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   Table of Contents      
ORIGINAL ARTICLE
Year : 2022  |  Volume : 27  |  Issue : 2  |  Page : 125-133

Nurses as gifted artists in caring: An analysis of nursing care concept


1 PhD Candidate in Nursing, Student Research Committee, Isfahan University of Medical Sciences, Isfahan; Faculty Member, Nursing and Midwifery School, Kermanshah University of Medical Sciences, Kermanshah, Iran
2 Faculty Member, Department of Medical Education, Medical Education Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Faculty Member, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
4 Faculty Member, Endocrine and Metabolism Research Center and Department of Biostatistics and Epidemiology, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
5 Faculty Member, Nursing and Midwifery Care Research Center; Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission01-Feb-2021
Date of Decision07-Apr-2021
Date of Acceptance20-Dec-2021
Date of Web Publication14-Mar-2022

Correspondence Address:
Mr. Nasrollah Alimohammadi
Isfahan University of Medical Sciences, Hezarjerib Ave, Isfahan
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnmr.IJNMR_465_20

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  Abstract 


Background: Nursing care happens with the artistic presence of the nurse in the care setting. Despite its importance in nursing, yet many ambiguities surround its definition and characteristics. The aim of this study was to analyze the concept of nursing care. Materials and Methods: This concept analysis was conducted using Walker and Avant's approach. An extensive literature search was done in the Medline, CINAHL, Embase and SID databases to find articles published in English between 1988 and 2019. The search keywords were “care”, “nursing care”, “concept”, “concept analysis”, and similar words. According to Walker and Avant's approach, after selecting the concept and determining the aim of analysis, 3742 references were reviewed and 68 articles and 2 books were selected to determine and extract the defining attributes, antecedents, consequences, and empirical referents of the nursing care concept. Results: The three main defining attributes of the concept were relationship, compassion, and professional action. The antecedents were nurse-related, client-related and environment-related, and the consequences were for nurses, clients and community. Conclusions: The defining attributes, antecedents, and consequences determined in the present study help better understand the concept of nursing care. This study highlights the importance of the communicative, caring, and advocacy roles of nurses and their compassionate professional action in the promotion of individual and community health.

Keywords: Concept, nursing care, nursing


How to cite this article:
Hadadian-Chaghaei F, Haghani F, Taleghani F, Feizi A, Alimohammadi N. Nurses as gifted artists in caring: An analysis of nursing care concept. Iranian J Nursing Midwifery Res 2022;27:125-33

How to cite this URL:
Hadadian-Chaghaei F, Haghani F, Taleghani F, Feizi A, Alimohammadi N. Nurses as gifted artists in caring: An analysis of nursing care concept. Iranian J Nursing Midwifery Res [serial online] 2022 [cited 2022 May 18];27:125-33. Available from: https://www.ijnmrjournal.net/text.asp?2022/27/2/125/339424




  Introduction Top


Nursing care aims to provide care to individuals, families, groups, and communities throughout their lives[1]. The care concept is not unique to nursing, and it is widely used in other disciplines.[2] But the unique function of nurses is to provide care to sick and healthy individuals.[3] Nursing and care are closely linked together; hence, nursing is the most involved profession in caring behaviors, processes,[4] and relationships.[5] Throughout the history of the nursing profession, there have been different perspectives on nursing care.[5] Sometimes it is referred to as the planned process, which is developed and undergone by a trained nurse through personal nurse-client relationship and formed the essence of nursing,[6] sometimes it is defined as the most important role of professional nurses, and is considered as a part of nursing metaparadigm[7] The concepts of care, nursing and nursing care still seem to have occupied the minds of many experts over the years. This is due to the difference between theorists' view of the nursing and its central concept, care. For example, Nightingale (1852) described nursing as a duty-oriented profession, Rogers (1989) as a humanities practitioner, Newman (1991) as a health-oriented profession, and Leiniger (1996) and Watson (1997) as a science of care.[8] With all these interpretations of the concept of nursing care, we have to accept that it is a valuable concept and care is core of nursing education, health-related rules, and ethical principles for nurses.[6]

Despite the importance of the concept of care in nursing and the many of studies into its attributes,[5],[9],[10],[11] nursing professionals and clinical nurses have no clear definition of this concept.[12] Therefore, the application of the concepts of care and nursing in different situations has not created the same perception and has always been associated with challenges.[8] On the other hand, due to the progresses and technologies made in the nursing profession[13] and the emergence of new diseases.[13] It is to be hoped that the search for the meaning of the concept with concept analysis will open the way for its understanding that.[14] Concept analysis is an effective way to clarify the ambiguities surrounding concept Walker and Avant's approach one of the various methods available for concept analysis[15] and one of the simplest and most comprehensible methods available.[16] Therefore, in the present study, tried to be refined the meaning of nursing care by identifying important attributes, antecedents and consequences and empirical use with the walker and Avant's approach. The main questions of the study “How is nursing care refined in the literature?” And “What are its attributes, predecessors, consequences, and empirical references?”


  Materials and Methods Top


This concept analysis study was conducted using Walker and Avant's approach[15] in a 13-month period from 2018 to 2019. This approach has eight main steps as follows:

  • Selecting the concept
  • Determining the aims or purposes of analysis
  • Identifying all possible uses of the concept
  • Determining defining attributes
  • Identifying a model case
  • Identifying borderline, related and contrary cases
  • Identifying antecedents and consequences
  • Defining empirical referents.


In this study, the concept of nursing care was selected. The main study questions were “How nursing care is defined in the literature?” and “What are its attributes, antecedents, consequences, and empirical referents?”

In order to collect the required data, nursing and health-related literature were reviewed. For this purpose, an online search was performed in the Medline, CINAHL, EMBASE, and SID databases. The search date was set from 1988, i.e., the year the concept of care was introduced in nursing as a distinct concept,[17] to December 2019. The searched keywords were “care”, “nursing care”, “concept”, “concept analysis”, and related to the concept of nursing care. These keywords were searched in the titles, abstracts, and the main texts of the articles. Besides, the reference lists of the retrieved articles were manually searched to find relevant studies. Inclusion criteria were accessible full-text, English language and review, concept analysis, quantitative, or qualitative design. The primary search included 3742 records. Selection of the most relevant articles was done in a five-step record selection process in order to reduce the possibility of errors and biases in selection. Duplicated records (n = 178) and articles because of languages (n = 29) were excluded. Then 936 articles that their titles or abstracts were related to the concept of nursing care were assessed and then, the most relevant articles were selected (n = 168). Finally, 68 articles and 2 books, fulfilling the inclusion criteria, were included in the final analysis [Figure 1].
Figure 1: Flowchart of the selection process of the concept analysis

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Ethical considerations

This project was supported and approved by the ethics committee of Isfahan University of Medical Sciences with the project number IR.MUI.RESEARCH.REC.1397.455 as part of the doctoral dissertation


  Result Top


Identifying all possible uses of the concept

Use of the Concept: All applications of the concept were identified by reviewing the related literature.[15] The word “Care” is both noun and verb. As a noun it means concern, careful attention and attentive or therapeutic help for a person who is in need. As a verb “care” means feel concerned and look after and fulfill needs.[18] Also the word “Nursing” is derived from the root word nurse and is used both as an adjective and a noun. When it is used as an adjective, it refers to a woman who is feeding a baby with breast milk.[19] When it is used as a noun, it refers to the job of being a nurse.[20]

Defining attributes of the concept

Three main defining attributes identified in this study for the concept of nursing care include relationship, compassion, and professional action [Figure 2].
Figure 2: The conceptual framework for the concept of nursing care

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Attributes

Relationship: Relationship is considered as the essence of care, and nursing care is considered as an intervention,[21] which is undergone by nurses in the form of interpersonal interaction.[6] The art of nursing is to establish a caring relationship through which nurses compassionately use their knowledge, skills, and judgment.[22] Nursing care is an interpersonal and interactive process between nurse and client.[6] Nurse-client relationship includes both feelings and behaviors.[5] When a nurse, as a caregiver, enters the world of another person to understand him/her, their relationship results in the phenomenon of care and helps nurture personhood.[23] Consequently, nurses need to be committed and trained individuals with good communication skills[24] in order to establish trust-based relationships with their clients,[25] collect necessary data from them, provide the required data to the physicians, thereby facilitating the treatment process[24] and improving the clients' physical, emotional, and mental recovery.[25]

Compassion: Care is considered as an emotion and a sense of compassion or empathy for clients that motivates the nurses for client care.[5] Compassion includes empathy, the ability to understand and accept others' feelings, and kind toleration of distress in self and others.[26] It is a kind effort for reducing suffering[27] and thereby, is considered the essence of client-centered care and nursing. People who need nursing care consider themselves in need for compassion.[26] Compassion arises the nurses' feelings for helping those people who are enduring suffering and motivates the nurses for helping them.[28] Compassion has direct and indirect effects not only on personal relationships, but also on humanity and community. Contrarily, its absence can cause emotional distance among humans and result in their indifference to each other's suffering.[29]

Professional action: Nurses' professional action, which refers to their caring role, is performed through the nursing process.[7] It depends on their direct presence for clients.[17] Nurses provide care to clients to protect their health, manage their illnesses and symptoms, and help them reach the highest level of functionality and self-care ability.[7] Nurses need to have creativity, art, skills, and expertise in order to establish meaningful interactions with the clients, collect data about their preferences and cultural contexts, use analytical and critical thinking skills, assess conditions and equipment, and develop a unique nursing care plan in collaboration with clients and other healthcare providers.[30] After implementing this plan, they have to compare the clients' behaviors with behavioral standards and nursing goals, determine whether the clients have achieved behavioral balance,[31] promote their hopefulness, and hence, improve their coping with ailment, pain, and suffering.[6] Effectiveness of nursing interventions is determined through observing and measuring the clients' behaviors or interviewing them. In this step, nursing goals are reassessed, the level of their attainment is assessed, and new problems and goals are identified.[32] Assessment of nursing interventions is performed through asking questions such as “Is the client moving towards the determined goals?”, “Have the goals been attained?”, and “Do the predetermined problems still exist?” If answers to these questions show poor progression of the clients' conditions towards recovery, the nurses need to determine the relevant cause.[33]

Identifying antecedents and consequences

Antecedents of the concept

Antecedents are events that happen before the occurrence of the intended concept and refer to the necessary conditions for its occurrence.[15] In the present study, the antecedents of the concept of nursing care were grouped into three categories: nurse-related, client-related, and environment-related antecedents [Figure 2].

Antecedents

Nurse's effective communication skills: Nursing practice is based on interpersonal relationships[34] and nurses need communication skills in order to communicate with their clients and colleagues.[35] Nurses need to be present for the clients[17] and communicate with them,[24] because care delivery is a process that happens through therapeutic interactions between the nurse and client.[6] Accordingly, those nurses who are able to use the nursing process based on effective verbal and non-verbal communication are more successful in attaining care-related goals.[36]

Nurse's adequate professional knowledge: Nurses need to be committed and trained individuals to be able to provide quality client care.[24] Knowledge-related prerequisites for nursing care include professional and academic education and familiarity with Information and Communication Technology (ICT). Moreover, nurses need to update their knowledge through continuing education programs.[37]

Nurse's competent clinical skills: Besides professional knowledge, nurses need clinical/technical skills to perform clinical tasks and nursing procedures.[22] They also need competence, information, critical thinking, and appropriate questioning for successful performance of nursing skills and quality care delivery.[7] Competent nurses can provide quality care, and thereby, improve their own and clients' satisfaction.[22]

Altruistic attitude: Nurses also need to have an altruistic attitude towards the clients,[38] ability to empathy with the clients and their families,[39] sense of helping others, compassion.[40] Through an altruistic attitude,[38] nurses can actively listen to their clients, understand their emotions and feelings,[41] and develop individualized care plans in collaboration with them.[34]

Cultural competence: Clients are from different cultures and have different needs; hence, nurses need to pay careful attention to these issues, especially cultural difference.[42] In communities with wide cultural diversity, nurses need to have considerable cultural insight and knowledge to be able to pay attention to and respect their clients' knowledge and provide them with culturally-appropriate care.[35] Cultural incompetence may impair nurse-client relationships and result in negative care- and health-related outcomes.[42]

Nurse's effective leadership skills: Management is one of the nursing roles; therefore, nurses need leadership and managerial skills for effective nursing care delivery.[43] Effective care is performed through the interactive efforts of different healthcare providers. In addition, nurses need leadership and managerial skills to facilitate joint care planning and clinical decision-making in collaboration with the clients and different healthcare providers.[31] Nurses with good leadership and managerial skills welcome constructive criticism to improve the healthcare providers' relationships, reduce impulsive behaviors, create senses of loyalty and responsibility, and deliver effective nursing care.[44]

Ability to support clients and their rights: Nurses are in the best position for supporting the clients[45] so that client advocacy is considered as one of their main professional roles.[43] Through active client support, nurses can protect the clients' values and independence, improve their safety, self-control and quality of life,[46] and enhance their own professional power, professional status and job satisfaction.[46] Before the year 2000, client advocacy was a concept to track medical errors and protect the clients against the healthcare providers' incompetence or abusive behaviors. However, client advocacy was later extended to include preservation of client privacy, confrontation with inappropriate rules and policies, and identification and correction of inequalities in healthcare delivery.[47] In order to more strongly support clients and more appropriately identify and manage their problems and concerns, nurses need to identify clients' needs.[48]

Ability to perform research and use research results: Nursing should be research-based[49] because research-based practice improves client outcomes and facilitates quality care delivery.[50] The nurses need to have adequate information about the existing healthcare-related evidence.[50] Using research results helps empower nurses because it reduces the use of haphazard and traditional actions, develop care and nursing standards, improve care quality, and enhance client safety.[50] Nurses who base their actions on scientific evidence are more flexible, avoid old routines, make better decisions, provide care with higher quality, reduce the clients' hospital stay and hospitalization-related costs, and improve cost-effectiveness of care services.[51]

Client's individual characteristics: Client as a human has individual characteristics such as gender, age, marital status, and educational level that can affect his/her perception of nursing care and provide clues about how to plan care. A nurse needs to plan and provide individualized care based on the clients' individual characteristics.[52] Moreover, respecting human dignity and the uniqueness of each person is among the professional values of nursing.[1]

Situational characteristics: Situational characteristics include client satisfaction,[53] family background, culture, and all other characteristics of a client in a given situation, which can affect his/her perception of the process of care. Each client is a unique person and a coherent undividable whole with unique culture, values, and beliefs and has freedom to choose from the available caring options.[54]

Client's ability to identify self-care deficit needs: In the contemporary world, clients not only are not passive, but are knowledgeable and capable of learning.[55] They are aware of their social rights and are able to seek and find care resources in real and virtual worlds using ICT.[55] Therefore, they can identify their self-care deficit needs, update their knowledge during the process of care, and ask their questions to improve treatment and care outcomes.[56] In fact, it is the ability to identify self-care deficit needs that requires clients to seek nursing care; these needs motivate nurses to provide nursing care for their fulfillment.[31]

The holistic view human being's dimensions (bio-psycho-social-spiritual) indicates that there is a close relationship between humans and their environment.[57]

Physical environment: Physical environment includes care-related equipment, clean air (ventilation), clean water, effective drainage, lighting, quietness, nutrition, and heat.[58] Moreover, physical environment relates to the geographical position of a country, city, or village and the distance to care-related facilities.[51]

Cultural environment: Cultural environment refers to the cultural conditions in which care is delivered. Clients and nurses may have different cultural conditions; yet, through knowing the culture of clients and the immediate communities, nurses can improve the quality of their care services, and thereby, enhance client satisfaction.[35]

Organizational environment: In order to provide quality nursing care to nursing clients, a healthcare organization needs adequate number of knowledgeable and experienced staff. Besides, nursing care standards as well as strategies for organizational goal attainment are needed for the delivery of quality nursing care.[59]

Consequences of the concept

Consequences happen after the occurrence of a concept or event and usually produce new ideas or directions for research.[15] The consequences of the concept of nursing care in the present study were consequences for nurses, consequences for clients, and consequences for community [Figure 2].

Consequences for nurses: The consequences of nursing care for nurses include good spiritual feeling, satisfaction, purposefulness, self-esteem, respect for life and death, knowledge-based reflection, and love of nursing.[7] They also understand that they can overcome barriers to the attainment of their goals, and thus, feel greater hope and confidence in their abilities.[17],[40] Nursing care delivery also helps nurses to promotes their motivation and desire for quality practice, professional development, and inter-professional collaboration.[54]

Consequences for clients: Quality nursing care helps establish safe, kind, and empathetic relationships with clients[60] and, protects human dignity.[61] It also helps clients identify their feelings and emotions, acquire higher levels of self-awareness,[62] and fulfill their self-care deficit needs.[63] Other consequences of nursing care for clients are happiness,[64] healing, health promotion, sense of well-being, safety, peaceful death,[65] empowerment, and satisfaction.[40]

Consequences for community: Nurses form the largest group of healthcare providers in clinical settings; hence, the quality of nursing care can exert long-term effects on clients, families, healthcare organizations, and communities, as well as public attitude towards the quality of healthcare services in a given healthcare organization.[66] Furthermore, it many help manage healthcare-related costs,[66] promotes the context of healthcare delivery in communities, improves quality of life, and enhances public health.[62]

Model case

Model case is an example of the use of the concept, which represents all of its defining attributes and helps better understand the concept' meaning.[15]

Mrs. A is a nurse in a surgical ward. During the initial relationship at the shift handoff, she notices that one of her clients is a seventeen-year-old girl with right femoral fracture who has undergone surgery two days ago and is currently writhing in pain. The client has developed urinary retention since the last night and her family members refused urinary catheterization due to cultural issues. Mrs. A ensures client privacy, holds her hands, looks at her concerned face, sits on a chair next to her bed, and tells her that her pain is due to the contractions of her bladder muscles. Then she gently touches the client's bladder under her umbilical area and tells her that her bladder is completely palpable there. The client feels slight calmness and says that she cannot void. Mrs. A says the client: “If you trust me, we can find a solution”. The client agrees by nodding her head. Mrs. A says: “If you refuse catheterization, nobody can force you to undergo it. I understand why you and your family refuse catheterization. I am attempting to use other techniques in collaboration with yourself to empty your bladder, but you have to promise me that you will help me; otherwise, catheterization may be necessary to save your life”. The client becomes happy and Mrs. A opens water faucet, places a bedpan, and prepares her for voiding. While holding the nurse's hand, the client screams and says that it is impossible, but Mrs. A encourages her to do so. After several minutes, the client successfully empties her bladder. Their eyes glow with happiness. She presses Mrs. A's hands and says that she feels comfort. She thanks Mrs. A and says that she was very worried over catheterization. Mrs. A responds that the same worry had resulted in urinary retention.

Contrary case

A contrary case is an example showing what the concept is not.[15]

Mrs. B is a nurse in a coronary care unit where candidates for coronary angiography are admitted. At the night shift, a 45-year-old man is admitted to the unit to undergo angiography the next day. Mrs. B asks client's wife to leave the unit. The client gets worried and asks the nurse to allow his wife stay with him because she has no place in the city to stay at night. Mrs. B does not care, points to the ward rule sign, and directs the client's wife out of the unit. Then she assesses and documents client's vital signs as the following: Blood pressure: 130/75 mm Hg, Heart rate: 88 per minute, Respiratory rate: 18 per minute, and Oral body temperature: 37°C. The client thinks the whole night about her wife while Mrs. B indifferently writes her shift report and does her tasks. She does not notice that the client is awake all the night. At 06:00 am, she assesses and documents the client's vital signs as the following: Blood pressure: 140/85 mm Hg; Heart rate: 100 per minute; Respiratory rate: 20 per minute, and Oral body temperature: 37°C. The client unhappily looks at Mrs. B, says that he has been unable to sleep all the last night due to his worry about her wife, and asks her to allow him visit his wife. Mrs. B laughs; however, the client becomes unhappy at her laugh. At 07:00 am, Mrs. B takes the client to the angiography unit. In the way, the client continuously searches for his wife in the hospital corridor and wonders about her absence there. When they arrive at the angiography unit, the client sees a security staff of the hospital with bloody ear as well as his own brother with handcuffs accompanied by two police staff. He suddenly feels heart palpitation and squeezes his chest with his hand. Mrs. B becomes agitated and calls the angiography unit nurses for help. They assess his vital signs and record an electrocardiograph. Blood pressure is 190/110 mm Hg; hence, angiography is cancelled. At that time, the client prefers death for coming to that hospital and suddenly experiences nosebleed. Blood pressure is announced to be 240/140 mm Hg. He is connected to the cardiac monitoring system and his vital signs are assessed. Blood pressure is 240/150 mm Hg and Heart rate is 120 per minute. At this point, the client loses consciousness and develops respiratory arrest and ventricular fibrillation. Cardiopulmonary code is announced and the client dies after a 50-minute cardiopulmonary resuscitation.

Empirical referents of the concept

Empirical referents are ''classes or categories of actual phenomena that by their existence demonstrate the occurrence of the concept itself''[15] that referents relate directly to the defining attributes, though not directly to the concept itself, and may be used to measure the defining attributes and provide indirect evidence that demonstrates occurrence of the concept in a practice setting.[15] Empirical referents for nursing care may include (a) Caring relationship (Relational Caring Questionnaires, Nurse–Patient Relationship Questionnaire, Caring Nurse–Patient Interactions Scale); (b) Professional nursing care Behaviors (CARE-Q and CARE/SAT and Modified CARE-Q (Larson's Care Questionnaire)), Caring Behaviors Inventory and Caring Behaviors Inventory for Elders, Caring Behaviors Inventory and Caring Behaviors Inventory for Elders, Caring Behaviors Assessment Tool, Professional Caring Behaviors, Nyberg Caring Assessment Scale, Caring Ability Inventory, Caring Assessment Tools: CAT-V, CAT-Admin, and CAT-Edu, Caring Efficacy Scale, Holistic Caring Inventory); (c) Client Perception of nursing care (Caring Behavior Checklist and Client Perception of Caring Scale, Development of the Caring Factor Survey (CFS), an Instrument to Measure Patient's Perception of Caring); (d) Care Environment (Caring Attributes, Professional Self-Concept, and Technological Influences Scale, Methodist Health Care System Nurse Caring Instrument).[67] Each of the above instruments has its strengths and weaknesses and can be used according to the goal of the measurement and the characteristics of the context”. For example Larson's Care Questionnaire is one of these instruments. Its easy administration has turned it into the most commonly used instruments for nursing care measurement. It has 6 subscales of nurse availability: accessible (6 items), explains and facilitates (9 items), comfort sand (11 items), anticipates (5 items), Trusting relationship (18 items) following-up (8 items) and a total of 57 items. To calculate the score of each subscale, add the score of each item related to that subscale. To calculate the total score of the questionnaire, the score of all related items with Add up: The score range of this questionnaire will be between 57 and 285. The higher the score obtained from each subscale of this questionnaire, the higher the level of caring behavior and inverse.[68],[69]

Definition of the concept of nursing care

Based on the results of the present study, the concept of nursing care can be defined as: Nursing care is a compassionate professional action that begins with establishing an effective, professional, competent, humane and scientific relationship according to the client's culture and meet to his/her needs. This type of nursing care is provided for the client's health, professional development in the nurse and the promotion of community health, with the presence of the nurse and the client's participation, in accordance with his characteristics and taking into account environmental conditions and facilities.


  Discussion Top


This study analyzed the concept of nursing care based on Walker and Avant's approach to concept analysis. The findings revealed that the conditions for nursing care delivery depend on the characteristics of nurse, client, and environment.

In present study, findings revealed that nurses having good relationship with the clients are doing the real nursing care, and any nursing care without such a relationship is incomplete. Also, the results of the present study revealed that the nursing care is a human practice, and it can be said that the nursing care cannot be separated from the care he/she provides. Also care without compassion is a body without heart. Morse et al.[11] considered care as a joint human behavior, an ethical necessity or ideal (to protect human dignity), an affect (consisting of emotion, compassion, or empathy), an interpersonal relationship (between nurse and client), and a nursing intervention. In a comparative study, they concluded that care is a human factor and a sense of compassion and empathy for clients, which is based on reciprocal relationship, trust, respect, and commitment. They considered compassion as an inseparable part of nursing and criticized the lack of a firm theoretical framework about the concept of nursing care to be used in nursing research and practice.[5] Similarly, Ghafari and Mohammadi reported that nursing care is the fulfillment of clients' needs, an altruistic and empathetic feeling, committed service delivery, and a holy and routine activity.[10] Zamanzadeh et al.[3] noted that compassionate nursing is a type of care in which nurses establish relationship with clients, put themselves in the clients' shoes, and attempt to understand their conditions in order to identify and manage their problems and concerns. All of these studies emphasize the importance of compassionate relationship.

Dalpezzo noted that the professional action of nursing care is process-like, skill-based, comprehensive, ethical, and participatory and has both personal and interpersonal aspects.[22] Therefore, professional action is a key and critical part of nursing care. In fact, when the nurse's relationship with the patient is compassionate, but the assessment, diagnosis, planning, implementation, and evaluation are not done well, nursing care has not happened yet. Can a nurse without hands provide nursing care?

The nurse-related antecedents in present study showed the nurses who can begin their relationship with verbal and body language skills, can deliver successful nursing care. Similarly Hermann et al.[70] noted that demonstrating courtesy and politeness of nurse with positive nonverbal body language, like contact with smile or sitting down, play importance role to the patient's communication experience. Competent clinical skills can make the nurse's hands stronger. The nurses with an altruistic attitude consider nursing care for alleviating the clients' concerns as their humanistic responsibility and never hurt the clients' emotions and feelings with inappropriate behaviors. The nurse's altruistic skill adds human value to the care provided by him/her. That is why no one has claimed that nursing care, can be done with machine, and effective leadership is the prerequisite for all the three defining attributes of nursing care, which were mentioned in this study. The findings in present study, highlighted the importance of nurses' physical presence for nursing care delivery. In other words, the care provided by non-nurse individuals is not nursing care, because the nurse, with all her/his abilities, plays a key role in the implementation of quality nursing care practice. These findings were confirmed by previous studies.[10],[22],[66]

Clients' characteristics were also among the antecedents of nursing care in the present study. This is also mentioned in the findings of Morgan and Yoder.[71] Hence, nurses need to understand their clients' situations, treat them with kindness, and improve their senses of trust and safety. In fact, the art of nursing is to provide individualized care based on the unique characteristics of each client. Also, environment was found as the other antecedent for nursing care concept. Similarly, Koy et al.[66] directly referred to environment as an antecedent of nursing care, while Mhlanga et al.[72] indirectly referred to environment by considering standard instruments, processes, structures, consequences, and contents as the antecedents of care quality. The environment can on the one hand improve nursing care quality,[58] but on the other inappropriate physical, organizational, and cultural environment may degrade nursing care to simple physical care measures and result in the failure of quality nursing care delivery even in the presence of competent nurses. Overall, environment, with all its capabilities, plays a key role in delivering quality nursing care to the needy client.

The present study findings showed that the consequences of nursing care for nurses are higher job motivation, greater self-confidence, better professional performance, and professional development. Professionally competent nurses have good communication skills, altruistic attitude towards their clients, and satisfaction with the clients' healing and calmness, and value their position in professional care delivery.[17],[40] A nurse, who can use her/his relationship, compassion, and professional action to provide nursing care, will never feel real fatigue, because his/her resistance to the difficulties of caring will increase. In addition, she/he does not feel loneliness and communicates with others with a sense and language full of respect, a respect suitable for herself/himself and her/his client.

According to the results of the present study nursing care has different positive consequences for clients, including self-awareness, successful need fulfillment, happiness, health promotion, healing, well-being, safety, empowerment, and satisfaction. In line with this finding, previous studies reported the consequences of nursing care for clients as better healing ability,[17] empowerment, satisfaction,[10],[66] better mental experience, and healthier physiological status.[5] By client' satisfaction, he/she knows that the nurse understands him/her; this helps for his/her early recovery. Client knows that the nurse sees him/her not as a body, but as a respectable person who needs nursing care.

The consequences of nursing care for community in the present study were deeper senses of empathy and responsibility, better healthcare delivery context, high quality of life, higher public health status, and lower healthcare-related costs. Similarly, two earlier studies reported that nursing care reduces healthcare-related costs[10] and helps better manage budget.[66] Costs, in turn, can affect both the process and the consequences of nursing care.[73] Nursing care that is done with good social relationships, with love and kindness and with capable hands on competent nursing always remains in the minds of the people in community. It should be borne in mind that this concept analysis was ultimately only a careful examination and description of concept of nursing care in the scientific literature. Since the concepts have a dynamic nature, changing by the cultural, social, and contextual factors.[74] Therefore, one of the limitations of the walker & Avant method and this study was failure to examine nursing care in the clinical field. It is suggested that the components obtained from this concept be used in clinical education of nursing students and continues education courses for clinical nurses. Also, more research should be done to examine the views of clinical nurses on the components of the concept of nursing care obtained from this study.


  Conclusion Top


Paying due attention to nursing care has a direct effect on community health care. The concept of nursing care must be clarified if we want applicable nursing care based on nursing sciences. The nurses need to attempt to develop their competences for nursing care development. They need to be aware of client and community capacities. Finally, healthcare organizations need to clarify them expect criteria required for providing quality nursing care, as well as necessary resources, instruments, and programs to develop nurses.

Acknowledgements

The authors consider it necessary to express their sincere gratitude to the jury of the dissertation, the staff of the library of the School of Nursing and Midwifery of Isfahan University of Medical Sciences (Grant number 397672).

Financial support and sponsorship

Isfahan University of Medical Sciences

Conflicts of interest

Nothing to declare.



 
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