HusserlE.EdmundHusserlÕsPhe-nomenology.WestLafayette,IN:PurdueUniversityPress;1994.34.WebsterG,JacoxA,BaldwinB.Nursingtheoryandtheghostofthereceivedview.In:McCloskeyJ,GraceHK,eds.CurrentIssuesinNursing.2nded.London,UnitedKingdom:BlackwellScientiÞc;1985.35.Schwartz-BarrottD,KimSK.Anexpansionandelab-orationoftheHybridModelofconceptdevelop-mentinnursing.In:RodgersBL,KnaßKA,eds.Con-ceptDevelopmentinNursing:Foundations,Tech-niques,andApplications.Philadelphia,PA:Saun-ders;2000:458.Copyright©2012LippincottWilliams&Wilkins.Unauthorizedreproductionofthisarticleisprohibited.
FEATUREARTICLEDevelopmentofaConceptualFrameworktoGuideaProgramofResearchExploringNurse-to-NurseCommunicationJANEM.CARRINGTON,PhD,RNResearchcanbeproblemortheorydriven.Problem-drivenresearchfacilitatesalimitedunderstandingofaphenomenon,andasaresult,itisgenerallynotassoci-atedwithbuildingscience.Theory-drivenresearch,incomparison,permitstheresearchertofocusontheunder-lyingfactorsofaphenomenonandthengeneralizeresultstofurtheradvancethescience.1Theory-drivenresearchisfosteredandstrengthenedthroughtheuseofacon-ceptualframeworkoracollectionofconceptsandas-sumptionsintegratedintoameaningfulconfigurationandfacilitatestheorydevelopment.2,3Aconceptualframe-workthataccuratelyrepresentsanabstractorglobalviewofaphenomenonofinterestcanguideaprogramofresearchandtheorydevelopment.4Thepurposeofthisarticlewastoshowhowtheuseofpreviousre-searchandtheoreticalderivationcanfacilitatethede-velopmentofaconceptualframeworkthatwillservetoguideaprogramofresearchexploringnurse-to-nursecommunication.BACKGROUNDNursinginformaticsmodelsexistintheliterature.5–10Consistentwithgrandtheories,thesemodelsarehighlyabstractandcapturethedisciplinaryknowledgeofnurs-inginformatics;however,theylackthespecificsfortest-ing.11Fewexamplesofconceptualframeworksthatsupporttheorydevelopmentininformaticsexistintheliterature.Thismaybeperpetuatedbythelackofex-amplesintheliteraturedescribingaprocessofconcep-tualframeworkdevelopment.Strategieshavebeendescribedtoguidetheprocessoftheorydevelopmentsuchastheoryanalysis,theorysyn-thesis,andtheoryderivation.12Theusefulnessofeachmethodisdeterminedbytheexistingstagesoftheorydevel-opmentwithintheliterature.Forexample,theoryanalysisCIN:Computers,Informatics,Nursing&June2012293CIN:Computers,Informatics,Nursing&Vol.30,No.6,293–299&CopyrightB2012WoltersKluwerHealth|LippincottWilliams&WilkinsResearchinnursinginformaticshasbeende-scribedasproblembasedratherthantheoryguided.Furthermore,fewexamplesexistintheliteraturewheretheprocessoftheorydevelop-mentisdescribed.Thisarticledescribesapro-cessusedtodevelopaconceptualframeworkthatsupportsatheory-drivenprogramofresearchinnursinginformatics.TheconceptualframeworkcombinesSymbolicInteractionTheoryandInfor-mationTheory.ConstructsofSymbolicInteractionTheory(mind,self,andsociety)andInformationTheory(entropy,negentropy,redundancy,proba-bility,andnoise)werethenorganizedaccordingtoGerbner’sCommunicationModel.Theoryderiva-tionwasthemethodusedfororganizingabstractconstructsandreducingthemtoameasurablelevel.Theoryderivationwassupplementedwithinitialresearchfindings.Themeasurableormiddle-rangeconstructswerethenorganizedinameaningfulmannerforconceptualframeworkdevelopment.Theuseoftheoryderivationtode-velopaconceptualframeworktosupporttheory-drivennursinginformaticsresearchwillbediscussed.Theframeworkentitled‘‘EffectiveNurse-to-NurseCommunication’’thatguidesaprogramofresearchwillthenbepresented.KEYWORDSConceptualframework&Informationtheory&SymbolicinteractiontheoryAuthorAffiliation:CollegeofNursing,UniversityofColorado,AnschutzMedicalCampus,Denver.Theauthorhasdisclosedthatshehasnosignificantrelationshipswith,orfinancialinterestinanycommercialcompaniespertainingtothisarticle.Correspondingauthor:JaneM.Carrington,PhD,RN,13120E19thAve,Room4227,Aurora,CO80045([email protected]).DOI:10.1097/NXN.0b013e31824af809Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
isausefulstrategywhenatheoryhasbeendevelopedandispreparedforfurtherexaminationthroughitsapplica-tionindifferentcontexts.Theorysynthesis,incompar-ison,canbeusedwhenempiricalevidenceexiststosupportthetheorywithintheliterature.Finally,theoryderivationisausefulmethodwhenthereisnoempiricalevidenceforthetheory,andnoprevioustheorieshavebeenfoundsuitabletostudythephenomenonofinterest.12Theconceptualframeworkpresentedinthisarticleisbasedonresearchinwhichdocumentingandreceiv-ingnurseswereinterviewedtoelicittheirperceptionsofthestrengthsandlimitationsusingtheelectronichealthrecord(EHR)tocommunicatepatientstatusassociatedwithaclinicalevent(orchangeinthepatient’scondi-tion).13,14ResearchershaveexploredtheEHR’seffec-tivenessasadocumentationsystem.13–15FewexamplesofresearchexistwheretheeffectivenessoftheEHRasacommunicationsystemwasexplored.TheseresultssuggestthatthereislittleempiricalevidencethattheEHReffectivelysupportsnurse-to-nursecommunication.There-fore,fewtheoriesexisttosupportthisprogramofre-search,andtheoryderivationisthemostsuitablestrategytodevelopaconceptualframeworktofurtherstudytheeffectivenessoftheEHRasacommunicationsystem.METHODSTheprocessoftheoryderivationaccordingtoWalkerandAvant12isafive-stepprocess:(1)reviewofthelit-eratureforcurrenttheories,(2)thinkcreativelytoputtheorytogether,(3)selectparenttheoryforuse,(4)de-terminecontenttobeusedfromparenttheory,and(5)de-veloporredefineconceptsfromparenttheoryforstudyofphenomenonofinterest.12Areviewoftheliteraturewascompletedasthefirststepinthisprocess.Nursescommunicatepatientstatususingthetwocommunica-tionsystems,theEHRandverbal.Verbalchange-of-shiftreportisgenerallybelievedtobebothaneffectivemethodtoexchangerelevantpatientinformationandsupportsteambuildingandprofessionaldevelopment.16–23TheeffectivenessoftheEHRasacommunicationsystemhasbeenexploredwithconflictingresults.TheEHRsupportsfrequentdocumentation,legibility,24–27anddataentry;however,theEHRwasperceivedasnotsupportingcommunicationbynurses.13–15Furthermore,thework-aroundscreatedbynurseswhenusingtheEHRtocom-municatepatientstatushavethepotentialtothreatenorcompletelydisruptnurse-to-nursecommunicationposingathreattopatientsafety.13,14Researchershaveexplorednurse-to-nursecommuni-cationandattemptedtoidentifystrategiestoimprovethecognitiveprocessingofverbalchange-of-shiftreportorthementalprocessingofperceivedinformationandtheirassociatedactions.28MnemonicsorSBAR(situation,background,assessment,andrecommendation)isusedtoincreasecognitiveprocessingandremindthenurseofim-portantpatientinformation.29Additionalresearchsoughttocompareinformationexchangedinchange-of-shiftre-portandthenurses’notesandfoundthatinformationthatoccursfrequentlyinthenursingnoteswasalsomentionedmorefrequentlyinverbalchange-of-shiftreport.29Further-more,thenursingnotescontainedmoreinformationthanthatgiveninchange-of-shiftreport.29Thecorrelationbetweennurse-to-nursecommunica-tionandpatientoutcomeshasyettobeexplored.30–33Unfortunately,thesetwomethodsofnurse-to-nursecom-munication,EHRandverbalchange-of-shiftreport,maybeineffectiveandpotentiallythreatenpatientsafety.2Thisprocesslentsupporttotheuseoftheoryderi-vationforthedevelopmentofaconceptualframeworktosupportthestudyofnurse-to-nursecommunication.Buildingonthisprocess,datawerereviewedfrompastresearchtoidentifyandorganizekeyconceptsandcon-structthetheory.13,14THEORETICALLINKSelectionofaparenttheoryisthethirdstepinthepro-cessofdevelopingaconceptualframeworkusingthe-oryderivation.Thefocusofthisprogramofresearchisnurse-to-nursecommunicationusingtheEHRandwillusehumanfactorsresearchmethodstoultimatelyval-idatetheframework.Humancomputerinteractionisdefinedastheinteractionofthepersonandtechnologywithinhis/herworkenvironmentandcombinescogni-tive,computer,andinformationsciencetoarriveatthede-sign,implementation,andevaluationofapplications.34,35Consistentwiththeelementsofhumancomputerinter-action,theparenttheorymustcontaintheoriesthatallowforthestudyoftheuserandtechnologywithinhis/herenvironment.Informaticsgrandtheoriesdonotmeetthiscriterionastheymodelthegeneralitiesofnursinginfor-maticssuchasorganizinginformaticsresearch,5–8theelementsofthediscipline,9,10andtheroleoftheinforma-ticists.7Therefore,basedonthedatafromthepreviouslydescribedresearch,SymbolicInteractionTheoryandInformationTheorywereselected.SymbolicInteractionTheoryfacilitatestheexplorationoftheuserofthecom-municationsystem.Thecriticalelementofthisresearchiscommunication;therefore,acommunicationtheorywasselected,specifically,InformationTheory.Gerbner’scom-municationmodelorganizestheconceptsinameaningfulmannertostudythecommunicationprocess.SymbolicInteractionTheorySymbolicInteractionTheorywasdescribedbyMead36andfurtherdevelopedbyBlumer.37Initially,Meadheld294CIN:Computers,Informatics,Nursing&June2012Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
thatthekeyconceptstoprocessingandunderstandingcommunicationweremind,self,andsociety.Thesecon-ceptswerefurtherdevelopedbyBlumerandaretheunder-pinningsofSymbolicInteractionTheory.Expandingtheconceptofthe‘‘mind’’fromMead’searlierwork,Blumerproposedthatmeaningsarepro-cessedandmodifiedastheyareencounteredthroughaninterpretativeprocess.Meaningsarecreatedbasedonwhatisintheperson’sworld,suchasphysicalobjects,andotherpeople.Blumer37alsosuggeststhatindivid-ualswillcreatemeaningbasedonorganizationsorin-stitutionsofwhichtheyareamember.Therefore,theconceptofmindthenreferstotheindividual’sinter-pretativeprocessoftheenvironment.Theconceptof‘‘self,’’asdescribedbyMead,36consideredtheindividualcharacteristicsoftheperson.Blumer37describedtheselfashowhumansalsore-spondtothingsonthebasisofthemeaningsthatthethingshavefortheindividualorself.Theconceptofselfisthenconcernedwithhowtheindividualdefineshimself/herselfasinfluencedbycognition,socialposi-tion,pressuresontheself,andgroupaffiliation.‘‘Society,’’thethirdconceptofSocialInteractionTheory,asfurtherdevelopedbyBlumer,37describeshowthepersoninterpretsmeaningbyhis/hersocialinterac-tionswithpeersorcolleagues.Inotherwords,thepersonwillinterpretmeaningbasedonthemeaningsappliedbyhis/herpeersaslearnedthroughsocialinteraction.Theconceptofsocietythensuggeststhatthemeaningsheldbytheindividualcanbeinfluencedwhenamemberofagrouporwhengroupmembershipchanges.FromSymbolicInteractionTheory,thethreecon-ceptsofmind,self,andsocietywillbeappliedtotheconceptualframework.Theseconceptsdescribehowapersoninterpretseventsasinfluencedbyhis/herenvi-ronment,his/heraffiliations,andpeers.InformationTheoryInformationTheory,asdevelopedbyShannon,consistsofthreeelements;thesender,device,andreceiver.38Thesenderconstructsthemessageandusesthedevicetocommunicatewiththereceiver.Entropy,negentropy,redundancy,probability,andnoisearetheconstructsofInformationTheoryandwillbefurtherdescribed.Entropyisameasureoftheuncertaintyastothecontentofthemessageortheinformationcontainedwithinthemessage.Forexample,inthesituationofnurse-to-nursecommunicationofaclinicaleventsuchashypotension,entropywouldbeincreasedifthemes-sagecontainedinformationregardingthepatient’sdiet.If,however,thereceivingnurseenteredveryspecificandrelevantinformationintheEHR,butthereceivingnursedidnotaccesstheinformation,thistoowouldresultinincreasedentropy.Entropyisgreater(orlessinformation)whenthecontentsofthemessagearerandom,ornotaspredictable,andthemeaningofthemessageislessclear.39–41Theantonymofentropyisnegentropyorincreasedinformation.Informationre-ducesentropyandincreasesnegentropy.If,usingthesameexamplefromabove,thereceivingnursedescribedtheclinicaleventandthepatientassess-mentandtheinterventionsinitiated,thiswouldreduceentropyandincreasenegentropy.Furthermore,ifthereceivingnurseaccessedthepatient’sEHRandreadthemessage,thiswouldfurtherreduceentropyorincreasenegentropy.Redundancyoccursinbothverbalandwrittencom-munication.Veryoften,redundantorrepetitiousmes-sagesaresent.Examplesofredundancyincludelengthyandrepetitiousmessages.Nurse-to-nursecommunica-tionisinherentlyredundant.Followingaclinicalevent,thereceivingnursewilldocumentapatientassessment,aprogressnote,andacareplan.Thedocumentingnursewillalsocommunicatewiththereceivingnurseduringchange-of-shiftreport.Thereceivingnursemayreceivetheinformationthroughmultipleentrieswithinthedocumentationsystemandhearthesameinformationduringtheshiftexchangeprocess.Theredundancyin-creasesinformationorincreasesnegentropyandde-creasesentropy.39–41Informationisnotalwaystransmittedaccurately;noisecandistortthecontentormakeitdifficulttointer-pretthemessage.Noiseincreasesuncertainty,resultinginincreasedentropy.38,42Noiseresultswhenthemessageeitherdoesnotreachthereceiverorreachesthearrivesinamannerthatisnotunderstandablebythereceiver.43Iftherespondingnurseentersrelevantinformationregard-ingtheclinicaleventandpatientstatus,butthereceivingnursecannotlocatetheinformationfromwithintheEHR,thisinterruptionincommunicationistheresultofnoiseandincreasedentropybydecreasinginformation.ThefinalelementofInformationTheoryisproba-bility,whichaddressesthelikelihoodofamessagebeingdevelopedandthelikelihoodofspecificsubjectmatter.Closelyrelatedtoentropyoruncertainty,probabilitydis-tributionsdeterminevariousprobabilitiestoanactualmes-sageinagivensetofpossibilities.38–43Entropyincreasesasthenumberofpossiblemessagesthesendercanselectincreases.41Forexample,ifapatientexperiencedaclinicaleventorsuddenchangeincondition,thereceivingnursehasthepotentialofreceivingfewerandmorepinpointedmessages.Thismakesitmucheasiertopredictthemessagesentbythedocumentingnurse,therebydecreasingen-tropy.If,however,thepatientdidnotexperienceasuddenchangeincondition,thereceivingnursehasthepotentialofreceivingseveralmessagesofvariedsubjectmatter.Asaresult,thiscouldincreaseentropy.CIN:Computers,Informatics,Nursing&June2012295Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gerbner’sCommunicationModelGerbner’s44modelofcommunicationservesasamethodoforganizingtheconceptsusedfromSymbolicInter-actionTheoryandInformationTheory.Gerbner44sug-gestedthatcommunicationbeginswithanevent,suchasaclinicalevent.Theresponder,ordocumentingnurse,witnessestheeventanddecidestocommunicatetheeventtoanotherperson.Toeffectivelycommunicatetheevent,thepersonnegotiateselementsofthecom-municationsystem,orEHRandverbalchange-of-shiftreport,andconsiderstheformatofthemessage.Thereceiver,orreceivingnurse,negotiatesthecommunica-tionsystemtoreceivethemessage.Giventhemessage,thereceivercanactontheinformationandcontinuecareforthepatient.Operationalizingthestimulusforcommunicationasaclinicaleventallowsforafocusedexplorationofnurse-to-nursecommunication.Aclinicaleventisde-finedasasuddenandunexpectedchangeinthepa-tient’scondition.13,14Aclinicaleventmaybeaprecursortofailuretorescueordeathduetocomplicationofther-apyandwasderivedfromthelife-threateningcomplica-tionsreportedbySilberetal45andNeedlemanetal.46Thefourthstepintheprocessoftheoryderivationinvolvestheadoptionofthecontentorstructurefromtheparenttheorythatwillbeusedfortheconceptualframework.ThebasicconceptsfromSymbolicInter-actionTheoryandInformationTheoryaremind,self,society,entropy,negentropy,redundancy,andnoise.TheseconceptsarelistedanddefinedinTable1.CONCEPTREDUCTIONDevelopingorrefiningconceptsintermsofthephe-nomenontobestudiedisthefifthandfinalstepintheprocessoftheoryderivation.Conceptrefinementwasdoneusingconceptreduction,whichisaprocessthatmovesconceptsfromaveryabstractleveltoamea-surableoroperationallevelorfromconstructtocon-ceptlevels.Conceptreductionwascompletedusinganagreementprocess.Twoexpertinformaticsandsystemsresearchersjudgedtheprocessuntil100%agreementwasreached.Thesevenconstructspreviouslydescribed(mind,self,society,entropy,negentropy,redundancy,andnoise)areveryabstractandcannotbemeasuredintheircurrentstate.Datafromresearchwerereviewed;constructswereidentifiedandthenreduced.13,14Forexample,mind,self,andsocietyservedasatheoreticallinkandcanbeoperationalizedasperceptionoftheevent.Itemsthatmaydeterminethenurses’perceptionoftheeventwouldbethenurses’perceptionofthepa-tients’acuityduringtheeventandtheirpastexperiencecaringforpatientswithsimilarevents.Theempiricalindicatorsprovideameansofstudyingtheconceptsservingastheinstrumentsormethodofmeasuringtheoperationalcomponents.47Continuingwiththeexampleabove,thetheoreticallinkofmind,self,andsocietyhasbeenoperationalizedtothereceiver’sorresponder’sperceptionoftheevent.Factorsthatmayinfluencethenurses’perceptionoftheeventcouldincludetheperceivedpatientacuityandpastexperiencecaringforpatientswithasimilarevent.Whileeffectivecom-municationisthegoal(concept),itispossiblethatthereisactuallyaspectrumofeffectivecommunicationthatwouldrangefromineffectivetoeffective.Patientsafety(operationalcomponent)istheoutcomeofthestimu-lusandalsocouldrangefromgoodpatientoutcometofailuretorescueevent.Therefore,patientsafetyasanoutcomemayencompassarangeofpatientstatusespostclinicalevent.Congruencebetweentheconepts,or-ganizingoperationalcomponents,empiricalindicators,andtheoreticallinksforeachconceptasillustratedinTable2thengiverisetoaconceptualframework.RESULTSModelDevelopmentDepictionoftheconstructsfurtheradvancestheprocessoftheoryderivationasdescribedbyWalkerandAvant.12Thisstepallowstheresearchertoseethefluidityandconnectivityoftheconstructs,asillustratedinFigure1.AbovethedottedlineinFigure1illustrateshowtheconstructsarelinkedbeginningwiththeeventtotheTable1TheoryConstructsandTheirDefinitionsTermDefinitionMindTheindividual’sinterpretationoftheenvironmentSelfTheindividual’sdefinitionofthemselvesSocietyTheinterpretationsheldbytheindividualasinfluencedbygroupdynamicsEntropyAmeasureoftheuncertaintythereceiverhasaboutwhatinformationmaybecontainedwithinthemessageNegentropyInformationthatinformstheactionsofthereceiverRedundancyMessagesthatarerepetitious,whichincreasesnegentropyProbabilityThelikelihoodofamessagebeingdevelopedandthespecificsubjectmatterNoiseMessagesthateitherdonotreachthereceiverorthatreadthereceiverinamannerthatisnotunderstandable;noiseincreasesentropy296CIN:Computers,Informatics,Nursing&June2012Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
responderperceptionsandcharacteristics,communica-tion,receiverperceptionsandcharacteristics,andfinallytheoutcomeoftheclinicalevent.BelowthedottedlineinFigure1,thefinalstepintheprocessofconceptualframe-workdevelopmentisdepicted.Aclinicaleventisanun-expectedandsuddenchangeinthepatient’sconditionasFIGURE1.EffectiveNurse-to-NurseCommunicationFramework.Arrowsindicatedirectrelationships;curvedlinedepictsconsistencybetweentheconnectedconcepts;straightlinesarelowerconceptsandareanindicationofmoreabstractconstructs;bracketsignifiesrelationshipstoallenclosedvariables.Table2Concepts,OperationalComponents,EmpiricalIndicators,andTheoreticalLinksConceptsOperationalComponentsEmpiricalIndicatorsTheoreticalLinkStimulusClinicaleventAnunexpectedclinicaleventGerbner’sCommunicationModelResponderanalysisRespondingnursePersoncaringforapatientwhohasaclinicaleventSenderPerceptionofeventPatientacuity,nursingprocess,andplanofcareMind,self,societyPersonalcharacteristicsNursingexperienceMind,self,societyPerceptionofverbalcommunicationInformationtocontinuecareMind,self,societyPerceptionofwrittencommunicationsystemStrengths,limitations,potentialsolutionsofelectronicdocumentationwithandwithoutnursinglanguagesEntropy,negentropy,redundancy,probability,noiseSpectrumofeffectivecommunicationElectronicandverbalElectronicdocumentationandverbalchange-of-shiftreportDeviceSystemcharacteristicsImpactoforganizationoncommunicationContextReceiveranalysisReceivingnursePersonwhoassumescareofpatientwithclinicaleventReceiverPerceptionverbalcommunicationInformationtocontinuecareEntropy,negentropy,redundancy,probability,noisePerceptionofwrittencommunicationsystemStrengths,limitations,potentialsolutionsofelectronicdocumentationwithandwithoutnursinglanguagesEntropy,negentropy,redundancy,probability,noisePerceptionofeventPatientacuity,nursingprocessandplanofcareMind,self,societyPersonalcharacteristicsNursingexperienceMind,self,societyStimulusoutcomePatientsafetyResolve,rescueevent,transferGerbner’sCommunicationModelCIN:Computers,Informatics,Nursing&June2012297Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
perceivedbytherespondingRN.TherespondingRN,basedonhis/hercharacteristicsandclassificationoftheevent,willchoosetocommunicatetheeventanddeterminethemessage,usingtheEHRandverbalchange-of-shiftreport.Thecharacteristicsofthesystemmayinfluencecommunication,unitculture,forexample.ThereceivingRNreceivesthemessageand,basedonhis/hercharacter-isticsandclassificationoftheeventandmessage,willcontinuecare.Adiagramhasbeenusedtoillustratetheconcepts,operationalizations,andtheirsuggestedrela-tionships.Thismodelsuggeststhatpersonalcharacter-isticsofboththerespondingandreceivingnursesandhoweachclassifiestheclinicaleventshaveanimpactonthecommunicationsystem(verbalchange-of-shiftreportandtheEHR)andthenpatientsafetyoutcomes.Directrelationshipsareindicatedbyarrows.Thecurvedlinedepictsconsistencybetweentheconnectedconcepts.Straightlinesarelower,moreabstractconcepts.Thebracketisusedtosignifythattherearerelationshipsbetweenallenclosedvariables.Twopointsshouldbemaderegardingtheillustrationoftheconceptualframework.First,theconceptualframeworkislinear.Themodelpresumesthatthere-sponderandreceiver(basedontheirindividualcharac-teristics)mayperceivetheclinicaleventdifferentlybasedontheirindividualcharacteristicsandthateffective,con-sistentcommunicationwillhelptoalleviatethisdif-ferenceinperceptions.Second,themodelhypothesizesthatconsistentcommunicationwillresultinapositiveclinicaleventoutcome.AssessmentoftheConceptualFrameworkThefinalphaseisdeterminationofthevalidityoftheconceptualframework.First,consistentwiththeintentofaconceptualframework,thismodelreflectsacol-lectionofconceptsandassumptionsthatareintegratedintoameaningfulconfigurationoftheprocessofnurse-to-nursecommunicationofaclinicaleventandincludespatientoutcomesandmayserveasaguidetowardnurs-inginformaticstheorydevelopment.2–4Second,thecon-ceptualframeworkcanbeassessedforitsusefulnesstosupportnursingresearch.Aligningthenursingparadigmwiththeconstructsoftheconceptualframeworkcanperformthisassessment.Thenursingparadigmconsistsofpatient,nurse,health,andenvironment,andeachisrepresentedintheconceptualframework.48Thiscon-ceptualframeworkhasoperationalizedtheseconstructsasclinicalevent(patient),respondingandreceivingnurse(nurse),health(clinicaleventoutcome),andcommuni-cationsystem(environment).Theconceptualframeworkcontainsthenursingparadigmthatisfurtherevidenceofthemodel’susefulnessfornursingtheorydevelopment.Third,thismodelhasbeenvalidatedbyexpertinfor-maticsandsystemsresearcherswhoreviewedthepro-cessofframeworkdevelopmentuntil100%agreementwasreached.Finally,themodelthenneedstobetestedusingnursingresearch.Usingqualitative,quantitative,ormixedresearchmethods,thefollowingresearchques-tionscouldbeaskedtofurthertesttheconceptualframe-work.Doesthemannerinwhichnursesclassifyclinicaleventsinfluencecommunicationpatternsandpatientoutcomes?Whatnursecharacteristicsinfluencetheirclassificationofaclinicalevent?Thepurposeofthisar-ticlewastodemonstratetheprocessofdevelopingaconceptualframework.SummaryThepurposeofthisarticlewastodescribetheprocessofdevelopingaconceptualframeworkusingthepro-cessoftheoryderivationusingintegratedtenetsfromSymbolicInteractionTheory(mind,self,andsociety)andInformationTheory(entropy,negentropy,redun-dancy,andnoise)andGerbner’s44communicationmodeltoguideaprogramofresearch.Theprocessoftheoryderivationbeganwiththeidentificationofconceptsfromresearch.Then,usingthemethoddescribedbyWalkerandAvant,12conceptswerelinkedtoeachother,demonstratingthehigherleveloftheprocessofcom-munication.12Theconceptswerethenorganizedhier-archicallybylevelofabstraction.Finally,theconceptswereoperationalizedanddefinedandillustratedwithproposedrelationships.Thedevelopedconceptualframe-workisconsistentwiththedefinitionpresentedandcontainstheconstructsofthenursingparadigm(patient,nurse,health,environment),supportingitsusefulnessforgeneratingnursinginformaticstheory.Thisconceptualframeworkwasfoundtobesuitableforguidingapro-gramofresearchexploringnurse-to-nursecommunica-tion.Thisarticleaddstothebodyofnursingandnursinginformaticsknowledgebyguidingthereaderthroughaprocessofframeworkdevelopmentfortheory-drivenre-searchandinformaticsresearch.AcknowledgmentsTheauthorthanksJoyceA.Verran,PhD,RN,FAAN,forassistanceinthedevelopmentandreviewofthemanuscriptandSuzanneLareau,MS,RN,FAAN,forreviewingthismanuscript.REFERENCES1.VerranJ.Thevalueoftheorydriven(ratherthanproblem-driven)research.SeminNurseManag.1997;5(4):169–172.2.HuckabayL.Theroleofconceptualframeworksinnursingpractice,administration,education,andresearch.NursAdminQuart.1991;15(3):17–28.3.NyeEI,BerardoFM.EmergingConceptualFrameworksinFamilyAnalysis.NewYork:Macmillan;1966.298CIN:Computers,Informatics,Nursing&June2012Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
4.JohnsonDE.OneConceptualModelofNursing.PaperpresentedatVanderbiltUniversity,Nashville,TN;1968.AscitedinMeleisA.TheoreticalNursing:DevelopmentandProgress.3rded.Philadelphia,PA:Lippincott;1997.5.EffkenJA.Anorganizingframeworkfornursinginformaticsresearch.ComputInformNurs.2003;21(6):316–325.6.GoosenW.Nursinginformaticsresearch.NursRes.2000;8(2):42–54.7.GravesJR,CorcoranS.Thestudyofnursinginformatics.ImageJNursSch.1989;21:227–231.8.StaggersN,ParksPL.DescriptionandinitialapplicationsoftheStaggers&ParksNurse-ComputerInteractionFramework.ComputNurs.1993;11(6):282–290.9.SchwirianP.NIpyramid:amodelforresearchinnursinginformat-ics.ComputNurs.1986;4:134–136.10.TurleyJP.Towardamodelfornursinginformatics.ImageJNursScholarsh.1996;28(4):309–313.11.HigginsPA,MooreSM.Levelsoftheoreticalthinkinginnursing.NursOutlook.2000;48(4):179–183.12.WalkerLO,AvantKC.StrategiesforTheoryConstructioninNursing.4thed.NewJersey:PrenticeHall;2004.13.CarringtonJM.Theeffectivenessoftheelectronichealthrecordwithstandardizednursinglanguagesforcommunicatingpatientstatusre-latedtoaclinicalevent.DissAbstrInt.2008;69(03):AAT3297974.14.CarringtonJM,EffkenJA.Strengthsandlimitationsoftheelectronichealthrecordfordocumentingclinicalevents.ComputInformNurs.2011;29(6):360–367.15.AshJS,BergM,CoieraE.Someunintendedconsequencesofinfor-mationtechnologyinhealthcare:thenatureofpatientcareinforma-tionsystem-relatederrors.JAmMedInformAssoc.2004;11:104–112.16.NorbergA,AsplundK.Patternsofspeech.NursTimes.1987;83:64–67.17.WolfA.Nursingrituals.CanJNursRes.1988;20:59–69.18.JordanP.Psychiatricwardhand-overs.NursTimes.1991;87:40–42.19.ParkerJ,GardnerG,WiltshireJ.Handover:thecollectivenarrativeofnursingpractice.AustJAdvNurs.1992;9:31–37.20.HollandK.Anethnographicstudyofnursingcultureasanex-plorationfordeterminingtheexistenceofasystemofritual.JAdvNurs.1993;18:1461–1470.21.LiukkonenA.Thecontentofnurses’oralshiftreportsinhomesforelderlypeople.JAdvNurs.1993;18:1095–1100.22.McMahonB.Thefunctionofspace.JAdvNurs.1994;19:362–366.23.SherlockC.Thepatienthandover:astudyofitsform,functionandefficiency.NursStand.1995;9:33–36.24.DennisKE,SweeneyPM,MacdonaldLP,MorseNA.Pointofcaretechnology:impactonpeopleandpaperwork.NursEcon.1993;11(4):229–248.25.HammondJ,JohnsonHM,VarasR,WardCG.Aqualitativecomparisonofpaperflowsheetsvs.acomputer-basedclinicalinformationsystem.Chest.1991;99:155–157.26.KorstL,Eusebio-AngejaA,ChamorroT,AydinC,GregoryK.Nursingdocumentationtimeduringimplementationofanelectronicmedicalrecord.JNursAdm.2003;33(1):24–30.27.SmithK,SmithV,KrugmanM,OmanK.Evaluatingtheimpactofcomputerizedclinicaldocumentation.ComputNurs.2005;23(5):132–138.28.RiesenbergLA,LeitzschJ,LittleBW.Systematicreviewofhandoffmnemonicsliterature.AmJMedQ.2009;24:196–204.29.LamondD.Theinformationcontentofthenursechangeofshiftreport:acomparativestudy.JAdvNurs.2000;31(4):794–804.30.BuddHR,AlmondLM,PorterKA.AsurveyoftraumaalertcriteriaandhandoverpracticeinEnglandandWales.EmergMedJ.2007;24:302–304.31.HaigKM,SuttonS,WhittingtonJ.SBAR:asharedmentalmodelforimprovingcommunicationbetweenclinicians.JtCommJQualPatientSaf.2006;32:167–175.32.HorwitzLI,MoinT,GreenML.Developmentandimplementa-tionofanoralsign-outskillscurriculum.JGenInternMed.2007;22:1470–1474.33.TalbotR,BleetmanA.Retentionofinformationbyemergencydepartmentstaffatambulancehandover:dostandardizedap-proacheswork?EmergMedJ.2007;24:539–54234.MyersB,HollanJ,CruzI.Strategicdirectionsinhuman-computerinteraction.ACMComputSurv.1996;28:794–809.35.StaggersN.Human-computerinteraction.In:EnglebartS,NelsonR,eds.InformationTechnologyinHealthCare:AnInterdisciplinaryApproach.NewYork:HarcourtHealthScienceCompany;2001:321–345.36.MeadH.Mind,Self,SocietyFromtheStandpointofaSocialBehaviorist.MorrisCW,ed.Chicago,IL:UniversityofChicagoPress;196737.BlumerH.SymbolicInteractionismPerspectiveandMethod.Berkley,CA:UniversityofCaliforniaPress;1969.38.ShannonCE.Themathematicaltheoryofcommunication.In:ShannonCE,WeaverW,eds.TheMathematicalTheoryofCom-munication.Chicago,IL:UniversityofIllinoisPress;1967:31–125.39.Campbell,J.GrammaticalMan:Information,Entropy,Lan-guage,andLife.NewYork,NY:Simon&Schuster,Inc;1982.40.CloverTM,ThomasJA.ElementsofInformationTheory.2nded.Hoboken,NJ:JohnWiley&Sons,Inc,Publications;2006.41.PierceJR.AnIntroductiontoInformationTheorySymbols,Sig-nals,andNoise.2nded.NewYork:DoverPublications;1980.42.WeaverW.Recentcontributionstothemathematicaltheoryofcommunication.In:ShannonCE,WeaverW,eds.TheMathematicalTheoryofCommunication.Chicago,IL:UniversityofIllinoisPress;1967:3–28.43.RezaFM.AnIntroductiontoInformationTheory.NewYork:DoverPublications;1994.44.GerbnerG.Towardageneralmodelofcommunication.AVRev.1956;171–195.45.SilberJH,WilliamsSV,KrakauerH,SchwartzJS.Hospitalandpatientcharacteristicsassociatedwithdeathaftersurgery:astudyofadverseoccurrenceandfailuretorescue.MedCare.1992;30(7).615–629.46.NeedlemanJ,BuerhausP,MattkeS,StewartM,ZelevinskyK.Nurse-staffinglevelsandthequalityofcareinhospitals.NEnglJMed.2002;346:1715–1722.47.DulockH,HolzemerW.Substruction:improvingthelinkagefromtheorytomethod.NursSciQ.1991;4(2):83–87.48.Fawcett,J.AnalysisandEvaluationofContemporaryNursingKnowledge.Philadelphia,PA:F.A.DavisCompany;2000.CIN:Computers,Informatics,Nursing&June2012299Copyright 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ResearchArticleConceptDevelopmentof“NursingPresence”:ApplicationofSchwartz-BarcottandKim’sHybridModelFatemehMohammadipour,PhD,1,2ForoozanAtashzadeh-Shoorideh,PhD,3,*SoroorParvizy,PhD,4MeimanatHosseini,PhD51SchoolofNursing&Midwifery,ShahidBeheshtiUniversityofMedicalSciences,Tehran,Iran2LorestanUniversityofMedicalSciences,Khorramabad,Iran3DepartmentofNursingManagement,SchoolofNursing&Midwifery,ShahidBeheshtiUniversityofMedicalSciences,Tehran,Iran4Nursing&MidwiferySchool,IranUniversityofMedicalSciences,Tehran,Iran5DepartmentofCommunityHealthNursing,SchoolofNursing&Midwifery,ShahidBeheshtiUniversityofMedicalSciences,Tehran,IranarticleinfoArticlehistory:Received29June2016Receivedinrevisedform6January2017Accepted11January2017Keywords:QualitativeResearchNurse-PatientRelationsHumanismPatientSatisfactionsummaryPurpose:Althoughnursingpresenceisafoundationforprofessionalnursingpracticeandhasknownpositiveoutcomessuchaspatientsatisfactionandrecovery;itisnotwellknown.Theambiguitysur-roundinghowtodefinenursingpresencehaschallengeditsevaluationandeducation.Therefore,inanattempttodiscoverattributesofthisunderdevelopedconceptandstudyingitinanewcontext,conceptdevelopmentisessential.Thepurposeofthisstudywastoclarifytheconceptofnursingpresencethroughconceptdevelopment,toproduceatentativedefinitionofthissubjectiveconceptinclinicalpractice.Methods:ConceptdevelopmentwascarriedoutusingSchwartz-BarcottandKim’shybridmodelincluding,theoretical,fieldworkandfinalanalysisphases.First,29relatedarticlesavailableontheda-tabasesfrom1990e2015werereviewedandanalyzed.Then,22interviewswereconductedwith19participants,followedwithinductivecontentanalysis.Atlast,anoveralldefinitionwasperformed.Results:Nursingpresencecanbeexplainedasco-constructedinteractionidentifiedbydeliberatefocus,task-oriented/patient-orientedrelationship,accountability,clarification,andubiquitousparticipation.Nursingpresencerequiresclinicalcompetence,self-actualization,reciprocatingopenness,andconduciveworkingenvironment.Worthwhilecommunications,balance/recovery,andgrowthandtranscendencearethemainconsequencesofthisconcept.Conclusion:Co-constructedinteractionunderscoredthevalueofthenursingpresenceasanintegralcomponentofcaringwithhumanisticandpatient-centeredapproaches.Thefindingscouldhelpclinicalnurseshaveabetterunderstandingofthenursingpresence.Findingsalsocanimproveeducators’andmanagers’knowledgefordevelopingandconductingappropriateeducationstrategiesandcaringac-tivitiestofacilitatethepromotionofnursingpresence.©2017KoreanSocietyofNursingScience,PublishedbyElsevierKoreaLLC.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).IntroductionNursescanprovidealinkbetweentheimpersonaltechnologicalworldandthehumanworldthroughtheirprominentroleinthehealthcaresystem;however,developingandpromotinghuman-isticapproachescompriseamajorchallengefornurseeducatorsandmanagers[1].Humanismisafar-reachingmovementinphi-losophyandpsychologythatrecognizesthepersonalandsubjectivedimensionsofthehumanexperienceascentraltoknowingandvaluing,anditisalsoafundamentalvalueinmanynursingtheoriessuchasHumanisticNursingPractice,HumanCaring,andHumanBecoming[2].PatersonandZedradconsiderexistentialinvolvement,comprisedofhavingthepresence,toformnursingaction[3].Parsebelievesthattruepresenceofanursewiththepatientgivesapersonalsignificancemeaningtothesituation[4].Watsonarguesthatnursesuseamethodofbeingor“presence”insteadofusingasetofbehaviorsforperforminginterventions[5].Nursingpresenceisanessentialaspectofcare:abasicconceptinallnursinginterventions;vitalforpatientsafetyandthenursingprocess[3].Itisacomplexconceptthatwasfirstintroducedinto*Correspondenceto:ForoozanAtashzadeh-Shoorideh,PhD,DepartmentofNursingManagement,SchoolofNursing&Midwifery,ShahidBeheshtiUniversityofMedicalSciences,Vali-AsrAvenue,NiayeshExpy,Tehran,Iran.E-mailaddress:f_atashzadeh@sbmu.ac.irContentslistsavailableatScienceDirectAsianNursingResearchjournalhomepage:www.asian-nursingresearch.comhttp://dx.doi.org/10.1016/j.anr.2017.01.004p1976-1317e2093-7482/©2017KoreanSocietyofNursingScience,PublishedbyElsevierKoreaLLC.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).AsianNursingResearch11(2017)19e29
thenursingliteraturein1962[5];however,manyofitsdimensionsremaintobefullydescribed,determined,orunderstood[5e7].Studieshavedefinedpresenceasaninterpersonalandinter-subjectiveexperiencethatchangesthenurseaswellasthepa-tient[6].Nursingpresencehasalsobeenassociatedwithlisteningandtouch[5],describedasahumanisticqualityofrelating[7].Itisalsoconfusedwithconceptssuchasmutuality,compassion,sup-port,empathy,nurturance,andtherapeuticuseofself[8],andoc-casionally,itisarguedthatthisconcepthasthesamebasicattributesastheartofnursingandcaring,andshould,therefore,becombinedwiththem[9].Despiteitslackofacleardefinition,nursingpresenceformsthecentralconceptofseveralothernursingtheories[5].Althoughmorestudiesareneededtoconfirmwhathappensifnursingpresenceismingledwithsimilarconcepts,studieshaveshownthattheambiguityandmultipledefinitionsofnursingpresencehaveimportanteffectsonitseducation,research,andpractice[7,10e12].Innursingeducation,whileprofessionalexpectationsareconsistentwiththeconceptofnursingpresence[7],nursingpres-enceisachallengingconceptfornursingstudentstograspandimplement[10].Therefore,introducingandteachingnursingpresencecomponentsearlyinthebaccalaureatenursingcurricu-lumwillemphasizetheessentialvalueofrelationalengagementwithclients[7].Inresearch,severalstudieshaveidentifiedpositiveoutcomesinrelationtotheexperienceofnursingpresencesuchasdecreasedincidenceofpressureulcersandfalls[3],improvedstress,cortisollevels,problem-focusedcoping[13],andpatientsatisfaction[14,15]afterapplicationofanursingpresenceprogram.Indeed:accordingtoambiguitiesaroundtheconceptofnursingpresence,thereislittleagreementonnursingpresenceprograms.KostovichandClementidevelopedanursingpresencetrainingprogramwhichfocusedonthe“beingwith”roleofthenursesduringapatientcareencounter.Thisprogramfocusedonthepresentationsincludedinformationaboutcaringforpatientssuchasrelationshipbuilding,providingassurance,respect,truthfulness,patient-centeredproblem,holisticcare,andoutcomeofcare[3].InPenqueandKearney’sstudy,nurseswereinstructedandeducatedtoapplytheselectedtechniquefornursingpresencesuchasusingthesmilingandemotingpositiveenergy,mindfulnessmeditation,breathforcentering,guidedim-agery,holdingsilencewithapatient,andactivelistening[14].AnandJo’snursingpresenceprogramfocusedonreinforcingtheestablishmentofhumanrelationships,usingempathy,activelistening,andidentifyingnonverbalcommunicationmessages[13].Infact,despitethemethodsmeasuringtheoutcomesofnursingpresence,theyaremeaninglessiftheoccurrenceofpresenceitselfisnotidentifiedorclarifiedastheintervention[11].Inpractice,someotherstudieshaveshownthatnursingpres-encehasaprofoundeffectonthehealingprocess[3,10,12],andreductioninnursingpresencehasbeenfoundtoincreaseaggres-sionamongpatientsandviolencetowardsstaffandmaycauselonelinessandanxietyforthepatients[7,12].However,studieshaverevealedunfavorablelevelsofcommunicationbetweenpatientsandnurses,andonly32.8%ofnursingcarewasdirectcareand,67.2%wereothertypesofcare[15].InIran,moststudiesconductedontheevaluationofpatientsatisfactionimplythatnursingserviceshavenotbeenabletofullysatisfypatientexpectations[15e17].Accordingtosomestudiesonpatientsatisfaction,takingintoac-countvariousaspectsofcaringbehavior,ithasbeenshownthatthehighestmeanofpatientsatisfactionwasonlyrelatedtotechnicalaspectofcaringbehavior[3,14,15].However,mostpatientshavestatedtheirimportantneedasnursingpresence[15,17].Thisperspectivewascontrarytotheviewsofnursesthathadclassifiednursingpresenceamongtheleastimportantcaringbehavior[15].OtherstudiesconcerningthequalityofcareinIranindicatethathumanisticnursingpresenceisdescribedbypatientsasqualityofnursingcare[17].Giventheeffortsmadeinseveralstudiestoclarifytheconceptofnursingpresence[3,6,9,12],itcanbeinferredthatalthoughthenecessityandbenefitsofnursingpresenceastheessenceofnursingcare[5]areacknowledged,themeaninganddimensionsoftheconceptremaincontroversialandaredeemedworthyofattentioninnursingpractice[3,10].AsParsearguesthatavarietyoffactorscancontributetoanimprovednursingpractice,knowledgeisthemainelementthathelpsnursestomeettheirobligationstowardshumanity[4].Itis,therefore,necessaryfornursestounderstandandembracetheconceptofnursingpresenceandacknowledgeitsimportancebeforetheycanaffectchangesintheirbehavior[3].SomeauthorsusedconceptanalysistoresolvetheambiguitiesofnursingpresenceviaWalkerandAvant’sstrategy[9,11].Unfor-tunately,thismethodofconceptanalysisisanintegrationofwhatisknownaboutaconceptataspecialpointintimeandlimitedinthatitdoesnotproducenewideasorinsight[18].However,inconceptdevelopment,theoreticalanalysisoftheliteratureandtheanalysisofempiricaldataarecombinedtorefine,analyze,anddefinetheconceptofinterest[19].Conceptdevelopmentisespeciallyusefulwhenstudyingaconceptinanewcontext[18].Applyingbothempiricalandtheoreticaldataovercomesthelimitationsofconceptanalysisandprovidesacomprehensivecontext-baseddefinitionoftheconcept[19].Sincenursingpresencepossessesdifferentmeaningsfordifferentindividualsdependingontheculturewithinwhichtheyliveortheirdegreeofdevelopment[5,14]andaccordingtodisagreementamongresearchersaboutthedefinitionoftheconcept,conceptdevelopmentcanbeusedtoresolvetheambi-guitiesregardingtheconceptofnursingpresenceanditsuseinclinicalcare.Astheprominentfeatureofthehybridmodelforconceptdevelopmentliesinitsstageoffieldwork[19]andsincethisstudyaimstoshowessentialcharacteristicsandoperationaldefinitionofnursingpresenceinanewcontext,thehybridmodelwouldbethebestmethodtochoose[18].Thevoicesadvocatinghumanisticcareandemergingaspartoftheknowledgederivedfromthehistoryandculturesofdifferentsocietiesinfluenceopenlyencouragingandsupportinghumanrightsforguidingsocialandethicalbehaviorstowardstheactual-izationofhumanpotentialswithinorganizationsandsocieties[1].Therefore,thepresentstudywasconductedtodeveloptheconceptofnursingpresenceinIraniansocietytopromoteanunderstandingofthisconceptinapplicationtothequalityofcare.MethodStudydesignThehybridmodelconsistsofthreestagesoftheoretical,fieldworkandanalyticalphasesaccordingtoSchwartz-BarcottandKim’smethod[19],selectedasthemostappropriateapproachtoconceptdevelopment(seeFigure1forasummaryofthestudydesign).DatacollectionandprocedureThefirstpartofthestudywasperformedasasystematicreviewdevelopedbasedonthestagesproposedbytheCentreforReviewsandDissemination’s(CRD)guidanceforundertakingreviewsinhealthcare[20].Beforebeginningthereview,aprotocolwasdevelopedwiththefollowingcomponents:1.Thereviewquestion:Howisnursingpresencedescribed?Howcannursingpresencebemeasured?F.Mohammadipouretal./AsianNursingResearch11(2017)19e2920
2.Articletypes:Thepresentstudyreviewedeveryoriginalarticlepublishedonthesubjectofnursingpresenceincludingquanti-tative,qualitative,meta-analysis,meta-synthesis,exemplar,mixedmethod,andinstrumentdevelopmentstudies.3.Searchstrategy:Thesearchwascarriedoutusingkeywordssuchaspresence,presencing,present,incombinationwithhealing,therapeutic,true,caring,andnurseornursinginelectronicda-tabasesofPubMed,CINAHL,Medline,andProQuestdatabasesandPersiandatabasesforarticlespublishedbetweenJanuary1st,1990andJuly31st,2015,usingthesearchoptionsprovidedineachdatabaseandEndNotesoftware.Theinclusioncriterionusedforselectingthearticlewashavingkeywordsinthetitle,abstract,orlistofkeywords.Exclusioncriterionwaspublishingthearticlesinnon-Englishandnon-Persianlanguage.Theinitialsearchyielded301articles.Aftereliminatingrepeatedtitles,86articlesremained.Followingreviewoftheab-stractsandtheapplicationofinclusionandexclusioncriteria48ofwhichwereirrelevantandwerethusexcluded.Thefulltextsoftheremaining38articleswerereviewed.Then,theTransparentReportingofEvaluationswithNon-randomizedDesigns(TREND)checklistwasusedtoassessthequalityofthequantitativearticlesFigure1.MajorcomponentsofthestudydesignbasedonSchwartz-BarcottandKim’shybridmodel.Figure2.Theflowchartofdecisionsmadeforselection,criticalappraisalanddataextractionfortheoreticalphase.Note.COREQ¼consolidatedcriteriaforreportingqualitativeresearchchecklist;TREND¼transparentreportingofevaluationswithnonrandomizeddesignschecklist.F.Mohammadipouretal./AsianNursingResearch11(2017)19e2921
andtheConsolidatedcriteriaforReportingQualitativeresearch(COREQ)checklistforthequalitativearticles[20].Atthisstage,12articleswereexcludedand26articlesremained.Tocompletethesearch,thereferencesattheendofeacharticlewerealsoreviewed.Thisstepofthesearchledtotheselectionofthreeadditionalar-ticles,makingatotalof29articles(SeeFigure2forasummaryofthisprocessbasedonthePRISMAflowchart).Inthesecondphase,qualitativedatawerecollectedthroughin-depthinterviews.Giventhereciprocatingnatureoftheconceptofpresence,thefieldworkphasebeganwithfivenurse-patientdyads.Consideringpotentialdifferencesintherulesandregulationsfordifferenthospitalsandtoensuremaximumvariability,publicteachinghospitalsandhealthcarecentersaffiliatedwithotherpublicandprivateinstitutionsweresampled.Theinterviewswereconductedwithpatientsfromdifferentethnicitiesanddifferentmedicalcondition(generalinformationaboutparticipantsareprovidedinTable1andTable2).Togainarichunderstandingofthenatureofnursingpresence,othersourcesofdatasuchasmedicalrecordsandinterviewswiththetwonursemanagersandtwofacultymemberswereincluded(generalinformationabouttheseinformantsareprovidedinTable2).Participantswereselectedthroughpurposefulsampling.Theinclusioncriteriaconsistedofhavingthephysicalabilitytoparticipateinthestudy,minimumageof18,theabilitytoreadandwriteandholdverbalcommunication,awillingnesstotakepartandconsentingtobeinginterviewed,aminimumhospitalstayoftwodays,andtheabilitytodistinguishbetweennursesandotherserviceproviders,andnurses’willingnesstoparticipateinthestudywhilehavingaminimumofbachelor’sdegree.AfterobtainingtheapprovaloftheEthicsCommitteeaswellasinformedwrittenconsentsandpermissiontorecordtheinterviewsfromtheparticipants,semi-structuredinterviewswereconductedwiththeparticipantsusingtheinterviewguide.Basedonthemainaimofthestudy,theinterviewbeganwithanopenquestion.In-terviewswithpatientswereconductedseparatelyfromnursesinaprivatesecludedareaoftherestingroominthehospitalward.Interviewswithnurseswereconductedinasecludedareaoftherestingroom.Interviewsbeganwiththenurseswithgeneralquestionsabouttheirworkshiftandwiththepatientswithques-tionsaskingtodescribeadayatthehospital.Thefocuswasthenturnedtotheconceptofnursingpresence.Thefollowingquestionsweregiventotheparticipants:“Pleasesharewithmeyourexpe-riencesaboutnursingpresenceifthereareany?”“Wouldyoudescribeyourperspective,feeling,andthinkingasyouexperiencedthem?”“Whatwillhappenwhilehavinganursingpresenceexperience?”“Whatarethecharacteristicsofnursingpresence?”“Pleasedescribeapersonwhodoesnothavethepresence?”Concurrentlywiththeinterviews,fieldnotes(includingtheo-retical,methodological,andobservationalnotes)basedonSchwartz-BarcottandKim[19]weretakenduringtheobservationsmadebynurse-patientinteractions.Forthegreaterclarityandcomprehensivenessofthedataandtheemergedcategories,twoparticipantswereinterviewedtwice,makingforatotalof21in-terviewswith19participants.Thedurationoftheinterviewsvariedfrom25to70mindependingonparticipants’circumstancesandinterestindescribingtheirexperiencesandperceptions.Theobservationsandinterviewswereconductedoveraperiodof5months(fromApriltoAugust2015).Datasaturationoccurredwiththe16thinterview;however,forgreaterrigorofthedatafurtherinterviewswereconductedalthoughresultinginnonewdata.Inthefinalanalyticalphase,findingsfromthetheoreticalandfieldworkphasewerecomparedtoproducearefineddefinitionsupportedbybothliteratureandparticipants’perspectives[19].Inthisstudy,theresearcherscontinuedtheirtheoreticalstudiesalongsidethefieldwork,enablingaprofoundimmersionbytheendofthedatacollectionstageandafullquestioningofallthepreviousfindingsthroughthenewlygaineddata.Thedataobtainedduringthetheoreticalandfieldworkphasesofthestudywerethencompared,andanalyzed,andthemainthemeswereextracted,andtheconceptofnursingpresencewasdefinedbasedontheemergedconceptsandindicators.Consequently,thisfinaldefinitionwassupportedbyboththeoreticalandempiricaldata.DataanalysisInthefirstphase,aftercarefulreview,thefulltextofthearticleswasimportedtoMAXQDAversion10.0(UdoKuckartz,Berlin,Germany),andgiventhestudyobjectives,meaningunitswerecodedandanalyzedinthreecategories:antecedents,attributes,andconsequence.Similarcodeswereclassifiedunderthesub-categories,andthenthesubcategoriesformedthemaincategories.Themethodsandtoolsdevelopedformeasuringtheconceptofnursingpresencewerealsoexamined.Pointsofagreementanddisagreementwereultimatelyidentifiedaccordingtotheviewsexpressedbytheresearchteam.Inthesecondphase,MAXQDAversion10.0(UdoKuckartz,Berlin,Germany)wasusedtomanagethedata.Theanalysisofthedatawasconductedusinginductivecontentanalysisapproach,whichisoftenusedwhenthedataaredirectlyextractedfromtheparticipants,andthereforedoesnotrequiretheuseofpre-determinedcategories[21].DatawereanalyzedusingthemethodproposedbyGraneheimandLundmanincludingtheinterviewtranscription,determiningtheunitofanalysisandmeaningunit,summarizingthemeaningunit,determiningtheinitialcodes,classifyingsimilarcodeundermorecomprehensivecategories,anddeterminingthethemes[21].RigorTheaccuracyandrigorofthedataweredeterminedusingLincolnandGuba’scriteria[17,21].ToincreasethecredibilityoftheTable1CharacteristicsofPatientsParticipatedinFieldworkPhase.NumberGenderAge(yr)EducationalstatusDiagnosisLengthofdisease(yr)WardTypeofhospitalHospitalizationlength(d)1Male32CollegiateLeukemia1OncologyTeachingcenter132Female42DiplomaBreastcancer6OncologyTeachingcenter103Male50CollegiateCOPD14RespiratoryTeachingcenter94Female38CollegiateAsthmaeRespiratoryTeachingcenter55Female49PrimaryAngina7CardiacTeachingcenter86Male50PrimaryAngina9CardiacPrivatecenter97Male28CollegiateESRD10InternalTeachingcenter108Male37DiplomaDiabetes15InternalPrivatecenter99Female37CollegiatePelvicfractureeSurgicalPrivatecenter310Female50PrimaryCholelithiasiseSurgicalTeachingcenter4Note.COPD=ChronicObstructivePulmonaryDisease;ESRD=EndStageRenalDisease.F.Mohammadipouretal./AsianNursingResearch11(2017)19e2922
data,theresearchersprolongedtheirimmersioninthestudyandthedataandtheirengagementwiththeparticipants.Thedataobtainedthroughtheinterviewsweretranscribed,coded,andreviewedbytheresearchteam.Toensurecompatibilitywithpar-ticipants’experiences,thefulltextofthecodedinterviewswasdistributedbetweentwoparticipantsforrevision.TwoexpertsandtwonursingPh.D.studentsthenreviewedtheinterviewsandtheextractedcodesandthemes.Toincreasetheconfirmabilityoftheresults,thestagesoftheresearch,itsmethodology,andthede-cisionsmadeinthesestagesweredescribedindetailstofacilitatefollow-upforfutureresearchers.Allthedocumentsandevidenceweresecurelystoredtoenablefurtherinvestigations.Thestudycontextandparticipants’detailswerefullydescribedtoenabletheaudiencetoproperlyjudgethetransferabilityofthefindings.EthicalconsiderationThisstudywasapprovedbytheInstitutionalReviewBoardoftheShahidBeheshtiUniversityofMedicalSciencesofIran(IRBno.SBMU2.REC.1394.146).ResultsTheoreticalphase1.CharacteristicsanddefinitionofconceptThewordpresenceisderivedfromtheoldFrenchwordpresenceandLatinpraesentiaandconsistsof“prae”meaning“infront”andthe“sens”meaning“being”[5].TheOxfordEnglishDictionaryde-finespresenceas“apersonorathingthatexistsphysically;aplaceorspaceoppositeoraroundaperson;socializationandinteractionwithsomeone.”Researchersdefinenursingpresenceasaninter-subjectiveencounterbetweenthepatientandthenurseinwhichthenurseencountersthepatientasauniquepersoninauniquesituationandchoosestodedicateherselftothecareofthispatient;thisinter-subjectivetruthcanleadtochangeinbothparties.Nursingpresenceisinfluencedbytheuniqueness,connectingwiththepatient’sexperience,sensing,goingbeyondthescientificdata,knowingandbeingwiththepatient[6].Finfgeld-Connettarguesthatpresenceisaninterpersonalprocessidentifiedwithsensitivity,holism,intimacy,vulnerability,andadaptationtouniqueconditionsandinwhichpatientsexhibittheirneedforpresence.Nursesshouldalsobeinclinedtowardspresenceandpracticeitinanenvironmentthatdirectsthemtowardit.Nursesshouldhavethepersonalandprofessionalmaturityandconducttheirworkaccordingtoethicalprinciplessuchasrespectforpersonaldifferences.Thisprocessleadstoanimprovedmentalwell-beingforboththenursesandpatientsandanimprovedphysicalwell-beingofthepatients.Thenatureofthisprocessenablesitspersistenceonlyasdictatedbytheconsequencesitbrings[9].Someotherresearchersbelieveindifferentlevelsofpresence[5,9,11].Mostrecentresearchers,withtheexceptionofMcMahonandChristopher[7],havediscardedtheattempttodifferentiatelevelsortypesofnursingpresence[5].Theydefinepresenceasaninterventionofbeingwithotherswhoareinneedbothphysicallyandmentally.Morespecifically,presencede-pendsonacombinationofthenurse’scharacteristics,theclient’scharacteristics,thenurseeclientdyadcharacteristics,environ-mentalfactors,andpracticeconsiderationsrequiringthenursetocalmlyassessthepatients’conditionsandmakeprofessionalde-cisionsabouttheproperdoseandmethodofensuringpresence,i.e.thenursedecideswhetherornottohaveamerephysicalpresenceandobservetheeventsfromdistance,ortooverstepthephysicalboundaryandjoininonthepatient’sexperience[7].2.AttributesThreeattributesemergingfromthisconceptincludedatten-tiveness,physicalbeingthere/mentalbeingwith,andholisticparticipation.Attentivenessshowsthecompletefocusofnurses’attentionontheirpatients,toallowforatrueclosenessincludingbeingfreeofotherresponsibilitiesandthoughts[10].Attentivenesshasbeenfrequentlyrepeatedintheliteraturebyanurse’swillingnesstointeractwithpatients(n¼13),activelistening(n¼17),eyecontact(n¼10),calmspeech(n¼7),andempathywithclients(n¼10).Physicalbeingthere/mentalbeingwithhasbeenfrequentlyrepeatedinliteraturebysensing(n¼9),acceptingpatient’suniqueness(n¼19),subjectiveconnectionwiththepatient’sexperience(n¼11),beingwiththepatientalongwithdoingfor(n¼12),andadapttopatient-centeredness(n¼15).AsstatedbyIseminger,presencemeansmorethanjustprovidingforthepa-tient’sphysicalneedsbysimplyimplementinganursinginter-vention.Itmeansextensiveknowledgeofthepatient,apersonwhoisvulnerableandneedsthesafetyfromnurse,beingresponsivetotheuniquenessofpatient[10].Holisticparticipationreflectscreatinganenvironmentusingthetotalresourcesofmind,body,spirit,andtheemotionsofnursetofacilitatethediscoveryofhealingwhichhappenswithinthepa-tients[10].Holisticparticipationischaracterizedbymutuality(n¼13),availability(n¼9),professionalsharing(n¼17),human-isticsharing(n¼14),mental-emotionalsharing(n¼13),andspiritual-ethicalsharing(n¼12).3.AntecedentsInreviewingtheexistingstudies,fourcategoriesemergeincludedprofessionalcompetence,personalmaturity,opennesstoexperience,andenvironmentalissues.Table2CharacteristicsofNurses,Managers,andFacultyMembersParticipatedinFieldworkPhase.NumberGenderAge(yr)OrganizationalpositionEducationOrganizationWardLengthofexperienceworkingasaclinicalnurse(yr)11Female34RegisteredNurseBSTeachingcenterOncology912Male38RegisteredNurseBSTeachingcenterRespiratory1413Male36RegisteredNurseBSPrivatecenterCardiac1014Male29RegisteredNurseMSTeachingcenterInternal515Female37RegisteredNurseBSTeachingcenterSurgical1316Female52NursemanagerMSTeachingcentere2817Male48NursemanagerMSPrivatecentere2418Female46FacultymemberPhDFacultyofnursingandmidwiferyDepartmentofnursingmanagement1219Female40FacultymemberPhDFacultyofnursingandmidwiferyDepartmentofmedical-surgicalnursing2Note.BS=BachelorofScienceinnursing;MS=MasterofScienceinnursing;PhD=DoctorofPhilosophyinnursing.F.Mohammadipouretal./AsianNursingResearch11(2017)19e2923
Mostoftheresearchersnotetheimportanceofthenurse’sskillandknowledgeasantecedentsfornursingpresence[7,10e12].Professionalcompetenceassumesthatanurse,whoiscomfortablepracticingandhasacompletetheoreticalknowledge,hasanadvantagewhenfacedwithaclinicalsituationinwhichpresenceisindicated[7,9].Professionalcompetenceisanantecedentofnursingpresencecharacterizedbyprofessionalmaturity(n¼19),clinicaljudgment(n¼9),professionalethics(n¼10),andappro-priaterelationalknowledgeandskill(n¼11).Personalmaturity,facilitatestheabilityofnursestocompart-mentalizepersonalissuesanddisallowanyexternalfactorsthatinterferewiththeircapacitytoprovideholisticparticipation[7].Personalmaturityhasbeenexhibitedinresearchresultsthroughattentiontometa-physicalneeds(n¼13)andattemptingself-improvement(n¼10).Inthecontextofunmetneed,apatient’sopennesstopresenceisessentialandthenurseisinvitedintothepatient’sexperience[6e8].Inaddition,thenurseshouldbewillingtoengageinpatient’sexperience[3,15].Opennesstoexperienceisidentifiedbytheopennessofthenurse(n¼14),andopennessofthepatient(n¼17)asanantecedentfornursingpresence.Nursingpresencedoesnotoccuronlythroughthepersonandthenurse.Theworkingenvironmentcanalsopavenursingpres-enceviaappropriatehumanresources(n¼7),time(n¼11),nursing-valuingworkingclimate(n¼10),communicationsup-portingclimate(n¼14),organizationalconstruct(n¼12),balancebetweenroleandtechnology(n¼8),andappropriateworkload(n¼9).4.ConsequencesTherearethreecategoriesofconsequences:improvedre-lationships,mentalandphysicalwell-being,andgrowth.Gettingtoknowthepatientmore,theexperienceofhumanisticinteraction,andscientificandskillfulrelationshipwillexistwithinthescientific-humanisticinteractionexperience.Thispositiveimprovementincommunicationisworthwhileperse,evenifitdoesnotaffectpatient’srecovery.Nursingpresenceisassociatedwithenhancedmentalandphysicalwellbeing[9e11,13].Peaceofmind(n¼8),satisfaction(n¼18),strength(n¼10),andphysicalandpsychologicalrecovery(n¼21)arethemostimportantconsequencesinthementalandphysicalwell-being.Nursingpresencecanleadtopersonalgrowthinthenursethroughgreaterunderstandingandopenness(n¼7),psychologicalwell-being(n¼12),improvedperformance(n¼4),andincreasedpatient-centeredness(n¼17).5.MeasuringnursingpresenceGiventheambiguitiesintheconceptofnursingpresence,thereislittleagreementonmeasurement.PenqueandKearneyassessedtheeffectofnursingpresencewiththreeindicators,includingclearcommunication,respect,andlisteningbythenurse(itemsofpa-tientsatisfactionquestionnaire)[14].Todate,twoquestionnaireshavebeendevelopedformeasuringtheconceptofnursingpres-ence[22,23]:PresenceQuestionnaireforCaregivers(PQ-C)mea-surestheconceptfromthenurses’pointofviewusing48itemsinthreedimensionsofdedicatedattitude,opennessinperception,andreciprocalhumaneness[23]andPresenceofNursingScale(PONS)measurestheconceptfromthepatients’viewusing25-itemquestionnairewithnodimensions[22].Table3presentsin-dicatorsassociatedwiththepracticabilityoftheconceptofpresence.Fieldworkphase1.ParticipantcharacteristicAtotalof9nurses(fivewomen)participatedinthisstudy.Theparticipatingnurses’meanagewas40years(range:29-52years)whohadbeenworking2to28yearsinnursing(mean:13years).Atotalof10patientsparticipatedinthisstudy(fivewomen).Allweremarried,between31and50yearsold(meanage:41.3years),andhalfofthemhadcompletedhigherdegrees.Atotalofsixparticipantswerediagnosedwiththeirchronicdiseasemorethan5yearsbeforeadmissiontohospital.Theparticipatingpa-tientswerehospitalizedonaverageforeightdays(range:3-13days).2.AttributesTheattributesofnursingpresencefromtheparticipants’perspectivewerereflectedinfivemaincategoriesandonetheme,co-constructedinteraction.Whilethisthemewillbediscussedlater,anoverviewofthemaincategorieswillfacilitateanunder-standingofhowco-constructedinteractionemerged.DeliberatefocusDeliberatefocusshowsnurses’desireandplanstoinitiateinteractionwithpatientsthroughtheinformeduseofcommuni-cationstylessuchasactivelistening,establishingeyecontact,speakingsoftly,andshowingempathytothepatient,therebyenteringareciprocatingrelationshipwiththepatients.TouchandphysicalclosenessdidnotemergeforthisattributeinfieldworkphasebecauseofsomeculturalandreligiousbarriersinIran.Thedeliberatefocusisevidentinthefollowingremarkbyapatient:“Itmeansthatthenursewilllistentomeifsheiswillingto.I’mnotgoingtodiscussmyworkproblems;I’llbetalkingaboutwhat’simportanttobothofus.So,Ilistentohertoo.WhenI’mspeakingandshe’sshakingherhead,thismeanssheattendstome.”Table3IndicatorsAssociatedwiththeConceptofNursingPresence.ItemIndicatorsNursebehaviorsAppropriatetouchDedicatedtimeEyecontactHelpingPersonalizedinterventionsPhysicalclosenessCommunicationstylesAttentivelisteningDirectcontactwithpatientQuiettoneofvoiceReceivingverbalandnon-verbalSilenceSharingTrustEmotionalattitudesAcceptanceCompassionIntimacySensitivityPerceivedemotionsFeelingofbelongingRespectandtrustfortheotherTranspersonalconnectednessSenseofmutualopennessF.Mohammadipouretal./AsianNursingResearch11(2017)19e2924
Task-oriented/patient-orientedrelationshipThisattributeentailsthenurse’sunderstandingofthemes-sageconveyedbythepatientbeyondthetechnicalandobjec-tivedatareceived,sothat,giventheuniquenessofeverypatient,thenurseknowshowtoestablishamentalcontinuitywiththepatient’sexperience,andwhileperformingthetech-nicalaspectsoftheworkforthepatient,interactswithhimasawholeandcontinuestobepatient-oriented.Thenurseinstructorasserted:“Therewasacommittednurseintheurologydepartment.Itwasimpossibleforhertomissanyofthepatients’tasks.Shewasextremelycarefulwithallthepatients’procedures,sotheywouldbeperformedontimeandaccurately,butshenevertalkedtothepatientsandgavethemshortresponseswhenevertheyaskedanyquestions.Sheestablishednoverbalcommunication,suchassympathizingwiththepatientoraskinghowtheywereandneveraskedabouttheirproblems,andifshedidhavesympathy,itwasneverconveyedtothepatients.Incontrast,therewasanursewhowouldsometimesdelaydoingpatients’tasks.Butshealwaysestablishedagoodrapportwiththepatients.Shewouldconsolethemandmakethemfeelsafe.Thenonce,theycarriedoutapatientsatisfactionsurveyinthedepartment,andthesecondnursescoredthehighest,andthefirstnursescoredthelowest,eventhoughshenevermissedanyofthepatientcaretasks.”UbiquitousparticipationPresencehasareciprocatenature.Bymakingherselffullyavailableandsharinghumanistic,andmental-emotionalaspectsofherprofessionalexperience,thenurseparticipatesingivingmeaningtothepatient’suniqueexperience.Theinternalwardnursedescribed:“IremembermakingafireinasmallsteelpotonChaharshanbe-Suri(afirejumpingfestivalcelebratedbyIraniansontheeveofthelastWednesdaybeforethePersianNewYear)andhelpingthepatientsjumpoveritsoastoraisetheirspirits.Ontheotherhand,onceImadeaHaft-Seentable(atraditionaltabletoparrangementforthePersianNewYear)andhadthepatientssitarounditonthechairsIhadlaidoutuntilthearrivaloftheNewYear.Youcouldseethehappinessintheireyes.”ClarificationAccordingtotheparticipants,asanursewitnessesuniqueresponsesofpatients,thenurseestablishesaninteractionwiththepatientbyprovidinginformation,talkingtothepatientsortheirfamiliesaboutwhatthenursesdo,ormakingtheirbeliefsoractionsexplicitandresolvingambiguities.Apatientcommented:“Thenursewhocametochangethedressingonmywoundfirsttookapictureofthewoundandthentookanotherpictureaftershehadappliedmoredressingtoitandshowedthemtoustomakeusgrasphowthewoundwashealing.”Inthiscase,thenurseknowsthepatientisexpectedtoimprove.Thenursemakesthepatientrecognizethatthereispracticalpos-sibilityofwoundhealingandclarifiesthisconceptbytakingapicture.Clarificationcaninfluencepatients’attitudesandthereforetheirtrustonnursingcare.AccountabilityResponsivenessandethicsproveaccountabilityofanurse.Nursesandpatientsintheinterviewsconfirmedthisattribute.Apatientwithleukemiaexplained:“Onenight,IhadafeverduetofallingplateletcountandIhadnocompany.ThenightshiftnursestayedbymysideforlongerthanusualandkeptgivingmeafootbathandIwasembarrassedbecausemyrelativesweren’ttheretohelp,butsheconsoledmeandsaidthatshewasonlydoingherjob.Godblessher;shedidn’teventakeanapthatnight.”Inthiscase,thepatienthadperceivedthepresenceofnursebytherolesheplayedinadvocating,providing,andpromotingthebestpossiblecareforthepatient.Nursesareexpectedtoberesponsiblefortheirownactionsandensurethattheirinterventionisevidence-based,ethical,andconsistentwithstandards.Anurseasserted:“Whenapatientneedsanursetobebyhisbedside,Idon’ttellhimtogobacktohisbedandonlypromisehimtoconveythecasetohisdoctorortovisithimlater.IjustdothejobI’vebeenassigned.”3.AntecedentsTheantecedentsandconsequencesoftheconceptareoutlinedinTable4.Theanalysisoftheconceptofnursingpresenceintheinterviewsconductedwiththepatientsandnursesservesmainlyasanillustrationtoandvalidationoftheanalysisintheliterature.Clinicalcompetence,self-actualization,andreciprocatingopennessaswellasconduciveworkingenvironmentwerefoundinthein-terviewsasantecedentsofnursingpresence.Inthefieldworkstage,workengagementwasamainsubcate-goryofself-actualization.Nursesmentionedthattheinternalmotivationandjobattachmentaresoimportantfornursingpres-ence.Anursemanagersaidthefollowing:“Youhavetobeinterestedinyourjobsothatyoucanbecomeafriendofyourpatient.Ihadbeenacceptedinthreemorecareers,butIhavechosentobecomeanurseandafter28years,I’mnotregretful.WhereverIproudlytoldthatIamanurse.”Further,ongoingteaching-learning,andevaluationandfeed-backwerethemainothersubcategoriesofaconduciveworkenvironmentnotextractedfromtheliteraturereview.Thenursesacknowledgedtheimportanceofteachingtherelationalskillsbyorganizations.Onenursesaidthefollowing:“Thesystemcangivethenursescienceandknowledgethroughongoingeducationprograms.IfIlistentothepatientanddon’tknowwhattosay,itwon’tbenefitthepatient…Forexample,apatientsays:“I’mdiagnosedwithterminalcancer…stagefour,willIdieofcancer?”…Well,weourselvesdonotknowwhattosaytothispatient.Thatiswhytheorganizationmustteachushowtoencounterdifferentsituations.”Mostnursesexplainedthattheydidnotgetanyfeedbackafterpresencewiththeirpatients.Onenursesaidthefollowing:“Nursesshouldbeencouraged.If,forexample,inthenursingpresenceMrs.AisdifferenttoB,thisshouldbeseenandvaluedbythemanagers.AnursewithoutthepresenceandanursewithhighpresenceenjoyequalopportunitiesbecausethereisnofeedbackorF.Mohammadipouretal./AsianNursingResearch11(2017)19e2925
jobincentiveinappraisalsystem.Thenursingpresenceshouldhaveapositiveadvantage.”4.ConsequencesRegardingtheconsequencesofpresence,thefieldworkresultsshowedmanysimilaritieswiththefindingsofthetheoreticalstage,implyingthattrust,intimacy,andunderstandingdevelopedintheinteractionbetweenthepatientandthenursecreateaworthwhilecommunicationthatcontributestothepatient-nursegoals,andfullrecoveryandinnerbalancearemajorconsequencesofpresenceforpatients.Throughmeetingtheneedsofthepatientsandimprovingthenurses’performance,presencecanleadtotranscendentalcareandhelpnurses’personalgrowththroughenablingtheirmentalwell-beingandunderstandingofmeaningsandexperience.Themainfindingsofthisstage,whichdidnotemergethroughthere-viewoftheoreticalliterature,includethespiritualandinternalrewardsthenursesreceived.Asforthespiritualreward,onenurseargued:“Inthecriticalcareunit,throughnursingpresence,IfeelclosetoGod.IfeelthatGodanswersmyprayers.Imean,Iactuallygotothepatients’bedsideandpray.I’mnotareligiousfanatic,butIbelievethatGodexists,andwe’llgetwhatwegive,evenifnobodyisthankful.”5.ThefinaldefinitionMeaningsoftheconceptemergedinageneralthemeofco-constructedinteraction,implyingthatprofessionalbehaviorscancoexistwithemotional-socialbehaviors,andthenurseandpatientcanjointocreatemeaningsandfindthepathtorecovery.Outofthetheoreticalandfieldworkstages,acomprehensivedefinitionoftheconceptemerges:nursingpresenceisaco-constructedinteractionestablishedthroughdeliberatefocus,task-oriented/patient-orientedrelationship,clarificationofmeanings,ubiquitouspartic-ipation,andaccountability.Accordingtothisdefinition,apatientissomeonewhohasauniqueexperienceandisinvolvedinaninteractionwithanursewhohasbothpersonalandclinicalcompetenceanddesirestoaccompanythepatientinfindingthemeaningattachedtovariousdimensionsofhisexperienceandwhodoesnotconsiderthetechnicaldimensionofcareandperformingcaredutiesastheonlyimportantaffairs;suchanurseseekstoestablishacontinuitywiththepatients’uniqueexperience(seetable5).DiscussionThereisaclearneedtodefinethetentativedefinitionofnursingpresenceastheessenceofnursingcarethroughconceptdevelop-ment.Inthefirstphaseofthisstudy,literaturereviewindicatedthatmultipleconceptionsofnursingpresenceinthenursingliteraturehavemadeitdifficulttounderstand.Nursingpresenceisregardedbothasaqualityandasanintervention;nevertheless,eachsinglestudyhadconsideredonlydimensionsoftheconcept;thus,theconceptualizationofnursingpresenceintheliteraturewasincomplete.Inaddition,wediscoveredthatthemajorityofauthorsworkingintheareaofnursingpresencedefinethisconceptfromtheperspectiveofnurses;therefore,mostnursingpresenceinterventionstargetpatientswithoutincludingpatient’sperspec-tivesthatcanaffectnursingoutcomes.Reviewofliteratureshowedsimilarconceptssuchasempathy,compassion,andmutualitytopresence,limitingtheconcepttoitscognitivedimension,asnursingpresencefocusesonthepatientasawholeandcombinescognitive,behavioral,emotional,andspiri-tualdimensions,anditisonlyitscognitivedimensionthatcanbeidentifiedthroughempatheticverbalcommunication[8].Inastudy,Finfgeld-Connett[9]developedatheoreticalframeworkofnursingpracticebasedontheconvergenceofpresence,theartofnursing,andcaring[9].However,accordingtothefollowing,thiscombinationdoesnotseemcorrect.Thepurposeofcaringistoaidself-actualizationandgrowthinothersandenablingthepatienttoperformself-care;however,caringmaynottargetonlypeople;ratheritmaytargetartifactsorideas.ArtifactsmayrefertoanexpensivepartofequipmentandideastoaresearchhypothesisTable4AntecedentsandConsequencesofNursingPresence:FinalDefinition.GroupThemeandCategoryAntecedentsA.Clinicalcompetency1.Concurrentlycombinationexperimentalknowledgeandskill2.Concurrentlycombinationextra-experimentalknowledgeandskillB.Self-actualization1.Attentiontometa-physicalneeds2.Self-improvement3.Workengagement(informants)C.Reciprocatingopenness1.Completeopennessofthenurse2.OpennessofthepatientD.Conduciveworkingenvironment1.Facilitatingsources2.Supportiveandvaluingmanagement3.Role-balance4.Ongoingteaching-learning(informants)5.Evaluationandfeedback(informants)ConsequencesA.Worthwhilecommunications1.Increasingtrustandintimacy2.Scientific-humanisticinteraction3.MutualunderstandingB.Balanceandrecovery1.Internalbalance2.ComprehensiverecoveryC.Growthandtranscendence1.Personalgrowthofnurse2.Excellenceincaring3.Reward(informants)Table5AttributesofNursingPresence:FinalDefinition.ThemeCategorySubcategoryCo-constructedinteractionDeliberatefocus1.Nurse’swillingnesstobegininteractingwithpatients2.Activelistening,eyecontact,calmspeechandempathywithclientsTask-oriented/patient-orientedrelationship1.Extrasensoryknowing2.Acceptingpatientuniqueness3.Subjectiveconnectwiththepatient’sexperience4.Beingwiththewholenessofpatientalongwithdoingfor5.Adapttopatient-centerednessUbiquitousparticipation1.Mutuality2.Availability3.Professionalsharing4.Humanisticsharing5.Mental-emotionalsharing6.Spiritual-ethicalsharingAccountability1.Responsiveness2.EthicsClarification1.Providinginformation2.ResolvingambiguitiesF.Mohammadipouretal./AsianNursingResearch11(2017)19e2926
[24].Nursingpresence,however,istheessenceofthenurse-patientinteraction.Mostresearchersagreethatnursingpresenceisaconstructofcare[3,8].Itmaybeassumedthatcaringisumbrellaspresenceandalsoameansofshowingcare,sopresencecannotreplacecaring[3].Theartofnursinginvolvesamomentarysenseofmeaningmanifestedinthenurse’sactions,behavior,attitude,andinteractionsandreliesonperceptionandcreativityandinvolvesempathyandunderstanding[3,10];therefore,nursingpresenceencompassestheartofnursing.Nursingpresenceleadstoexperi-encingthemeansofgainingethical,artistic,empirical,andper-sonalknowingandallowsnursestousetheirmetaphysicalandempiricalknowledgeforfindingbetterwaysoffullymeetingtheirpatients’needs[3].Attheendofthisphase,threeattributesemerged:attentive-ness,physicalbeingthere/mentalbeingwith,andholisticparticipation.Antecedentsforthisconceptwere:professionalcompetence,personalmaturity,opennesstoexperience,andenvironmentalissues.Improvedrelationship,mentalandphysicalwell-being,andgrowthwerethemainconsequencesofthisconcept.Inthesecondphase,theintervieweesrevealedthatnursingpresenceinvolves“deliberatefocus”,“task-oriented/patient-ori-entedrelationship,”“ubiquitousparticipation”,“accountability”,and“clarification”.Dataanalysisrevealedthatsomeoftheattri-butesemergedinthefieldworkphasewerecompatiblewiththoseofthetheoreticalphase.Oneoftheattributesofthenursingpresencewas“deliberatefocus,”whichwasthesameas“attentiveness”extractedfromtheliteraturereview.Attentivenessisillustratedfollowing:presence,sharesfeaturessimilartoactivelisteningandtheconceptofmindfulness.Itisanintentionalclosenesswiththepatientleadingtoawareness,moreknowingandameaningfulconnection[14].InIslamicandPersianculture,individualsareprohibitedfromspendingtimewiththeoppositesexortouchingthemwiththepurposeofconveyingempathy[17].Consequently,thepatientsandnursesdidnotrefertothesebehaviorsasthepresenceofnurse;however,thepatientsornursesdidnotemphasizethegenderdifferenceasabarriertonursingpresence.Oneoftheotherextractedattributeswas“task-oriented/pa-tient-orientedrelationship.”Thisattributeiscompatiblewith“physicalbeingthere/mentalbeingwith”wasextractedfromil-lustrationssuchas:explanationsofnursingcarefrequentlyfocussolelyonthepsychomotorskills,the“doingfor”component,accomplishedbythenurse,butnursingpresenceis“beingwith”and“doingfor”patients[3].Anotherattributewas“ubiquitousparticipation.”Thisattributewasharmoniouswith“holisticparticipation.”Holisticparticipationwasextractedfromillustrationssuchas:“sharingpositiveexperi-enceswithwomen,suchaslookingatamagazineorpaperwithbabytoysorclothes,wasdescribedaspresencebyregisteredpsychiatricnurses”[12].“Accountability”wasanotherattributederivedfromthefield-workphase.Inthisstudy,however,theliteraturereviewphasedidnotrevealthisattribute.Accountabilityisrelatedtoindividualsresponsibleforasetofactionsoractivitiesanddescribingoransweringtheirperformance[25].Understandingallintervieweesconcerningthenursingpres-ence,aspacewasfilledwithresponsiblepresencecreatedbythenursewithasenseofcommitment,cheerfullylisteningtothepa-tient’srequests,andrespectfullyrespondingtotherequirements.Accountabilitymeanstakingresponsibilityforone’snursingac-tionsandomissions,upholdingbothprofessionalstandardsandpatientcarequalityoutcomes,andwhilebeinganswerabletothoseinfluencedbyone’spractice[26].Theintervieweesdiscussedaccountabilityinrelationtonursingpresence.ThisfindingisconsistentwiththeresultsofastudywhichexploredthemeaningofnursingcarequalityinIran,inwhichparticipantsdescribedaccountabilityalignedwiththenursingpresence[16].Interestingly,patientsandthenursesinasurgerywardintheUnitedStatesdiscussedaccountabilityastwoelementsofknowledgeandpres-ence[25].Theresultsofastudyrevealedthatimplementationofbedsideshiftreportingenhancednursesperceptionofaccount-abilitybecausebothnursesandpatientshadtheopportunityforcheckingandclarifyinginformationaboutthepatient’sstatusandplanofcare[26].Itseemedthatvisualizingpatientsandprioritizingcarethroughnursingpresenceprovidethemostaccurateinfor-mationaboutthepatientandimproveprofessionalisminnursing,foundrelatedtoaccountability.Therefore,thisattributeshouldbeconsideredinthenursingpresenceprogramswithrespecttothefactthattheparticipantsconsideredaccountabilityasequivalenttonursingpresence.“Clarification”wasanotherattributederivedfromthefieldworkanalysisandtheoreticalphaseanalysisdidnotrevealit.Clarifica-tionmeansmakingastatementorconcepteasiertounderstand[2].Mostoftheparticipantsemphasizedthatnursingpresenceinvolvessharingopinions,givingfeedback,usingappropriatelanguage,andhelpingpatientstounderstandhealthcareoptions.Thisattributemaybethesameas“illuminatingmeaning”intheoryofhumanbecoming.ParsearguesthatprocessesandthepracticedimensionsforthosechoosingParse’stheoryincludeilluminatingmeaning,synchronizingrhythmsandmobilizingtranscendence[4].Theempiricaldataidentifiedfourantecedentsandthreeconsequencesfornursingpresencetoo.However,throughthefieldworkfindings,“workengagement,”“ongoingteaching-learning,”and“evaluationandfeedback”werethemainsub-categoriesofself-actualizationandconduciveworkenvironmentasantecedents,andspiritualandinternalrewardsasthemainsubcategoriesof“growthandtranscendence”werenotextractedfromtheliteraturereview.Thesefindingsmayrelatetothefactthatinspiteofthelackofexternalmotivationandorganizationalsupportaswellasinsufficientopportunitiesfortheirpreparationforwork[27],theseprerequisitesgeneratestrongmotivationsandpropelthemtowardsaccomplishingbettercare.TheinnerrewardwasalsorelatedtorememberingGodatwork.Nursesreportedthatthroughnursingpresencetheirprecisionofcareandreli-giousbeliefsincreased.TheyconsideredthepositiveoutcomesofnursingpresenceassensingGodintheircaring.AsIraniansareMuslims(98%),thisiscommoninIranianculturebecauseoftheirreligiousbeliefs.TheyseeGod’ssupervisioninalllifestages,includingtheircaring.Therefore,participants’viewsandexperi-enceswentbeyondworkreward,andthismeantthemaninnerrewardthatrelatestoGod.Inthefinalanalyticalphase,comparingthedefinitionofnursingpresenceasseenintheliteraturewithwhatdescribedbythepar-ticipants,bothsimilaritiesanddifferenceswerenoted.Themostdistinguishedfindingrevealedinbothsetsofdatawasthatnursingpresenceisaco-constructedinteraction.Co-constructionhasbeendescribedas“thejointcreationofanac-tion,activity,identity,ideology,interpretation,stance,institution,skill,emotion,orotherculturallymeaningfulrealityincluding,co-ordination,cooperation,andcollaboration”[28].InIranandmostothercountries,thebiomedicalmodelisstillthedominantmodelofprovidinghealthcare.Issuessuchasevaluationandfeedbacksystem,ongoingteaching-learning,andaccountabilitycanbeindicativeofgreaterfocusputonthetechnicalaspectsofcareanditsstrictandinflexiblerules.Nevertheless,thereisstillatendencytowardaholisticviewinwhichboththenurseandpatientdesirethepatient’sinvolvementinthetreatmentplans.Accordingtothisview,notonlydothepatientsunderstandnursingpresencethroughaclarificationofmeaningsonthenurses’part,butalsoF.Mohammadipouretal./AsianNursingResearch11(2017)19e2927
theyadmittonurses’presencewhentheybuildaninteractionwiththeminwhichtheyarewholeheartedlybytheirsidewhileper-formingtheirroutinetechnicaldutiesandattendtothemthroughuniquehumanisticbehaviorsandassistthemintheirsearchforapathtorecoverythroughaubiquitousparticipationonthepartofboththenurseandthepatients.Inastudywiththeaimofdevelopingpracticablehumanisticcareindicators,eightcomponentsofautonomy,empathy,holisticcare,individualization,decision-makingparticipation,friendlyenvironment,assessmentofcustomeropinion,andappropriateuseofcaretoolswereidentified[29],inwhichtask-oriented/patient-orientedrelationshipfeaturewascompatiblewithassessmentofcustomeropinionholisticcare,autonomy,andindividualization,andubiquitousparticipationfeaturewasassociatedwithdecision-makingparticipationandfriendlyenvironment.ContributionandrecommendationThisstudy’sfindingshavegreatimplicationsfornursingedu-cation,practice,theory,andresearch.Undergraduateeducationisstillfocusedonthemedicalpara-digm,theprogressofthedisease,andempiricalknowledge.Pre-paringnursingstudentsforpatient-centeredcarerequiresanidentificationandunderstandingofthehumanfactorsassociatedwithcare[1],andsomenursescholarsarguethattheconceptofhumanismisdefiningfeatureofthenursingprofession[1].Resultsofthisstudyprovidenurseeducatorswithlanguageuponwhichtheymaydeveloplearningactivitiesandteachingstrategies.Studentscanbepreparedfornursingcarewithanexpandedcapacityforpresence.Forexample,giventheimportanceofdeliberatefocus,mindfulnesseducationcanbeoftremendousinteresttonurseeducatorsandmanagers.Mindfulnessisatrans-formativeprocesswhereonecanpromotehis/herabilitytoexpe-riencepresencewithawareness,attention,andacceptance.Afterimplementingamindfulness-basedstressreductionprogramfornurses,theparticipantswillbemorefullypresentintheirinter-actionwithothers[7].Thedefinitionofnursingpresencealsocanstimulateresearchthatseekstoexploreexperiencesassociatedwithteachingnursingpresence.Thedefinitionproposedinthiswork,derivedfromtheliteratureandcontext,willassistnursemanagersandeducatorstoeffectivelyarticulateandevaluatenursesandstudentnurses’attainmentofbehaviorsrelatedtoit.Innursingpractice,findingscouldincreasetheknowledge,awareness,andskillsofnursesintreatingtheneedsofpatients.Furthermore,nursingmanagerscanidentifytheexpectationsofnursingpresence,includingthein-servicetrainingcoursesonthevalueandimportanceofpresencesothatthenursingpresencecanfulfillthecaringmorethanbefore.Sincenursingpresencecanbefosteredbythehospitalandpositivelycontributetotheorganiza-tionaldevelopment[10],hencepatientswillbesatisfied,andprofitabilitywillincrease.Throughoutcomesfoundonthisconceptandtheprinciplethatnursingpresenceismutual,nursesmayreceivebenefitfromdevelopingthisconcept.Consideringconductiveworkenviron-mentasanantecedentfornursingpresence,supervisorsathospitalwardsandmanagerscansupportnurses’caringtodevelopsuc-cessfulnursingpresencestrategies.Furtherstudiesarerecom-mendedontheeffectofthesechangesonnursingpresenceindifferentsettings.Connectingtheoriestopracticesupportsnurses’knowledgeandpractice.Giventheimportanceofunderstandingtheconceptofnursingpresenceinmoreconcreteterms,theresultsofthepresentstudycanbeusedinConceptual-Theoretical-Empirical(C-T-E)System-BasedNursingPractice.SincetheconceptofnursingpresenceintheoriesofhumanisticcaringparadigmadvocatedbyPatersonandZedrad,Parse,Watson,Orem,andNewmanisdefinedinambiguousandabstractterms,itmaybedifficulttobeimple-mentedinclinicalpractice.FawcettarguesthatC-T-Estructureiscompletedwhenrelevantempiricalindicatorsareidentifiedincludingstandardsfornursingpractice,anassessmentformat,aclassificationsystem,interventionprotocols,aqualityassuranceprogram,andaninformationsystem[30],so,theattributesderivedfromthisdefinitionandthecondi-tionsleadingtoitcanbeappliedtodesignempiricalindicatorssuchasassessmenttoolsandinterventionprotocols.Innursingresearchconceptanalysisisnecessarywhennotoolsexistformeasuringacertainconceptoravailabletoolscannotassesstheconceptinthegivenstudypopulation[22].Giventhatthepresentstudyexaminesthepatients’perspective,itcanbeusedasabasisforthedesignofinstruments.Itisrecommendedtodesignatoolthatcanmeasurenurses’presencefromthepatients’perspectivewithrespecttopatient-centerednessobjectives,therelationshipbetweenthenurse’spresenceandpatientsatisfaction[3,14,17],thepatients’failuretounderstandthetechnicalitiesofcare,theirabilitytounderstandnursingpresence[14,15],andlimitationsinthequestionnaire[22]previouslydesignedformeasuringnurses’presencefromthepa-tients’perspective(suchasthefailuretoconductanexploratoryfactoranalysisasamethodofverifyingtheconstructvalidity).Aswasseeninasmallportionofthearticles,ifthenursingpresencecansatisfyandhealpatients,morestudiesmustbedesignedtodocumenttheseoutcomeswithavalidinstrument.LimitationsTheliteratureanalysisofthetheoreticalphasewasbasedonstudiesinseveralcountriesintheWesternworld,buttheempiricaldatawerelimitedtoonecountry.Aswithmostqualitativeresearch,theresultsofthesecondphasearenotgeneralizabletoallsettings.Inthismodelofconceptdevelopment,thepurposeofthefieldworkphaseistoexploreempiricalexplanationsfortheresultsintheliteratureandnotempiricalgeneralizability.Furthermore,there-sultsoftheliteratureanalysismostlycoincidedwiththede-scriptionsoftheinterviewedinformants,whichindicatetheprobablevalidityoftheanalyzedconceptinotherplaces.Althoughtheterm‘accountability’hasbeenrepeatedlymentionedinnursingliterature,thisterminrelationtonursingpresenceismentionedmorefrequentlyinthefieldworkofthefindingsofthisstudy.ThisfindingreportedinasmallportionofstudiesconductedinIranandotherplacesandisconsideredasalimitation.ConclusionDevelopingconceptsrelatingtothetheoriesofhumanisticcaringparadigmmayprovideimportantandvaluabledirectionsforpatientcarestrategieswithunifyinglanguageforplanningcareanddefininginterventions.Bynursingpresenceasaco-constructedinteraction,nursesthroughouttheworldcanparticipatewithpa-tientstoachievetheirfinalgoals.Ashumandimensionsofcarewithregardtotheculturalandreligiousconsiderationsareimportant,internationalcross-culturalresearchofthenursingpresencewouldbeofgreatpriority.ConflictofinterestTheauthorshavenoconflictofinterestdisclosurestodeclare.F.Mohammadipouretal./AsianNursingResearch11(2017)19e2928
References1.FawcettTJ,RhynasSJ.Re-findingthe‘humanside’ofhumanfactorsinnursing:helpingstudentnursestocombineperson-centredcarewiththerigoursofpatientsafety.NurseEducToday.2014;34(9):1238e41.http://dx.doi.org/10.1016/j.nedt.2014.01.0082.MalinskiV.Modelsandtheoriesfocusedonhumanexistenceanduniversalenergy.In:ButtsJB,RichKL,editors.Philosophiesandtheoriesforadvancednursingpractice.Ontario,Canada:Jones&BartlettLearning;2013.p.446e80.3.KostovichCT,ClementiPS.Nursingpresence:puttingtheartofnursingbackintohospitalorientation.JNursesProfDev.2014;30(2):70e5.http://dx.doi.org/10.1097/NND.00000000000000454.BournesDA,MitchellGJ.Humanbecoming:RosemarieRizzoParse.In:AlligoodMR,editor.Nursingtheoristsandtheirwork.8ed.Missouri,UnitedStatesofAmerica:Mosby;2014.p.464e95.5.SmithTD.Theconceptofnursingpresence:stateofthescience.SchInqNursPract.2001;15(4):299e322.discussion3e7.6.DoonaME,ChaseSK,HaggertyLA.Nursingpresence.Asrealasamilkywaybar.JHolistNurs.1999;17(1):54e70.http://dx.doi.org/10.1177/0898010199017001057.McMahonMA,ChristopherKA.Towardamid-rangetheoryofnursingpres-ence.NursForum.2011;46(2):71e82.http://dx.doi.org/10.1111/j.1744-6198.2011.00215.x8.GardnerDL.Presence.In:BulechekGM,McCloskeyJC,editors.Nursingin-terventions:essentialnursingtreatments.Philadelphia,UnitedStatesofAmerica:W.B.Saunders;1992.p.316e24.9.Finfgeld-ConnettD.Qualitativeconvergenceofthreenursingconcepts:artofnursing,presenceandcaring.JAdvNurs.2008;63(5):527e34.http://dx.doi.org/10.1111/j.1365-2648.2008.04622.x10.IsemingerK,LevittF,KirkL.Healingduringexistentialmoments:the“art”ofnursingpresence.NursClinNorthAm.2009;44(4):447e59.http://dx.doi.org/10.1016/j.cnur.2009.07.00111.TavernierSS.Anevidence-basedconceptualanalysisofpresence.HolistNursPract.2006;20(3):152e6.12.EngqvistI,FersztG,NilssonK.Swedishregisteredpsychiatricnurses’de-scriptionsofpresencewhencaringforwomenwithpost-partumpsychosis:aninterviewstudy.IntJMentHealthNurs.2010;19(5):313e21.http://dx.doi.org/10.1111/j.1447-0349.2010.00691.x13.AnG-J,JoK-H.TheeffectofaNursingPresenceprogramonreducingstressinolderadultsintwoKoreannursinghomes.AustJAdvNurs.2009;26(3):79e85.14.PenqueS,KearneyG.Theeffectofnursingpresenceonpatientsatisfaction.NursManage.2015;46(4):38e44.http://dx.doi.org/10.1097/01.numa.0000462367.98777.4015.NegarandehR,HooshmandBahabadiA,AliheydariMamaghaniJ.Impactofregularnursingroundsonpatientsatisfactionwithnursingcare.AsianNursRes.2014;8(4):282e5.http://dx.doi.org/10.1016/j.anr.2014.10.00516.Zagheri-TafreshiM,Atashzadeh-ShoridehF,PazargadiM,BarbazA.Qualityofnursingcare:nurses’,physicians’,patients’andpatientfamilys’perspectives:aqualitativestudy.UNMF.2012;10(5):648e65http://unmf.umsu.ac.ir/article-1-1093-fa.html.Persian.17.Atashzadeh-ShooridehF,PazargadiM,Zagheri-TafreshiM.Theconceptofnursingcarequalityfromtheperspectiveofstakeholders:aphenomenologicalstudy.JQR.2012;1(3):214e28http://jqr.kmu.ac.ir/article-1-119-en.html.Persian18.Finfgeld-ConnettD.Qualitativeconceptdevelopment:implicationsfornursingresearchandknowledge.NursForum.2006;41(3):103e12.http://dx.doi.org/10.1111/j.1744-6198.2006.00045.x19.Schwartz-BarcottD,KimHS.Anexpansionandelaborationofthehybridmodelofconceptdevelopment.In:RodgersBL,KnaflKA,editors.Conceptdevelop-mentinnursing:foundations,techniques,andapplications.Philadelphia:Saunders;2000.20.CRD.Systematicreviews:centreforreviewsanddissemination’sguidanceforundertakingreviewsinhealthcare.York,UnitedKingdom:UniversityofYork;2008.21.GraneheimUH,LundmanB.Qualitativecontentanalysisinnursingresearch:concepts,proceduresandmeasurestoachievetrustworthiness.NurseEducToday.2004;24(2):105e12.http://dx.doi.org/10.1016/j.nedt.2003.10.00122.KostovichCT.DevelopmentandpsychometricassessmentofthePresenceofNursingScale.NursSciQ.2012;25(2):167e75.http://dx.doi.org/10.1177/089431841243794523.KuisEE,GoossensenA,vanDijkeJ,BaartAJ.Self-reportquestionnaireformeasuringpresence:developmentandinitialvalidation.ScandJCaringSci.2015;29(1):173e82.http://dx.doi.org/10.1111/scs.1213024.Mason-WhiteheadE,McIntosh-ScottA,BryanA,MasonT.Keyconceptsinnursing.London,UnitedKingdom:Sage;2008.25.CohenMZ,HausnerJ,JohnsonM.Knowledgeandpresence:accountabilityasdescribedbynursesandsurgicalpatients.JProfNurs.1994;10(3):177e85.26.JeffsL,AcottA,SimpsonE,CampbellH,IrwinT,LoJ,etal.Thevalueofbedsideshiftreportingenhancingnursesurveillance,accountability,andpatientsafety.JNursCareQual.2013;28(3):226e32.http://dx.doi.org/10.1097/NCQ.0b013e3182852f4627.NikpeymaN,AbedSaeediZ,AzargashbE,AlaviMajdH.Problemsofclinicalnurseperformanceappraisalsystem:aqualitativestudy.AsianNursRes.2014;8(1):15e22.http://dx.doi.org/10.1016/j.anr.2013.11.00328.JacobyS,OchsE.Co-construction:anintroduction.ResLangSocInterac.1995;28(3):171e83.http://dx.doi.org/10.1207/s15327973rlsi2803_129.LeeI,WangHH.Preliminarydevelopmentofhumanisticcareindicatorsforresidentsinnursinghomes:aDelphitechnique.AsianNursRes.2014;8(1):75e81.http://dx.doi.org/10.1016/j.anr.2014.03.00130.FawcettJ.Contemporarynursingknowledge:analysisandevaluationofnursingmodelsandtheories.Philadelphia,UnitedStatesofAmerica:F.A.DavisCompany;2006.F.Mohammadipouretal./AsianNursingResearch11(2017)19e2929
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