Malahat Nikravan-Mofrad*, Shahram Yazdani, Soleiman Ahmady and Mansoureh Zagheri Tafreshi

Department of Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

DOI : https://dx.doi.org/10.13005/bpj/835

Abstract

This paper analyzes the representative features of the nursing concept, based on the McKenna (1997) approach in nine steps. In general, nursing can be defined as follows: "Nursing is a profession that offers its services to patient(s) of all ages, ill or healthy during the whole lifespan; focuses on nursing care of patients, health promotion, and interaction between the individual and environment. Nursing is committed to human dignity, comprehensive patient care, professional commitment, respect for patients' rights, participation in patient care, adoption of good manners, and professional behaviour; and is committed to addressing patient needs, protection of safety, care, care follow-up, and improvement of patient's quality of life. This profession offers its services in the areas of patient's living environment, health care centers, society, legal or academic centers by people with good moral qualities, features of leadership/management/planning of change, features of problem-solving/decision-making, and professional behaviour, and also have university degree and proper certifications. The roles of nursing include providing cares, making communication, designing and implementing nursing procedure, leadership/management/planning of change in the care of patient, evaluation/follow-up care of patient, counseling/education, prevention/rehabilitation, and research."

Keywords

Nursing Concept; Analysis of Nursing; McKenna approach

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Introduction

Development of the model of nursing education based on the explanation of the role of nurses in the health system will not be possible without analyzing the nursing concept and its infrastructures. Nursing concept is a dynamic concept and constantly evolving in response to the new health needs of the patients. It is clear that providing a single definition for the nursing concept is too limited to be able to cover all aspects of this profession. By analysing the nursing concept we can achieve the three following objectives:

• To describe nursing to people who do not understand and have no knowledge about it
• To shed light on the role of nurses in a multidisciplinary health care team
• To expand nursing curriculum

Therefore this study was designed to analyze, explain elements and infrastructures, and identify the empirical indicators of the nursing concept using Mc Kenna (1997) approach.

To analyze the nursing concept, the McKenna method (McKenna, 1997) was used and according to it the concept was analyzed in the following 9 steps:

1. Select the nursing concept
2. Define the goals of the analysis of the nursing concept
3. Identify the meanings of the nursing concept
4. Determine the defining features of the nursing concept
5. Identify a model case or a specific example
6. Introduce alternative cases (what is not nursing)
7. Identify antecedents and consequences of nursing
8. Consider context and values of nursing concept
9. Identify empirical indicators of nursing concept.

Step 1: Selecting the concept of interest

In this step we answer the question “what are the elements and structures of nursing concept?”

            Concepts incorporated within a theory or separate from it, explain and describe a phenomenon. Therefore, if a concept is obscure it must be described in the form of propositions. Nursing is also a broad concept that can be examined at three levels (McKenna 1997):

• Global concepts of nursing: These are concepts represented by metaparadigm and include person, health, environment, and care.
• Middle-range concepts of nursing: Include the expansion of nursing global concepts through nursing theories and models that are defined under systemic, interactive, evolutional, and behavioral paradigms.
• Empirical concepts of nursing: These concepts are much more accurate and their boundaries can be determined. Each intermediate concept could include a wide range of these concepts.

Step 2: Stating the aim of nursing concept analysis

The outcome of a successful analysis of a concept includes the identification of reliable indicators to inform us of the various aspects of a concept. Until the structure of the nursing concept is not accurately analyzed, it cannot be clearly defined. Therefore, at this step the aim is to explain the elements and structures of the nursing concept according to the theories and models of nursing.

1-2) Nursing Metaparadigm (global concepts)

Key concepts that provide the foundation of the understanding of nursing are considered as the vital concepts in nursing programs and include the concepts of individual, health, environment, and nursing (McKenna 1997, Fawcett and DeSanto-Madeya 2013).

2-2) Nursing Philosophy

Nursing philosophy consists of protection, promotion, and optimization of health and capability, prevention of illness and injury, reduction of pain and suffering through the diagnosis and treatment of human response, and support in the care for individuals, families, communities and society (Edwards 1997, Meleis 2012).

2-3) Nursing Paradigms

Systemic Paradigm

Man is a system that interacts with its environment. Any incident or accident in the environment can affect the human system. Many nursing theories have their roots within the systemic paradigm and they often consider the patient as an open system (McKenna 1997). The theories under this paradigm are called outcome theories (Outcome T) and the most important nursing theories in this paradigm include Neuman’s healthcare system model, Johnson’s behavioral system model, and Roy’s compatibility model.

Interactional Paradigm

This paradigm is built based on the relationship between humans and the roles they play in society. In this paradigm, all human activities are described in terms of interaction. Theories derived from this paradigm are concerned with interactive processes between nurse and patient (McKenna 1997). Theories under this paradigm are called interaction theories (Interaction T) and the most important nursing theories in this paradigm consist of King’s access to goal theory and Orlando’s nurse-patient dynamic relationship model.

Developmental Paradigm

The central core of this paradigm is growth and development, maturity, and change. Based on this theory, human beings are constantly under physiological, social, cognitive, psychological, and spiritual development, and must pass through various stages. The role of the nurse is to encourage positive development and to eliminate obstacles to development. The theories under this paradigm are called humanistic theories (Humanistic T.) and the most important paradigms under this paradigm are Peplau’s interpersonal model, Travelbee’s interpersonal aspects of nursing model, and Betty Newman’s healthcare system model.

Behavioral Paradigm

This paradigm is derived from Maslow’s motivational theory and is concerned with human needs. In bahavioral paradigm individuals continue their existence and survival normally when their needs are met (McKenna 1997). Theories under this paradigm are called needs theories (Needs T.) and the most important nursing theories under this paradigm are Henderson’s nursing essence model, Orem’s self-care and failure in self-care theory, and Wiedenbach’s clinical nursing model: the art of helping.

2-4) Expanding Global Concepts of Nursing (Middle-range Concepts) through Nursing Theories and Models

To develop the global concepts of nursing, four concepts of human, health, environment, and nursing were studied from the viewpoint of nineteen nursing theorists (McKenna 1997, Kim and Kollak 2006, Meleis 2012). Summary of these definitions are as follows:

Person/Man

• Needs theorists (behavioral paradigm): Human beings, either ill or healthy, are biological creatures with inseparable mind and body with a certain share of fundamental human needs. Human needs are influenced by the environment, and as an integrated whole include physiological, emotional, or social needs.
• Interaction theorists (Interactional paradigm): Man, is a unique and developmental being, and has needs that might be subjective and not directly observable. He is a creature who is rational, emotional, social, and thoughtful, with feelings and capable of the informed determination of the goal, selection of different solutions, decision-making, and choosing means which lead to the goal.
• Outcome theorists (Systemic paradigm): Man is a behavioral system with secondary behavioral subsystems who maintains his stability through internal and external environments. He constantly strives to maintain his integrity and totality, and his reactions are as a whole unit. He also, interacting with the environment, is constantly changing.
• Humanistic theorists (developmental paradigm): Mankind as an integrative creature, objective, open and free to choose is interacting with his world. His existence consists of a physiological, psychological, socio-cultural, developmental, and spiritual entity. An inseparable whole that performs activities related to the course of life. Human is a dynamic model of energy and an open system interacting with environment. He is a valuable person to be cared, respected, and educated.

Health

• Needs theorists (behavioral paradigm): Health is a state of wholeness or integrity  of individual, his parts, and his methods of operation. Health is a collective process, influenced by environmental, physiological, and psychological factors. Unfulfilled needs encompass all health needs and the health of mind and body. Health is created under the influence of a safe and secure environment.
• Interaction theorists (interactional paradigm): Health is the human dynamic life experience that is obtained by continuous adaptation to stresses in internal and external environments. Health is more than the absence of disease, and is defined with the highest level of well-being. It can be explained as a sense of adequacy or well-being, fulfillment of needs, and feeling of comfort. Health is a state in which the person is physiologically, psychologically, and socially in a good condition, and it is not just the absence of disease or disability. Achieving the highest level of health regardless of race, religion, and economic, political, and social status is the inalienable right of all human beings.
• Outcome theorists (systemic paradigm): Health is the effective and efficient performance of the system in maintaining the balance and stability of the behavioral system. Health and disease are patterns of comparative changes, we cannot imagine them as two separate parts, because they increase and decrease consistently and form a state of life process. Health means successful adaptation, having control over life, and freedom to choose.
• Humanistic theorists (Developmental paradigm): Health is the unity and harmony between mind, body, and soul. When the patient is whole-heartedly in balance, and all his needs are met, the individual is in a desirable health condition. This is an indication of a favorable level of independence in each one of life activities that enables the individual to operate with his maximum potential.

Environment

• Needs theorists (behavioral paradigm): Environment includes internal and external aspects of life that affect the individual. Environment is a subcomponent of human, which forms the self-care integrated (environment-human) system and may positively or negatively affect the performance of the patient.
• Interaction theorists (Interactional paradigm): It includes the objective and subjective world of the individual. External environment is an organized social system that has defined borders. Internal environment encompasses the energy to adapt to constant changes of the external environment. Nurse is a part of the environment of the patient.

• Outcome theorists (systemic paradigm): Environment includes all physical, interpersonal, and socio-cultural factors that are not part of human behavioral system but influence it. Both internal and external environments can be a factor in creating Behavioral systems try to make them adaptable and compatible in reaction to environmental factors, and maintain their balance.
• Humanistic theorists (developmental paradigm): Environment consists of the whole human experience from his existence in the world (the Gestalt whole). Environment consists of all internal and external factors and/or effects that constitute the patient system. Stressors are part of the environment that may affect the individual during his lifetime and cause his move towards maximum dependence or maximum independence.

Nursing Cares

• Needs theorists (behavioral paradigm): Nursing consists of providing a professional assistance and a comprehensive service to meet the need of the patient. What nursing does is to place the patient in the best normal performance condition and to increase the ability to help and care for self, and to help for recovery from illness, or to deal with their effects. Nursing is a profession that with the aid of capability and knowledge helps the patient in performance improvement and health recovery (or a peaceful death).
• Interaction theorists (Interactional paradigm): Nursing is a humanistic profession that focuses on interpersonal and inter-subjective interactions and involves all unique potentials and limitations of both sides. An interpersonal process and a service that leads to change and impact of this change on others. Nursing service is provided to individuals who suffer for any reason. In other words, when an individual is no longer able to perform his role, nursing services come into play.
• Outcome theorists (systemic paradigm): Nursing is a socially valued service that its goal is to increase positive adaptability to the stimulating factor and stress, by the patient. Nursing is the external adjusting factor for maintaining the behavioral structure of the patient by manipulating the regulatory mechanisms or supporting the patient under stress.
• Humanistic theorists (developmental paradigm): Nursing is the humanistic knowledge about individuals and human’s health-illness experience that is created by mutual interactions of humanistic, ethical, scientific, personal, and professional care. Nursing is the practice of helping individuals to use the power within to achieve higher levels of knowledge, and to evaluate the potential effects of the environmental stressors, and to act in relation to them. Nursing guides human beings in finding the meaning of circumstances, choosing methods for creating health, and real and lively presence in everyday life.

Step 3) Finding Meanings Related to Nursing Key Concepts (Nursing Empirical Concepts)

In this step, by reviewing the literature related to the nursing concept (34 sources), first the fields that include the nursing concept were identified. This classification was totally preliminary. Therefore, at later stages, the nursing concept analysis areas were redefined. Table 1 represents an example that shows how sources are studied in relation with nursing empirical concepts. As shown in table 1, the researcher, at the same time as studying the source, encodes the sentences that have a relation with each of the primary concepts and places them in the relevant line. The researcher has also highlighted the important keywords in each sentence.

Table 1: Method of the extraction of basic concepts from source 4 Click here to View table

 

Step 4- Determining the Representative Features of Nursing Concept

At this step, after reviewing the fields related to the nursing concept, a new classification in eight areas was established. Thus, eighth sub-concepts, along with classifications related to each of them, were provided to illustrate different aspects of nursing. Accordingly, the representative features of the nursing concept can be summarized as following:

1. nursing goals
2. focus of nursing care
3. nursing professional values
4. audience of nursing care
5. fields of nursing care
6. features of the providers of nursing care
7. level of education of the providers of nursing care
8. role of nurses in providing nursing care

In the following, each of these features will be discussed in details.

4-1) Nursing Cares Goals

4-1-1) Addressing the needs of the patient

It means to indentify, understand and anticipate patient’s  unspoken needs, to obviate comprehensive needs, to find the disease cases, and also to maintain the balance in the physiological, psychological, and emotional system of the patient.

4-1-2) Patient care

It means to plan and implement direct and patient-centered care, during lifetime until death, in order to minimize patient’s suffering and pain.

4-1-3) Maintaining the patient security

Meaning to provide safe care, prevent secondary injury, and protect and defend the patient.

4-1-4) Following up the care of the patient

It means to follow up the implementation of treatment regimens, and to help patients to maintain, recover, and/or improve their health.

4-1-5) Helping the patient to achieve independence

It means providing patient-centered education, education in using methods of coping with changes in health, development of self-care activities, adaptation with changes in health, and also helping to increase the confidence of the patient for independence in the fastest possible time.

4-1-6) Improvement of the patient’s quality of file

It means health counseling with patients in order to achieve the highest level of heath, preventing illness and disability, and facilitating access, and maintaining the best possible quality of life until the end of life

(Cherie et al., 2005, Foley, 2003, adapted, and revised by Dr. S. McMahon, 2009, Johnson, 1968, Kemppainen et al., 2012, Joyce, 2008, McLennan Community College, 2014, Meleis, 2012, Monareng, 2012, Nursing Management, last update 2010, Olin, 2012, Nursing Programs Philosophical Concepts, 2013, Papathanasiou et al., 2013, Royal College of Nursing, 2012, Vaartio et al., 2006, Xiaohan, 2005, Yildirim and Özkahraman, 2011).

4-2) Focus of Nursing Care

4-2-1) Nursing patient

It means an individual who due to illness cannot meet his/her physiological-psychological-cultural needs, requires comprehensive and optimal nursing care with the help of the identification of human response to real or potential health threats, and human death and life experiences.

4-2-2) Health promotion

It means preservation, promotion, and optimization of health, development of health, increasing the scope of the health of individuals, and promoting the hygienic behavior patterns of the patient.

4-2-3) Interactions between individual and environment

Meaning the optimization of the environment and coordination of the physiological, psychological, social, and therapeutic interaction between the individual and the environment to promote health and recovery (Dossey, 2008, Dossey and Keegan, 2013, Johnson, 1968, Kemppainen et al., 2012, McLennan Community College, 2014, Meleis, 2012, Monareng, 2012, Papathanasiou et al., 2013, Royal College of Nursing, 2012,  Vollman and Martin-Misener, 2005).

4-3) Nursing is a profession committed to the following values

4-3-1) Human dignity

It means belief in the dignity and value of the patient, respect for independence and attention to the nature of man, and maintaining peace and dignity of the patients in deathbed.

4-3-2) Holistic care for the patient

It means that caring takes place with patient-centered approach and according to physiological, psychological, social, and spiritual integrity of the man, and providing equal care according to health requirements to all patients, with attention and respect to the unique needs of the patient, and in an effort to reduce his suffering and pain, in order to maintain and promote the health and strength of the patient, and with the help of establishing remedial interaction with the patient.

4-3-2) Professional commitment

It means responsibility to human health and professional performance, as well as accountability to decisions and professional performance.

4-3-4) Respect for patient rights

It means supporting and defending patient rights, respecting his/her culture and religious beliefs, and protecting patient’s privacy.

4-3-5) Participation in patient care

It means decentralization of decision-making and sharing decision-making with the health care team and patient along with respect for acknowledgment of the importance of the work of all members of the health care team.

4-3-6) Good manners

It means having integrity and honesty, and maintaining humanistic relationships with patient, performing compassionate care with empathy, and adoption of non-judgemental attitude towards the patient.

4-3-7) Professional behavior

It means commitment to professional values and standards and obligation to provide nursing services within the ethical and legal framework of the professional performance during the period of service (Carey, 2000, Cherie et al., 2005, College of Registered Nurses of British Columbia, 2013, College of Nurses of Ontario, 2009,  College of Registered Nurses of Nova Scotia, 2012, Dossey, 2008, Foley, 2003, Updated, adapted, and revised by Dr. S. McMahon, 2009, Habayeb, 1995, Kemppainen et al., 2012, McMahon, 2009, Meleis, 2012, Monareng, 2012, National council of state broads of nursing, 2011, Nursing Programs Philosophical Concepts, 2013, Papathanasiou et al., 2013, Royal College of Nursing, 2012, Swihart and Porter-O’Grady, 2006, Swihart, 2011, Xiaohan, 2005 )

4-5) Nursing care is provided in the following areas

4-5-1) Patient’s environment

Meaning home, temporary hospice and housing center, nursing home, and mentally ill institution.

4-5-2) Healthcare centers

It means hospitals and clinical centers

4-5-3) Society

Meaning social systems, physicians’ offices, health centers, rehabilitation centers, and health establishments.

4-5-4) Academic centers

It means nursing universities and colleges, research and informatics centers.

4-5-5) Legal centers

Meaning legal nursing center and legal nurse consulting (LNC) center (Meleis, 2012, Xiaohan, 2005, learn4good, 2014, ANA, 2015).

 4-6) Features of Nursing care providers (nurses)

4-6-1) Mood features

Meaning philanthropy, empathy, having good temper, having confidence in providing professional nursing services, and the ability to turn these emotional features into compassionate, sensitive, and appropriate care.

4-6-2) Leadership/management/planning of change features

Meaning playing the role of a leader, manager, and agent of change, and also health care regulator, and self-regulation.

4-6-3) Problem-solving/decision-making features

It means playing the role of the nurse as the analyst of the patient needs, evaluator of the health care measures, clinical ratiocinator, decision maker and health problem solver for the care of the patient.

4-6-4)Professional behavior features

It means having professional expertise, commitment to professional values, abiding the law, accountability and responsibility, being supportive of the physiological, psychological, and spiritual needs of the patient, and having educational and researching role (ANA, 2015, Banning, 2008b , Cherie et al., 2005, Foley 2003, Updated, adapted, and revised by Dr. S. McMahon, 2009, Jeffreys, 2008, Nursing Management, last update 2010, College of Registered Nurses of Nova Scotia, 2012, Vollman and Martin-Misener 2005, Royal College of Nursing, 2012, Banning, 2008a, Banning, 2008b, College of Registered Nurses of British Columbia, 2013, Yildirim and Özkahraman, 2011, Nursing Management, last update 2010, Nursing Programs Philosophical Concepts, 2013, Wade, 1999, Nursing Programs Philosophical Concepts, 2013, McLennan Community College, 2014 ).

4-4) Nursing services are provided for the following individuals or groups:

4-4-1-) Patient/patients: Meaning individual or family, ill or healthy, from all age groups, during the whole lifespan until death.

4-4-2) Groups

Includes associations, communities, and society(Royal College of Nursing, 2012, Espinoza and Walston, 2005, Xiaohan, 2005, Foley, 2003, Updated, adapted, and revised by Dr. S. McMahon, 2009).

4-7) T provider of nursing care (nurse) has the following educational degrees

4-7-1) Work certification

It mean the certificate for a graduate of nursing  that shows he/she has  the abilities necessary to care nursing patients.

4-7-2) Associate degree or two-year practical nursing certification

Meaning programs that are offered by small and local nursing colleges. Obtaining this degree takes 2-3 years, and it focuses more on practical and technical skills than theoretical courses. Graduates can apply for higher levels of education after graduation.

4-7-3) Bachelor Degree

It is a four year general nursing program that covers many domains of nursing services provision.

4-7-4) Masters Degree

It is an advanced level of graduate education for nurses and is the minimum required degree for nursing lecturers and managers. This degree prepares a nurse as a manager, an expert in health policies, and/or clinical nursing leader.

4-7-5) PhD: Nursing Doctor of Philosophy

It is a doctorate degree (doctorate of philosophy) that is a three-year program, which seeks to prepare students to combine scientific research with nursing roles and usually includes performing a research.

4-7-6) Practical Nursing Doctorate

It is a professional degree of graduate education that focuses on clinical aspects of the disease. Its curriculum generally includes advanced diagnosis procedures and treatment of the disease (learn4good, 2014, ANA, 2015).

4-8) Nursing provides the following roles by nurse

4-8-1) Creating the background for providing the care

It means creating an appropriate care environment by providing appropriate care grounds and delivering independent and collaborative care services and maintaining the continuity of care and patient support.

4-8-2)  Establishing relationship therapy

It means establishing and maintaining treatment relationship with patient,and at the same time establishing professional relationship with health care team.

4-8-3) Evaluation of the patient

Comprehensive evaluation of the patient to determine nursing diagnosis and assessment of evidences to solve problems.

4-8-4) Patient care planning

Means planning for decision-making and choosing nursing care based on patient responses.

4-8-5) Implementation of the patient care: It means the implementation of the nursing process and direct care of the patient to provide daily health needs, pain relief, management of drug administration, and caring for dying patients

4-8-6) Joint patient care: Meaning consultation and joint decision-making with other members of the health care team to provide health care and at the same time engage the patient and family in the care

4-8-7) Leadership/management/planning changes in the care of patient

It means intra-disciplinary and interdisciplinary coordination of the patient care, decision-making about patient management, and management, organization and leadership of the health care team.

4-8-8) Evaluation/follow-up of the patient care

It means evaluation of providing nursing services, reporting changes in health condition, evaluating the outcomes the expected from the patient, and following up with the care after patient discharge.

4-8-9) Counseling/educating the patient

It means providing sufficient information, counseling, and education to the patient, and also giving training to healthcare workers for the purpose of education and health promotion.

4-8-10) Prevention/rehabilitation

It means the development of personal and public hygiene, evaluating the available supporting resources, planning for the prevention of disease and illness, maintaining patient safety, providing palliative care, and providing rehabilitation care.

4-8-11) Research

Meaning participation in research activities related to health problems, and contribution to the development of health policies (Cherie et al., 2005, ANA, 2015, Banning, 2008b , Dossey, 2008, Johnson, 1968, McLennan Community College, 2014, College of Registered Nurses of Nova Scotia, 2012, College of Nurses of Ontario, 2009, Dossey, 2008, Foley, 2003, Updated, adapted, and revised by Dr. S. McMahon, 2009, Jeffreys, 2008, Meleis, 2012, Nursing Council of New Zealand 2012, Nursing Management, last update 2010, Nursing Programs Philosophical Concepts, 2013, Royal College of Nursing, 2012, Swihart and Porter-O’Grady, 2006, Sahlsten et al., 2007, Monareng, 2012, Nursing Council of New Zealand 2012, Sahlsten et al., 2007, Wade, 1999, Yildirim and Özkahraman, 2011, Xiaohan, 2005)

4-9) Screening Test of Necessity of the Features Explaining Nursing Concept

Summing up the features representative of nursing concept, we can define the nursing as follows:

“Nursing is a profession that provides its services to patients of all age groups, ill or healthy, during their whole life, and its focus is on nursing care for patient, health promotion, and interaction between the individual and environment. Nursing is committed to human dignity, comprehensive patient care, professional commitment, respect for patient’s rights, and participation in patient care; and is committed to the safety, follow-up care, giving assistance for gaining independence, and improving the quality of life of the patient. This profession provides its services in the areas of patient’s living environment, society, academic centers, or legal centers by people who have the features of good moral, leadership/management/planning of change, problem-solving/decision-making, and professional behavior, and also have university degree and work certificate. The role of nursing is providing care, establishing communication, designing and implementing nursing process, leadership/management/planning changes in the care of the patient, evaluation/follow-up of patient’s care, counseling/education, prevention/rehabilitation, and research.

In case a profession lacks any of these features, it cannot be called nursing. The features of the nursing profession are shown in detail in the following table

Table 2: Necessary features for the nursing concept  Click here to View table

 

Step 5) Identifying a “Model Case”

A model is a pure example that the nursing concept is used in it and should have all the features of the concept. It can be written in one or two paragraphs as a hypothesis: summary of a narrative that represents a real life event, or a clinical example that carefully explains a concept. According to McKenna, by giving an example from real life as a “model case” that covers all the features of the concept, the degree of transparency and credibility of the concept increases. Therefore, the model should include all the representative features of the concept (McKenna 1997).

Model Case

Ms. / Mr A, with Bachelor of Science in nursing (feature 7), is responsible for the care of a patient called Mohammad who is diagnosed with cirrhosis of the liver, Muhammad is hospitalized in gastroenterology ward (feature5). Mohammad is 45-year-old (feature 1) and one of the risk factors of his disease is excessive consumption of alcohol. He is in poor conditions because of esophageal varices bleeding. The risk of contamination during the health caring actions is high for him because of gastrointestinal bleeding. Mohammad’s appearance is not interesting either. Ms./Mr. A, by observing all protection measures, and without judging Muhammad’s life record, addresses him with respect and deals with his care (Features 3 and 4). He/she pays attention, with commitment, to the smallest changes in his physiological and psychological changes in relation to hemodynamic, electrolyte and hematological condition of Muhammad, along with establishing proper treatment communication with him.(feature 2  and 4). Mr./Mrs. A provides a list of Mohammad’s problems after examining him, consults with other healthcare team members in particular with his physician in connection with the required care, and develops his/her care plan in coordination with healthcare team members (feature 8). The goal of the healthcare team and him/her, at this stage of treatment intervention, is maintaining Mohammad’s hemodynamic condition and preventing further deterioration in his clinical status (feature 6).

What Ms. / Mr. A is doing is nursing.

Step 6) Identifying Alternative Cases of Nursing Concept

Alternative cases include examples of what is not the nursing concept. They include contrary cases, related cases, borderline cases, invented cases, and illegitimate cases.

6-1) Country Case

These are cases that do not cover the nursing concept, and sometimes their difference is obvious and clear to individuals.

Thus, if an individual acts this way his performance cannot be considered nursing:

• Obviating the health needs of the patients is not one of his goals.
• Does not care for health promotion and interpersonal interaction between the individual and environment
• Human dignity, comprehensive care for the patient, professional commitment, respect for patient’s rights, cooperation in patient’s care, and adoption of good manners, and professional behavior are not among his values.
• Does not pay attention to patient’s needs, maintaining security, care, follow-up care, achieving independence, and the quality of life of the patient
• The field of his service is not patient’s living environment, health care centers, community centers, universities and legal services centers.
• Lacks good morals, the features of leadership / management / planning change, the features of problem-solving / decision-making, and professional behavior feature.
• Lacks university degree and work readiness certification.
• Does not have the capabilities of planning and designing nursing process.

6-2) Related case

Related cases include those cases that have none of the features of the nursing concept but are seen as similar to the concept (table 3).

Table 3: Nursing subsets and the cases related to it

Nursing subsets	Related case
Community health nursing	Public health BSc
Mental health nursing	Clinical psychology
Radiology and imaging nursing	Radiology BSc

 

6-3) Borderline Case

Borderline cases include cases that are very similar to the nursing concept, but miss some of its defining features (table 4).

Table 4: Subset of nursing and borderline cases

Nursing subsets	Borderline case	Features missing in these fields
Obstetrics Nurse	Midwifery (Obstetrics) BSc	Obstetrics is a field that features 2 and 8 of nursing concept are not valid for it.
Nurse anesthetist	Anesthesia – Anesthesiologist	Anesthesia is a field that features 2, 5  and 8 of the nursing concept are not valid for it. Anesthesiology is a field that features 2 and 8 of the nursing concept are not valid for it.
Surgical nurse	Surgical technologist	Surgical technology is a field that features 2, 5 and 8 of the nursing concept are not valid for it.
Medical nurse	Medical doctor	Medicine is a field that features 2 and 8 of the nursing concept are not valid for it.
Advance clinical nurse	Medical specialist	Medical specialist is a field that features 2 and 8 of the nursing concept are not valid for it.
Family nurse	Family doctor	Family doctor is a field that features 2 and 8 of the nursing concept are not valid for it.
Nursing	Paramedicine	Paramedicine is a field that features 7 and 8 of the nursing concept are not valid for it.
Nursing	Health work	Health work is a field that feature 7 of the nursing concept is not valid for it.

 

6-4) Invented Case

Invented cases include cases that show the nursing concept out of its natural and normal context. These include cases that are not considered nursing but are tagged as nursing.

• providing any early clinical services to the patient (nursing assistance services)
• Injection services (without any knowledge and just doing injection)

6-5) Illegitimate Case

It includes improper use of nursing concept in real life.

• Taking care of patients and the elderly at home
• Taking care of children at home

Step 7) Identify Antecedents and Consequences of Nursing Concept

The importance of this step is in analysis of a field in which the concept is normally used. Antecedents are the events that come before the occurrence of the concept. They cannot be considered synonymous with causality. Antecedent may help the occurrence of the concept, it may be associated with the occurrence of the concept or its existence may be necessary for the presence of this concept (falling out of balance). Walker and Avant (1995) believe that nothing can be both an antecedent and a feature at the same time. Consequences are those events and outcomes that take place after the occurrence of the concept (return to balance) (McKenna 1997).

7-1) Antecedents of the nursing concept

• Patient’s falling/possibility of falling out of physiological, psychological, social, or spiritual balance
• Patient’s disability / lack of complete ability to confront and cope with occurrence of imbalance
• Need for help to achieve the highest level of health/independence

7-2) Consequences of the nursing concept:

• Return of the patient to the physiological, psychological, social, or spiritual balance
• Patient’s use of effective methods of confrontation and coping
• Achieving the highest level of health and independence in the patient (McKenna 1997, Kim and Kollak 2006, Meleis 2012)

Step 8) Considering Context and Values

As mentioned in previous section, concepts have different meanings based on the context in which they are used. For example, the concept of care in an African country like Congo is different from that of in a developed country like Japan, or a religious country like Iran, or a multicultural country like Canada.

The role of nursing in Iran in relation to context and values can be investigated in two sections

8-A) Iranian context of nursing

8-A-1) Literacy level and the possibility of self-care in Iran

By definition, health literacy is capacity of individuals to acquire, interpret, and understand basic health information which is necessary in making appropriate decisions. It can be concluded that the low level of health literacy in Iran has resulted in low level self care behaviors; it is necessary to pay more attention to the roles of healthcare team and to define more profound roles for them (Tehrani Banihasehmi et al., 2007). In Iran no research or seminars have mentioned the nurses as one of the most important training forces who can play a pivotal role in the health literacy level of society. This condition shows that the professional ability of nurses has completely been ignored in Iran’s health system, and there is no coherent planning to take advantage of this nursing role.

8-A-2) The culture of the relations between doctors and nurses in Iran

Summing up the findings of seven studies performed on this topic ,  it seems that more efforts are needed for training of both physicians and nurses to improve communication and collaborative care within the healthcare team (Namazi et al., 1390, Mehrayi, 1388, Masrur et al, 1391, Rostami et al. 1389, Ashktorab et al. 2011, Pakpour et al. 2104, Jasemi et al. 2013).

8-A-3) Perception of an Iranian nurse of him/herself and the atmosphere of the nursing system in Iran

The understanding of an Iranian nurse from him/herself is closely related with the atmosphere of the nursing system in the healthcare system. To evaluate this perception there is no choice but to listen to their messages and what they have in their hearts in this regard. For this purpose, the researcher, by surfing the internet, collected the latest messages (posts) and the comments written below them, being capable of a simple summary of nurse’s perception about themselves and about the health system. The summary of the view of the nurses can be classified in five categories:

• attitude of nurses about the realities of the nursing profession
• attitude of nurses regarding performing their professional duties
• Imposition of the nursing profession
• Injustice toward nursing profession
• The atmosphere of the health system of Iran with respect to the nursing profession

8-A-4) Iranian Society’s Culture on Nursing

There is no literature on the culture of the society in Iran regarding nursing. However, an overview of the movies and series, made by and broadcast from public television networks, represents the dominant culture about the identity and role of nursing in Iran. These conditions, from the viewpoint of the researcher, indicate the obscurity of the aspects of the nursing profession in the society.

8-B) Islamic Context of Nursing

The holy prophet of Islam in this regard says: everyone who tries to meet the needs of a patient, if satisfies or even if ceases to satisfy them, will be relieved of his/her sins like the day that was born. Among careers that people pursue there are professions which their material and economic aspects are insignificant and are considered holy and spiritual. The choice of these careers, in a way, is an indication of dedicated effort, spirit of self-sacrifice and selflessness, and mentality of patience and perseverance among people employed in these professions. The nursing is one those noble professions (Heydari-zadeh, 1993).

In conclusion, considering Iranian contexts and values, it is clear that Iranian-Islamic culture is influential on the value-centered and behavioral indicators of the nursing concept; therefore, these effects should be added to the previously mentioned parameters.

Step 9) Identifying Empirical Indicators

“These include explicit references to measure or evaluate the existence of the concept. It is this step that is often considered as the operationalization of a concept. When, equipped with these indicators, we can see a concept “beyond a shadow of a doubt”. However, regarding Walker and Avanet (1995) sometimes the concept is so abstract that even the defined indicators are also abstract and therefore, cannot be good empirical indicators. Such indicators are useful for research and performance, since they can provide criteria by which a concept can be measured. Empirical indicators can be measured relatively easy to identify tangible concepts. However, it is possible to specify such indicators even for abstract concepts” (McKenna 1997).

Empirical indicators of nursing concept are as follows:

1. Providing services to patient/patients, from all age groups, sick or healthy, and during their whole life
2. Focusing on nursing care for patient, health promotion, and interaction between the individual and environment.
3. Commitment to human dignity, comprehensive care for patient, professional commitment, respect for patient’s rights, cooperation in care for patient, and adoption of good manners and professional behavior with regard to Islamic values
4. Commitment to address the needs of the patient, maintaining security, care, follow-up care, assistance for achieving of independence, and promoting the quality of life of the patient.
5. Providing services in the areas of: the living environment of the patient, health care, communities, academic centers , or legal services centers
6. Providing services by people with good moral, leadership/management/planning of change, problem-solving/decision-making, and professional behavior features
7. Providing services by people with academic education, and nursing certification
8. Providing care, establishing communication, design and implementation of the nursing process, leadership/management/planning change in patient care, evaluation/follow-up of the patient care, counseling/education, prevention/rehabilitation, and research

Figure 1: The explanation model of the nursing concept Click here to View figure

 

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