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Caring for Residents of Eldercare Facilities: A Concept Analysis Huei-lih Hwang, PhD Huei-lih Hwang, PhD, is an Associate Professor at National Tainan College of Nursing, Nursing Department, Tainan, Taiwan.
Search term: Caring, concept analysis, elders in facilities Author contact: [email protected], with a copy to the Editor: [email protected]
PURPOSE: To report the results of an evolutionary concept analysis of caring in facilities that provide care for elders. SOURCES: Cumulative indices for CINAHL, ERIC, Academic Search Complete, PsychINFO, Medline, and CEPTS. RESULTS: Caring is an interactive process characterized by seeing, helping, and communicating, which are analogous to two wheels with one axle. Caring is preceded by individuality and followed by well-being. CONCLUSION: The findings explicate the core components of caring in facilities that provide care for elders. IMPLICATIONS: The metaphor of an axle and wheel can guide caregivers in delivering effective care as the demand for improved well-being of residents of eldercare facilities increases.
Introduction Institutional care for frail elders is a major concern for both developed and developing countries. Effective care services are needed in long-term care facilities (LTCFs) across countries and cultures (Huang, Lin, & Li, 2008; Natan, 2008), and caring is considered a core requirement for the delivery of high-quality care in eldercare facilities (Chao & Roth, 2005; Lin, Wang, Yarbrough, Alfred, & Martin, 2010). Although the attributes of caring have been extensively discussed in the literature, the understanding of the care concept in eldercare facilities is limited. The Oxford Dictionaries (2014) defines caring as “the practice of looking after those unable to care for themselves, especially on account of age or illness.” However, the specific practices associated with caring have not been comprehensively defined. Previous qualitative studies that have attempted to clarify the caring construct in elder care have focused on either the caring traits of hospital nurses (Liu, 2004) or on-the-job responsibilities of nurses in institutions (Bedin, Droz-Mendelzweig, & Chappuis, 2013), and some studies have even investigated specific factors that impede caring in eldercare facilities (Tuckett et al., 2009). In some quantitative systematic reviews (Papastavrou, Efstathiou, & Charalambous, 2011) and inductive meta-synthesis approaches (Finfgeld-Connett, 2008), caring is simply viewed as a process or category. Although these works are enlightening, they do not elucidate caring in residents of eldercare facilities. Since the conceptual content is determined by context, caring practices specifically for elders in LTCF might differ from those of other populations. Residents away from their own homes and families often © 2015 NANDA International, Inc. International Journal of Nursing Knowledge Volume ••, No. ••, •• 2015
encounter unfamiliar staff and rules. Because of the many potential difficulties, elders in this situation may have specific needs for caring. In addition to the need to clarify the caring construct in residents of eldercare facilities, another concern that motivated this study is the increasing institutionalization of elders due to industrialization and family structure changes. The current generation of elders in Taiwan was raised in an era when elders were highly respected and when as many as three generations lived harmoniously in one home. This generation now experiences loneliness, depression, and even abuse in eldercare facilities (Cheng, 2009). In light of the remaining work needed to guide the practice of elder care, this study integrated a list of descriptions related to caring in facilities. A thorough exploration of this concept could provide a platform for clarifying the roles of caregivers, which would increase care quality in eldercare facilities. Clarifying the concept and definition of caring for elder residents of care facilities would increase the effectiveness of care workers and services. Method To ensure conceptual clarity, this study used the evolutionary method of concept analysis developed by Rodgers (2000). This inductive and descriptive method ensures analytic rigor and provides a systematic approach for analyzing and explaining the concept of interest in this study. The steps of the method are identifying the concept of interest and associated terms; identifying the sample and collecting relevant data; analyzing data to identify attributes and the contextual basis of the concept; identifying a model case, if 1
Caring for Residents of Eldercare Facilities: A Concept Analysis appropriate; and identifying implications and hypotheses for further development of the concept.
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facilities was then used to construct a descriptive definition and a tentative model. Examples of the concept were chosen from the data to illuminate the concept.
The Concept of Interest and Associated Terms The concept of interest in this analysis was caring in eldercare facilities. The objectives of concept analysis were to explore caring in and for institutionalized elders, to establish the current use of the concept, and to determine its relevance to caregivers in LTCFs. Whereas the word “caring” has come to be used as a noun in the past two decades, it has historically been used to describe professional action with love and variability (Brilowski & Wendler, 2005). Most scholars use the term caring to denote action taken by healthcare staff to care for their clients. Several associated terms have emerged, such as care, support, and compassion. Data Collection Setting and Sample A comprehensive Internet-based literature review was performed to retrieve relevant literature published in the past 10 years (2004–2014). Data sources included academic journals in multidisciplinary literature databases, including CINAHL, ERIC, Academic Search Complete, PsychINFO, Medline, and CEPTS. Since conceptual definitions depend on the context (Risjord, 2009), a broad literature review was performed to explore caring in residents of eldercare facilities. The keywords used to search for relevant articles were caring, older people, and long-term care. The inclusion criteria were publication in English or Chinese and publication in a peer-reviewed journal. The initial search yielded 242 articles that met the inclusion criteria. After reviewing the titles and abstracts, the full texts were obtained for six relevant articles. An additional 36 articles that met the inclusion criteria were obtained through secondary methods, i.e., sources cited frequently by other authors but not obtained in the original search results. The final analysis included 44 articles and books. Data Analysis A thematic approach was used for content analysis through reflection, back and forth check with the data according to the nature of the method (Rodgers, 2000). Data collection was performed by gathering words, sentences, or themes from articles, which were then entered into a protocol with the following predetermined categories: themes, references, attributes, antecedents, and consequences. Categories of data were examined (attributes, antecedents, and consequences) and labeled with words or phrases, and major themes for each category were identified separately. A colleague with experience in concept analysis provided independent quality checks for data analysis, and the author and colleagues engaged in repeated discussions while analyzing the results. The resulting conceptual understanding of caring in eldercare 2
Results To achieve a comprehensive understanding of caring phenomena, researchers have applied various approaches, including epistemological perspectives to identify antecedents, attributes, and consequences of caring (Brilowski & Wendler, 2005; Sumner, 2006); qualitative research methods to investigate clinical geriatric nurses (Bedin et al., 2013; Juthberg & Sundin, 2010; Liu, 2004; Tuckett et al., 2009) and elders who receive care in institutions (de Guzman et al., 2012; Harrefors, Savenstedt, & Axelsson, 2009; Hwang, Tu, Chen, & Wang, 2012; Teeri, Leino-Kilpi, & Välimäki, 2006; Wu, White, Cash, & Foster, 2009); and scales for measuring caring in eldercare facilities (Hwang et al., 2012; Wolf, Zuzelo, Goldberg, Crothers, & Jacobson, 2006). This study synthesized these approaches and identified attributes, antecedents, and consequences of caring in residents of eldercare facilities. Attributes of Caring in Elders in Institutions Caring is both a skill and a mind-set. Eldercare facilities must provide a home away from home, often for life, as in the case of some disabled elders. Table 1 shows that the three major attributes of caring in eldercare facilities are seeing, helping, and communicating. The role of communicating is to coordinate the caring attributes of seeing and helping. Seeing Seeing is the ability of a caregiver to observe, feel, and listen in the presence of elders. Seeing involves being sensitive and having a relationship, which are needed to recognize the uniqueness of the elder and the need for relational interaction to make a holistic connection. Frail elders living in institutions are willing to accept some loss of liberty if they perceive that it is necessary to receive the care they require. However, elders living in care facilities may develop a passive mind-set and expect caregivers to provide relational interaction. They may expect caregivers to be sensitive to their need to feel that they still have, and will continue to have, value as human beings (Hwang, Hsieh, & Wang, 2013). Being sensitive is a foundation of caring that requires going beyond routine nursing practices. That is, the care worker must be emotionally open and available (Bedin et al., 2013) and must be active rather than passive when meeting people or speaking with people (Hwang et al., 2013; Wilkin & Slevin, 2004). In other studies, for example, categories or factors that support this caring attribute have been coded as showing respect, empathy, encouragement, or
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Caring for Residents of Eldercare Facilities: A Concept Analysis
Table 1. Attributes of Caring for Residents of Eldercare Facilities Attribute Seeing Being sensitive
Having a relationship
Communicating Helping Attending Enabling
Themes
Data analysis
References
Respect Empathy Encouragement Resident identity Understanding Intentional use of self Sharing Collaborative partnership Treating residents as family members Conducting relational activity Communicating Initiating conversation
EFA Phenomenology EFA Qualitative A Qualitative A Thematic A Qualitative A Conceptual A Qualitative A Qualitative A Qualitative A Qualitative A
Wolf et al. (2006) Liu (2004) Hwang et al. (2012) Tuckett et al. (2009) Hwang et al. (2013) Kubiak and Sandberg (2011) Hwang et al. (2013) Edwards and Chapman (2004) Hwang et al. (2013) Bedin et al. (2013) Berglund (2007) Hwang et al. (2013)
Instrumental activities Calming the body Comforting Attending to individual needs Discovering and facilitating possibilities
Quantitative SR Qualitative A EFA EFA Conceptual A
Papastavrou et al. (2011) Hwang et al. (2013) Hwang et al. (2012) Wolf et al. (2006) Edwards and Chapman (2004)
A, analysis; EFA, exploratory factor analysis; SR, system review.
expression (de Guzman et al., 2012; Hwang et al., 2013; Liu, 2004; Papastavrou et al., 2011; Wolf et al., 2006), applying a person-centered approach to care instead of a taskcentered approach (Tuckett et al., 2009), understanding without complaining (Hwang et al., 2013), and being available for relationship building (Kubiak & Sandberg, 2011). In a strong relationship, caring is characterized by sharing feelings, thoughts, and information reciprocally (Hwang et al., 2013), establishing a collaborative partnership (Edwards & Chapman, 2004), treating the caring recipient as a family member (Hwang et al., 2013), or conducting relational activities to maintain a close relationship (Bedin et al., 2013). In other instances, having relation may be demonstrated through visual reassurance or physical presence (de Guzman et al., 2012). In gerontological nursing, in which socialization and relationship building is more important than in other nursing fields (Tuckett et al., 2009), elders expect nurses to play roles similar to those of their own family members by helping them to live meaningfully and to adjust to unfamiliar living conditions in residential facilities (Cheng, 2009; Lee, 2010). Helping Helping is a critical physio-psychological attribute of caring for elders, who expect comfort and meaning in their late stages of life (Hwang et al., 2013). Helping involves attending and enabling, i.e., assisting elders and helping them to recognize their own capabilities. Frail elders who live in institutions are highly reliant on expert help for daily life activities such as socializing and for medical care such as nursing assessments. For example, elders may require staff assistance for eating, dressing, grooming, bathing, transporting, cleaning, visiting the
doctor, monitoring their health, and taking medication. In other studies, categories or factors that support this attending attribute have been coded as comforting (Hwang et al., 2012), monitoring and calming the body (Hwang et al., 2013), attending to individual needs (Wolf et al., 2006), and facilitating instrumental activities (Papastavrou et al., 2011). Helping is an attribute that caregivers exhibit by going beyond attending, e.g., caregivers may exhibit helping by treating elders as if they are capable of living meaningfully (Hwang et al., 2013), by facilitating them in discovering how they can live meaningfully in their remaining years (Edwards & Chapman, 2004), or by enriching their lives (Hwang et al., 2013). That is, helping may require emotional labor in addition to the physical labor needed to provide care. For example, for elders who are sick and/or depressed, helping may require emotional support during the healing process. Communicating Communicating is an attribute that caregivers display by coordinating seeing and helping between the caregiver and the care receiver. Effective communication is needed to achieve the main goals in a caring setting, e.g., providing physical care, exchanging information, showing support, and facilitating good social interaction (Wadensten, 2005). Through effective communication, carers can determine the most effective practices for daily care (Haugan, 2014) in nursing home settings. Communication is needed to integrate the needs of elders in LTCFs, including comfort, meaning, individuality, and relationships. Finally, communicating is important for making elders feel that someone is helping and watching them. 3
Caring for Residents of Eldercare Facilities: A Concept Analysis
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Figure 1. Attributes of Caring for Residents of Eldercare Facilities Seeing - Being sensitive
Helping Communicating
- Having a relationship
- Enabling
Figure 2. Conceptual Model of Caring for Residents of Eldercare Facilities Antecedence
Attributes
Consequences
Seeing - Being sensitive
Individual needs Organizational cultures
- Having relation Communicating - Coordinating Helping -Attending -Enabling
Elders - well-being Caretakers - well-being - caring practice
For example, clear communication between the elder and the caregiver is not only essential for a caring relationship that meets the individual needs of the elder (Berglund, 2007; Ganz, Fung, Sinsky, Shinyi, & Reuben, 2008), communication is also needed to integrate the caring attributes needed to provide elders with a satisfactory quality of life (Edwards & Chapman, 2004) and with health and well-being (Haugan, 2014). From a holistic perspective of caring, this study defined caring as an interactive process involving multidimensional acts and then conceptualized the concept by using the metaphor of two wheels and an axle (see Figure 1), in which the axle represents communication and the two wheels represent helping and seeing. With constant communication, both wheels rotate in unison. Otherwise, the wheels turn in different directions and stop moving. Further, caring can be delivered in a holistic and integrated way by integrating the wheels and axles of other caregivers. Another iterative process of the conceptual analysis cycle (Rodgers, 2000) is examining the antecedents and consequences of the concept by exploring the context in which the concept is used. The conceptual model of caring for residents of eldercare facilities is also presented in Figure 2. Antecedents of Eldercare Caring is preceded by the needs of the recipient, which are highly subjective and dependent on the specific situation and people involved (Nakrem, Vinsnes, & Seim, 2011). For example, elders might need more care and/or more constant care during a life crisis. For caring to occur, the recipient must express physical, psychological, or spiritual needs (Turkel & Ray, 2001). Thus, the antecedents to the 4
- Attending
caring process include expressing the need for caring and accepting caring. Studies indicate that the needs and types of caring required by elders depend on their gender, how many children they have, and their specific chronic illness (Huang et al., 2008). For instance, male elders value skillful, physical caring behavior, but female elders value emotional or affect caring. When staff do not build caring relationships with their residents, especially those who are frail and elderly, and do not provide personalized interventions, the residents may exhibit learned helplessness. The nature of caring is largely influenced by the political and economic structure of the country where the care facility is located and also by the organizational culture of the facility itself (Coffman, 2014; Kubiak & Sandberg, 2011). A conductive working milieu facilitates caring by recognizing the caring concept, by providing supportive supervisors, by having a clear division of labor, by providing integrative services, and by providing staffing and job training for staff to carry out caring (McGilton, Profetto-McGrath, & Robinson, 2013; Tuckett et al., 2009; Wang, 2009). Consequences of Caring The consequences of caring are usually positive in elderly residents of eldercare facilities. For example, studies of LTCF residents show that nurse–patient interaction can promote hope, satisfaction, mental wellness, meaning in life, self-transcendence, quality of life, independence, and multidimensional well-being (Abad-Corpa et al., 2012; Custers, Westerhof, Kuin, & Riksen-Walraven, 2010; Edwards & Chapman, 2004; Haugan, 2014; Haugan, Hanssen, & Moksnes, 2013). Theoretically, caring is a human-to-human relationship that facilitates nurses’ and patients’ process of being and becoming (Watson, 2008). Ideally, it contributes to well-being for both the caregiver and receiver and inspires caregivers to improve their professional skills and efficacy (Haugan, 2014). Recognizing the need for social interaction by residents can facilitate caring behaviors (Bedin et al., 2013). For example, our previous study (Hwang et al., 2013) revealed the importance of relational activities for caregivers and residents. Identifying an Example Case For a comprehensive conceptual analysis, a real-world example is helpful. One example that illuminates the above attributes, antecedents, and consequences is the experi-
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Caring for Residents of Eldercare Facilities: A Concept Analysis
ence of the author in caring for Wo (pseudonym), an elderly woman who had lived in a nursing home for 2 years after suffering a stroke. Each caregiver in this facility had a busy schedule managing routine activities for 6 to 12 residents. However, Wo was satisfied with the assistance she received from her caregivers. She enjoyed socializing with her caregivers because they treated her like a friend or family member. Caregivers helped her with her physical needs and shared news about current events with her. They even allowed her to help care for other residents and to learn the skills needed to be a caregiver. Wo said, “The feeling of having a friend living in the same house means a lot to people like me. However, some caregivers say negative things about me even though they don’t know me well. This makes me feel bad and makes me want to avoid those people. I realize that I must communicate with them so they can help me with my personal needs.” This example demonstrates the three attributes described above, i.e., seeing individuality and a relationship, attending to needs, and communicating seeing and helping. This study analyzed the elements of caring in an LTCF setting as perceived by both the givers and receivers of care. Discussion The results of this study are particularly telling in terms of the philosophical, physical, and psychosocial components of caring. Earlier studies described caring as the practice of providing emotional, physical, informational, practical, humanistic, and clinical care and comfort. Our proposed caring concept of seeing and helping through communication can be applied in the context of elderly care facilities. The results of this work go a step further by developing a wheel and axle model of caring to describe caring in LTCFs. The conceptualization of caring that emerged in this study is consistent with those based on earlier theories and models. Attributes of caring encompass the professional seeing skills, helping skills, and interpersonal communication skills needed to ensure the safety of residents and to attend to their needs holistically. These attributes correspond to the instrumental and expressive caring behaviors identified in an earlier systemic review of quantitative studies (Papastavrou et al., 2011) and are consistent with Watson’s (2008) definition of caring as creating a supportive/protective/corrective environment and with the Quality-Caring Model (Duffy & Hoskins, 2003), which is based on the claim that effective caring requires nurses to initiate, cultivate, and sustain interdependent relationships with patients or families. Attributes of seeing generated in this study correspond to the process of being with in Swanson’s (1991) Caring Theory, to the unconditional acceptance concept in Nursing as Caring Theory (Boykin & Schoenhofer, 2001), and to the concepts of embracing altruistic values, being sensitive, instilling faith and hope, and honoring others in Watson’s
(2008) Caritas processes. To achieve the seeing attribute, caring must be delivered with respect and commitment (de Guzman et al., 2012) when dealing with people and handling their affairs. The personal traits required for an effective professional caregiver also include flexibility and sensitivity to individual needs. Some scholars have also proposed that an effective caregiver requires a strong moral foundation, such as a commitment to act benevolently, and that a caring attitude is an antecedent of caring (Finfgeld-Connett, 2008). Additionally, most studies agree that, for most residents of eldercare facilities, the main concern is the attitudes of their caregivers (Kydd, 2009; Xie, Gau, Li, & Xu, 2009; Yang & Shyu, 2001). The caring attributes that are important to institutionalized elders are interrelated and not mutually exclusive. Caring in nursing is a communicative discourse between nurses and clients, regardless of the service environment or culture, the diagnosed illness, or the debility of the client (Sumner, 2012). This view is consistent with studies such as Berglund (2007) and Sumner (2012), which indicated that the patient has an illness self whereas the nurse has a professional self. However, both parties also have a personal self. For example, clients must communicate their needs, and the staff must help to meet those needs. Such communicative action in nursing constitutes the moral part of caring and is bidirectional: The nurse gains satisfaction from providing care, whereas the patient gains satisfaction from receiving care. Interestingly, communication is important not only between the giver and receiver of care, but also between seeing and helping within the caregiver. Caring is not innate; it is developed through maturity and cultivation (Finfgeld-Connett, 2008). To handle patients and professional tasks effectively, caregivers require maturity and good professional skills, which can only develop over time. Facilities that provide elder care and schools that offer education in caring must devote adequate resources to cultivating helping and communicating skills in their employees and students. The objective is to establish a sensitive culture in which individual needs are understood and in which a multidisciplinary approach to caring is supported. Conclusion To account for the perspectives of both the care recipient and the caregiver, this study conceptualized the essential elements of caring (seeing, helping, and communicating) as an axle and two wheels. The axle and wheel is a strong metaphor for the interactive relationship between caregivers and recipients in an eldercare facility and can guide caregivers in delivering effective care in daily activities. For residents of eldercare facilities, caring is preceded by individual needs and organizational culture and is followed by well-being. Although the concept analysis did not provide a definite conclusion, it identified directions for 5
Caring for Residents of Eldercare Facilities: A Concept Analysis further study (Tofthagen & Fagerstrøm, 2010). This caring concept model requires further validation and testing. Specifically, the model should be compared using different methodologies and using subjects in different countries. Further studies are needed to validate the model by exploring how the antecedents of elder care and attributes affect quality of life. Further quantitative studies are also needed to explore how the characteristics of residents and characteristics of eldercare facilities affect wellness in both the recipients and givers of care. The proposed model of the institutional caring concept also needs further validation for use in developing interventions to assist managers of public and private eldercare facilities in achieving highquality care for elders. Relevance to Clinical Practice The institutional caring concept provides a language for discussing the roles of nurses and caregivers in aged care facilities and for discussing the development of knowledge in the field of long-term care. For professionals and paraprofessionals, this synthesis adds depth to the caring concept. For caregivers, clarifying this concept has several implications: (1) it improves understanding of the nature of caring in eldercare facilities; (2) it increases awareness of the contextual factors that affect the delivery and appraisal of care in eldercare facilities; (3) it provides a language that elders, their families, and their caregivers can use for an open discussion of care quality and other concerns; and (4) it can be used to educate administrators and policymakers in the elements of effective and comprehensive elder care policies. Acknowledgments. We would like to thank the Research Council of Taiwan Nurse Association for funding this study under grant number TWNA-1022023. References Abad-Corpa, E., Gonzalez-Gil, T., Martínez-Hernández, A., BarderasManchado, A. M., De La Cuesta-Benjumea, C., Monistrol-Ruano, O., & Mahtani-Chugani, V. (2012). Caring to achieve the maximum independence possible: A synthesis of qualitative evidence on older adults’ adaptation to dependency. Journal of Clinical Nursing, 21(21/22), 3153–3169. doi:10.1111/j.1365-2702.2012.04207.x Bedin, M., Droz-Mendelzweig, M., & Chappuis, M. (2013). Caring for elders: The role of registered nurses in nursing homes. Nursing Inquiry, 20(2), 111–120. doi:10.1111/j.1440-1800.2012.00598.x Berglund, A. (2007). Satisfaction with caring and living conditions in nursing homes: Views of elderly persons, next of kin and staff members. International Journal of Nursing Practice, 13(1), 46–51. doi:10.1111/j.1440172X.2006.00602.x Boykin, A., & Schoenhofer, S. (2001). Nursing as caring: A model for transforming practice. Sudbury, MA: Jones & Bartlett. Brilowski, G. A., & Wendler, M. C. (2005). An evolutionary concept analysis of caring. Journal of Advanced Nursing, 50(6), 641–650. Chao, S., & Roth, P. (2005). Dimensions of quality in long-term care facilities in Taiwan. Journal of Advanced Nursing, 52(6), 609–618. Cheng, S. T. (2009). The social networks of nursing-home residents in Hong Kong. Ageing and Society, 29(2), 163–178. Coffman, S. (2014). Ray’s Theory of Bureaucratic Caring. In M. Alligood (Ed.), Nursing theorists and their work (8th ed.). St. Louis: Mosby/Elsevier.
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Custers, A. F. J., Westerhof, G. J., Kuin, Y., & Riksen-Walraven, M. (2010). Need fulfillment in caring relationships: Its relation with well-being of residents in somatic nursing homes. Aging & Mental Health, 14(6), 731–739. doi:10.1080/13607861003713133 Duffy, J., & Hoskins, L. (2003). The quality-caring model: Blending dual paradigms. Advances in Nursing Science, 26(1), 77–88. Edwards, H. E., & Chapman, H. M. (2004). Contemplating, caring, coping, conversing: A model for promoting mental wellness in later life. Journal of Gerontological Nursing, 30(5), 16–21. Finfgeld-Connett, D. (2008). Meta-synthesis of caring in nursing. Journal of Clinical Nursing, 17(2), 196–204. Ganz, D. A., Fung, C. H., Sinsky, C. A., Shinyi, W., & Reuben, D. B. (2008). Key elements of high-quality primary care for vulnerable elders. Journal of General Internal Medicine, 23(12), 2018–2023. de Guzman, A. B., Santos, C. I. Q., Santos, I. B. A., Santos, J. A., Santos, J. E., Santos, J. M. S., & Santos, V. E. E. (2012). Concept of care, caring expectations, and caring frustrations of the elderly suffering from chronic illness. Educational Gerontology, 38(5), 299–313. doi:10.1080/ 03601277.2010.544586 Harrefors, C., Savenstedt, S., & Axelsson, K. (2009). Elderly people’s perceptions of how they want to be cared for: An interview study with healthy elderly couples in Northern Sweden. Scandinavian Journal of Caring Sciences, 23, 353–360. Haugan, G. (2014). Nurse-patient interaction is a resource for hope, meaning in life and self-transcendence in nursing home patients. Scandinavian Journal of Caring Sciences, 28(1), 74–88. doi:10.1111/ scs.12028 Haugan, G., Hanssen, B., & Moksnes, U. K. (2013). Self-transcendence, nursepatient interaction and the outcome of multidimensional well-being in cognitively intact nursing home patients. Scandinavian Journal of Caring Sciences, 27(4), 882–893. doi:10.1111/scs.12000 Huang, J. J., Lin, K. C., & Li, I. C. (2008). Service needs of residents in community-based long-term care facilities in northern Taiwan. Journal of Clinical Nursing, 17(1), 99–108. Hwang, H. L., Tu, C. T., Chen, S., & Wang, H. H. (2012). Caring behaviors perceived by elderly residents of long-term care facilities: Scale development and psychometric assessment. International Journal of Nursing Study, 49(2), 183–190. Hwang, H. L., Hsieh, P. F., & Wang, H. H. (2013). Taiwanese long-term care facility residents’ experience of caring: A qualitative study. Scandinavian Journal of Caring Sciences, 27(3), 655–668. doi:10.1111/j.14716712.2012.01082.x Juthberg, C., & Sundin, K. (2010). Registered nurses’ and nurse assistants’ lived experience of troubled conscience in their work in elderly care: A phenomenological hermeneutic study. International Journal of Nursing Studies, 47(1), 20–29. Kubiak, C., & Sandberg, F. (2011). Paraprofessionals and caring practice: Negotiating the use of self. Scandinavian Journal of Caring Sciences, 25(4), 653–660. doi:10.1111/j.1471-6712.2011.00875.x Kydd, A. (2009). The care and wellbeing of older people: A textbook for health care students. Exeter, UK: Reflect Press. Lee, Y. C. (2010). Social support: A study of elderly in nursing homes (Unpublished master’s thesis). Chung Shan Medical University, Taichun. Airiti GCScholar database. Lin, Y. H., Wang, L. S., Yarbrough, S., Alfred, D., & Martin, P. (2010). Changes in Taiwanese nursing student values during the educational experience. Nursing Ethics, 17(5), 646–654. doi:10.1177/0969733010373011 Liu, S. J. (2004). What caring means to geriatric nurses. Journal of Nursing Research, 12(2), 143–152. McGilton, K. S., Profetto-McGrath, J., & Robinson, A. (2013). Implementing the supportive supervision intervention for registered nurses in a long-term care home: A feasibility study. Worldviews on Evidence-based Nursing, 10(4), 238–247. doi:10.1111/wvn.12004 Nakrem, S., Vinsnes, A. G., & Seim, A. (2011). Residents’ experiences of interpersonal factors in nursing home care: A qualitative study. International Journal of Nursing Studies, 48(11), 1357–1366. Natan, M. B. (2008). Perceptions of nurses, families, and residents in nursing homes concerning residents’ needs. International Journal of Nursing Practice, 14(3), 195–199. Oxford Dictionaries. (2014). Language matter. Retrieved from http:// www.oxforddictionaries.com/definition/english/caring Papastavrou, E., Efstathiou, G., & Charalambous, A. (2011). Nurses’ and patients’ perceptions of caring behaviours: Quantitative systematic review of comparative studies. Journal of Advanced Nursing, 67(6), 1191– 1205. doi:10.1111/j.1365-2648.2010.05580.x Risjord, M. (2009). Rethinking concept analysis. Journal of Advanced Nursing, 65(3), 684–691. doi:10.1111/j.1365-2648.2008.04903.x
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Rodgers, B. L. (2000). Concept analysis: An evolutionary view. In B. L. Rodgers & K. A. Knafl (Eds.), Concept development in nursing: Foundations, techniques, and applications (2nd ed., pp. 77–102.). Philadelphia: Saunders. Sumner, J. (2006). Concept analysis: The moral construct of caring in nursing as communicative action. International Journal for Human Caring, 10(1), 8–16. Sumner, J. (2012). Communication as moral caring in nursing: The moral construct of caring in nursing as communicative action. International Journal for Human Caring, 16(2), 20–28. Swanson, K. M. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161–166. Teeri, S., Leino-Kilpi, H., & Välimäki, M. (2006). Long-term nursing care of elderly people: Identifying ethically problematic experiences among patients, relatives and nurses in Finland. Nursing Ethics, 13(2), 116–129. Tofthagen, R., & Fagerstrøm, L. M. (2010). Rodgers’ evolutionary concept analysis—A valid method for developing knowledge in nursing science. Scandinavian Journal of Caring Sciences, 24, 21–31. doi:10.1111/j.14716712.2010.00845.x Tuckett, A., Hughes, K., Gilmour, J., Hegney, D., Huntington, A., & Turner, C. (2009). Caring in residential aged-care. Qualitative findings from an e-cohort sub-study. Journal of Clinical Nursing, 18(18), 2604–2612.
Turkel, M. C., & Ray, M. A. (2001). Relational complexity: From grounded theory to instrument development and theoretical testing. Nursing Science Quarterly, 14(4), 281–287. Wadensten, B. (2005). The content of morning time conversations between nursing home staff and residents. Journal of Clinical Nursing, 14, 84–89. doi:10.1111/j.1365-2702.2005.01283.x Wang, Y. (2009). From the point of adaptation to view employment and management foreign workers in long-term care facilities. Community Development Quarterly, 125, 472–485. Watson, J. (2008). Nursing: The philosophy and science of caring (2nd rev.). Boulder, CO: University Press of Colorado. Wolf, Z. R., Zuzelo, P. R., Goldberg, E., Crothers, R., & Jacobson, N. (2006). The Caring Behaviors Inventory for Elders: Development and psychometric characteristics. International Journal for Human Caring, 10(1), 49–59. Wu, S. C., White, A., Cash, K., & Foster, S. (2009). Nursing home care for older people in Taiwan: A process of forced choice. Journal of Clinical Nursing, 18(14), 1986–1993. doi:10.1111/j.1365-2702.2008.02697.x Xie, Y., Gau, G., Li, Y., & Xu, M. (2009). Overall service quality research in a long-term care facility in mid-Taiwan. Kuang Tien Medicine Journal, 4(7), 23–39. Yang, C. L., & Shyu, Y. I. (2001). Indicators of quality of care in nursing homes from the perspective of elderly residents. Journal of Nursing Research, 9(1), 53–62.
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Caring for Residents of Eldercare Facilities: A Concept Analysis Huei-lih Hwang, PhD Huei-lih Hwang, PhD, is an Associate Professor at National Tainan College of Nursing, Nursing Department, Tainan, Taiwan.
Search term: Caring, concept analysis, elders in facilities Author contact: [email protected], with a copy to the Editor: [email protected]
PURPOSE: To report the results of an evolutionary concept analysis of caring in facilities that provide care for elders. SOURCES: Cumulative indices for CINAHL, ERIC, Academic Search Complete, PsychINFO, Medline, and CEPTS. RESULTS: Caring is an interactive process characterized by seeing, helping, and communicating, which are analogous to two wheels with one axle. Caring is preceded by individuality and followed by well-being. CONCLUSION: The findings explicate the core components of caring in facilities that provide care for elders. IMPLICATIONS: The metaphor of an axle and wheel can guide caregivers in delivering effective care as the demand for improved well-being of residents of eldercare facilities increases.
Introduction Institutional care for frail elders is a major concern for both developed and developing countries. Effective care services are needed in long-term care facilities (LTCFs) across countries and cultures (Huang, Lin, & Li, 2008; Natan, 2008), and caring is considered a core requirement for the delivery of high-quality care in eldercare facilities (Chao & Roth, 2005; Lin, Wang, Yarbrough, Alfred, & Martin, 2010). Although the attributes of caring have been extensively discussed in the literature, the understanding of the care concept in eldercare facilities is limited. The Oxford Dictionaries (2014) defines caring as “the practice of looking after those unable to care for themselves, especially on account of age or illness.” However, the specific practices associated with caring have not been comprehensively defined. Previous qualitative studies that have attempted to clarify the caring construct in elder care have focused on either the caring traits of hospital nurses (Liu, 2004) or on-the-job responsibilities of nurses in institutions (Bedin, Droz-Mendelzweig, & Chappuis, 2013), and some studies have even investigated specific factors that impede caring in eldercare facilities (Tuckett et al., 2009). In some quantitative systematic reviews (Papastavrou, Efstathiou, & Charalambous, 2011) and inductive meta-synthesis approaches (Finfgeld-Connett, 2008), caring is simply viewed as a process or category. Although these works are enlightening, they do not elucidate caring in residents of eldercare facilities. Since the conceptual content is determined by context, caring practices specifically for elders in LTCF might differ from those of other populations. Residents away from their own homes and families often © 2015 NANDA International, Inc. International Journal of Nursing Knowledge Volume ••, No. ••, •• 2015
encounter unfamiliar staff and rules. Because of the many potential difficulties, elders in this situation may have specific needs for caring. In addition to the need to clarify the caring construct in residents of eldercare facilities, another concern that motivated this study is the increasing institutionalization of elders due to industrialization and family structure changes. The current generation of elders in Taiwan was raised in an era when elders were highly respected and when as many as three generations lived harmoniously in one home. This generation now experiences loneliness, depression, and even abuse in eldercare facilities (Cheng, 2009). In light of the remaining work needed to guide the practice of elder care, this study integrated a list of descriptions related to caring in facilities. A thorough exploration of this concept could provide a platform for clarifying the roles of caregivers, which would increase care quality in eldercare facilities. Clarifying the concept and definition of caring for elder residents of care facilities would increase the effectiveness of care workers and services. Method To ensure conceptual clarity, this study used the evolutionary method of concept analysis developed by Rodgers (2000). This inductive and descriptive method ensures analytic rigor and provides a systematic approach for analyzing and explaining the concept of interest in this study. The steps of the method are identifying the concept of interest and associated terms; identifying the sample and collecting relevant data; analyzing data to identify attributes and the contextual basis of the concept; identifying a model case, if 1
Caring for Residents of Eldercare Facilities: A Concept Analysis appropriate; and identifying implications and hypotheses for further development of the concept.
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facilities was then used to construct a descriptive definition and a tentative model. Examples of the concept were chosen from the data to illuminate the concept.
The Concept of Interest and Associated Terms The concept of interest in this analysis was caring in eldercare facilities. The objectives of concept analysis were to explore caring in and for institutionalized elders, to establish the current use of the concept, and to determine its relevance to caregivers in LTCFs. Whereas the word “caring” has come to be used as a noun in the past two decades, it has historically been used to describe professional action with love and variability (Brilowski & Wendler, 2005). Most scholars use the term caring to denote action taken by healthcare staff to care for their clients. Several associated terms have emerged, such as care, support, and compassion. Data Collection Setting and Sample A comprehensive Internet-based literature review was performed to retrieve relevant literature published in the past 10 years (2004–2014). Data sources included academic journals in multidisciplinary literature databases, including CINAHL, ERIC, Academic Search Complete, PsychINFO, Medline, and CEPTS. Since conceptual definitions depend on the context (Risjord, 2009), a broad literature review was performed to explore caring in residents of eldercare facilities. The keywords used to search for relevant articles were caring, older people, and long-term care. The inclusion criteria were publication in English or Chinese and publication in a peer-reviewed journal. The initial search yielded 242 articles that met the inclusion criteria. After reviewing the titles and abstracts, the full texts were obtained for six relevant articles. An additional 36 articles that met the inclusion criteria were obtained through secondary methods, i.e., sources cited frequently by other authors but not obtained in the original search results. The final analysis included 44 articles and books. Data Analysis A thematic approach was used for content analysis through reflection, back and forth check with the data according to the nature of the method (Rodgers, 2000). Data collection was performed by gathering words, sentences, or themes from articles, which were then entered into a protocol with the following predetermined categories: themes, references, attributes, antecedents, and consequences. Categories of data were examined (attributes, antecedents, and consequences) and labeled with words or phrases, and major themes for each category were identified separately. A colleague with experience in concept analysis provided independent quality checks for data analysis, and the author and colleagues engaged in repeated discussions while analyzing the results. The resulting conceptual understanding of caring in eldercare 2
Results To achieve a comprehensive understanding of caring phenomena, researchers have applied various approaches, including epistemological perspectives to identify antecedents, attributes, and consequences of caring (Brilowski & Wendler, 2005; Sumner, 2006); qualitative research methods to investigate clinical geriatric nurses (Bedin et al., 2013; Juthberg & Sundin, 2010; Liu, 2004; Tuckett et al., 2009) and elders who receive care in institutions (de Guzman et al., 2012; Harrefors, Savenstedt, & Axelsson, 2009; Hwang, Tu, Chen, & Wang, 2012; Teeri, Leino-Kilpi, & Välimäki, 2006; Wu, White, Cash, & Foster, 2009); and scales for measuring caring in eldercare facilities (Hwang et al., 2012; Wolf, Zuzelo, Goldberg, Crothers, & Jacobson, 2006). This study synthesized these approaches and identified attributes, antecedents, and consequences of caring in residents of eldercare facilities. Attributes of Caring in Elders in Institutions Caring is both a skill and a mind-set. Eldercare facilities must provide a home away from home, often for life, as in the case of some disabled elders. Table 1 shows that the three major attributes of caring in eldercare facilities are seeing, helping, and communicating. The role of communicating is to coordinate the caring attributes of seeing and helping. Seeing Seeing is the ability of a caregiver to observe, feel, and listen in the presence of elders. Seeing involves being sensitive and having a relationship, which are needed to recognize the uniqueness of the elder and the need for relational interaction to make a holistic connection. Frail elders living in institutions are willing to accept some loss of liberty if they perceive that it is necessary to receive the care they require. However, elders living in care facilities may develop a passive mind-set and expect caregivers to provide relational interaction. They may expect caregivers to be sensitive to their need to feel that they still have, and will continue to have, value as human beings (Hwang, Hsieh, & Wang, 2013). Being sensitive is a foundation of caring that requires going beyond routine nursing practices. That is, the care worker must be emotionally open and available (Bedin et al., 2013) and must be active rather than passive when meeting people or speaking with people (Hwang et al., 2013; Wilkin & Slevin, 2004). In other studies, for example, categories or factors that support this caring attribute have been coded as showing respect, empathy, encouragement, or
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Caring for Residents of Eldercare Facilities: A Concept Analysis
Table 1. Attributes of Caring for Residents of Eldercare Facilities Attribute Seeing Being sensitive
Having a relationship
Communicating Helping Attending Enabling
Themes
Data analysis
References
Respect Empathy Encouragement Resident identity Understanding Intentional use of self Sharing Collaborative partnership Treating residents as family members Conducting relational activity Communicating Initiating conversation
EFA Phenomenology EFA Qualitative A Qualitative A Thematic A Qualitative A Conceptual A Qualitative A Qualitative A Qualitative A Qualitative A
Wolf et al. (2006) Liu (2004) Hwang et al. (2012) Tuckett et al. (2009) Hwang et al. (2013) Kubiak and Sandberg (2011) Hwang et al. (2013) Edwards and Chapman (2004) Hwang et al. (2013) Bedin et al. (2013) Berglund (2007) Hwang et al. (2013)
Instrumental activities Calming the body Comforting Attending to individual needs Discovering and facilitating possibilities
Quantitative SR Qualitative A EFA EFA Conceptual A
Papastavrou et al. (2011) Hwang et al. (2013) Hwang et al. (2012) Wolf et al. (2006) Edwards and Chapman (2004)
A, analysis; EFA, exploratory factor analysis; SR, system review.
expression (de Guzman et al., 2012; Hwang et al., 2013; Liu, 2004; Papastavrou et al., 2011; Wolf et al., 2006), applying a person-centered approach to care instead of a taskcentered approach (Tuckett et al., 2009), understanding without complaining (Hwang et al., 2013), and being available for relationship building (Kubiak & Sandberg, 2011). In a strong relationship, caring is characterized by sharing feelings, thoughts, and information reciprocally (Hwang et al., 2013), establishing a collaborative partnership (Edwards & Chapman, 2004), treating the caring recipient as a family member (Hwang et al., 2013), or conducting relational activities to maintain a close relationship (Bedin et al., 2013). In other instances, having relation may be demonstrated through visual reassurance or physical presence (de Guzman et al., 2012). In gerontological nursing, in which socialization and relationship building is more important than in other nursing fields (Tuckett et al., 2009), elders expect nurses to play roles similar to those of their own family members by helping them to live meaningfully and to adjust to unfamiliar living conditions in residential facilities (Cheng, 2009; Lee, 2010). Helping Helping is a critical physio-psychological attribute of caring for elders, who expect comfort and meaning in their late stages of life (Hwang et al., 2013). Helping involves attending and enabling, i.e., assisting elders and helping them to recognize their own capabilities. Frail elders who live in institutions are highly reliant on expert help for daily life activities such as socializing and for medical care such as nursing assessments. For example, elders may require staff assistance for eating, dressing, grooming, bathing, transporting, cleaning, visiting the
doctor, monitoring their health, and taking medication. In other studies, categories or factors that support this attending attribute have been coded as comforting (Hwang et al., 2012), monitoring and calming the body (Hwang et al., 2013), attending to individual needs (Wolf et al., 2006), and facilitating instrumental activities (Papastavrou et al., 2011). Helping is an attribute that caregivers exhibit by going beyond attending, e.g., caregivers may exhibit helping by treating elders as if they are capable of living meaningfully (Hwang et al., 2013), by facilitating them in discovering how they can live meaningfully in their remaining years (Edwards & Chapman, 2004), or by enriching their lives (Hwang et al., 2013). That is, helping may require emotional labor in addition to the physical labor needed to provide care. For example, for elders who are sick and/or depressed, helping may require emotional support during the healing process. Communicating Communicating is an attribute that caregivers display by coordinating seeing and helping between the caregiver and the care receiver. Effective communication is needed to achieve the main goals in a caring setting, e.g., providing physical care, exchanging information, showing support, and facilitating good social interaction (Wadensten, 2005). Through effective communication, carers can determine the most effective practices for daily care (Haugan, 2014) in nursing home settings. Communication is needed to integrate the needs of elders in LTCFs, including comfort, meaning, individuality, and relationships. Finally, communicating is important for making elders feel that someone is helping and watching them. 3
Caring for Residents of Eldercare Facilities: A Concept Analysis
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Figure 1. Attributes of Caring for Residents of Eldercare Facilities Seeing - Being sensitive
Helping Communicating
- Having a relationship
- Enabling
Figure 2. Conceptual Model of Caring for Residents of Eldercare Facilities Antecedence
Attributes
Consequences
Seeing - Being sensitive
Individual needs Organizational cultures
- Having relation Communicating - Coordinating Helping -Attending -Enabling
Elders - well-being Caretakers - well-being - caring practice
For example, clear communication between the elder and the caregiver is not only essential for a caring relationship that meets the individual needs of the elder (Berglund, 2007; Ganz, Fung, Sinsky, Shinyi, & Reuben, 2008), communication is also needed to integrate the caring attributes needed to provide elders with a satisfactory quality of life (Edwards & Chapman, 2004) and with health and well-being (Haugan, 2014). From a holistic perspective of caring, this study defined caring as an interactive process involving multidimensional acts and then conceptualized the concept by using the metaphor of two wheels and an axle (see Figure 1), in which the axle represents communication and the two wheels represent helping and seeing. With constant communication, both wheels rotate in unison. Otherwise, the wheels turn in different directions and stop moving. Further, caring can be delivered in a holistic and integrated way by integrating the wheels and axles of other caregivers. Another iterative process of the conceptual analysis cycle (Rodgers, 2000) is examining the antecedents and consequences of the concept by exploring the context in which the concept is used. The conceptual model of caring for residents of eldercare facilities is also presented in Figure 2. Antecedents of Eldercare Caring is preceded by the needs of the recipient, which are highly subjective and dependent on the specific situation and people involved (Nakrem, Vinsnes, & Seim, 2011). For example, elders might need more care and/or more constant care during a life crisis. For caring to occur, the recipient must express physical, psychological, or spiritual needs (Turkel & Ray, 2001). Thus, the antecedents to the 4
- Attending
caring process include expressing the need for caring and accepting caring. Studies indicate that the needs and types of caring required by elders depend on their gender, how many children they have, and their specific chronic illness (Huang et al., 2008). For instance, male elders value skillful, physical caring behavior, but female elders value emotional or affect caring. When staff do not build caring relationships with their residents, especially those who are frail and elderly, and do not provide personalized interventions, the residents may exhibit learned helplessness. The nature of caring is largely influenced by the political and economic structure of the country where the care facility is located and also by the organizational culture of the facility itself (Coffman, 2014; Kubiak & Sandberg, 2011). A conductive working milieu facilitates caring by recognizing the caring concept, by providing supportive supervisors, by having a clear division of labor, by providing integrative services, and by providing staffing and job training for staff to carry out caring (McGilton, Profetto-McGrath, & Robinson, 2013; Tuckett et al., 2009; Wang, 2009). Consequences of Caring The consequences of caring are usually positive in elderly residents of eldercare facilities. For example, studies of LTCF residents show that nurse–patient interaction can promote hope, satisfaction, mental wellness, meaning in life, self-transcendence, quality of life, independence, and multidimensional well-being (Abad-Corpa et al., 2012; Custers, Westerhof, Kuin, & Riksen-Walraven, 2010; Edwards & Chapman, 2004; Haugan, 2014; Haugan, Hanssen, & Moksnes, 2013). Theoretically, caring is a human-to-human relationship that facilitates nurses’ and patients’ process of being and becoming (Watson, 2008). Ideally, it contributes to well-being for both the caregiver and receiver and inspires caregivers to improve their professional skills and efficacy (Haugan, 2014). Recognizing the need for social interaction by residents can facilitate caring behaviors (Bedin et al., 2013). For example, our previous study (Hwang et al., 2013) revealed the importance of relational activities for caregivers and residents. Identifying an Example Case For a comprehensive conceptual analysis, a real-world example is helpful. One example that illuminates the above attributes, antecedents, and consequences is the experi-
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Caring for Residents of Eldercare Facilities: A Concept Analysis
ence of the author in caring for Wo (pseudonym), an elderly woman who had lived in a nursing home for 2 years after suffering a stroke. Each caregiver in this facility had a busy schedule managing routine activities for 6 to 12 residents. However, Wo was satisfied with the assistance she received from her caregivers. She enjoyed socializing with her caregivers because they treated her like a friend or family member. Caregivers helped her with her physical needs and shared news about current events with her. They even allowed her to help care for other residents and to learn the skills needed to be a caregiver. Wo said, “The feeling of having a friend living in the same house means a lot to people like me. However, some caregivers say negative things about me even though they don’t know me well. This makes me feel bad and makes me want to avoid those people. I realize that I must communicate with them so they can help me with my personal needs.” This example demonstrates the three attributes described above, i.e., seeing individuality and a relationship, attending to needs, and communicating seeing and helping. This study analyzed the elements of caring in an LTCF setting as perceived by both the givers and receivers of care. Discussion The results of this study are particularly telling in terms of the philosophical, physical, and psychosocial components of caring. Earlier studies described caring as the practice of providing emotional, physical, informational, practical, humanistic, and clinical care and comfort. Our proposed caring concept of seeing and helping through communication can be applied in the context of elderly care facilities. The results of this work go a step further by developing a wheel and axle model of caring to describe caring in LTCFs. The conceptualization of caring that emerged in this study is consistent with those based on earlier theories and models. Attributes of caring encompass the professional seeing skills, helping skills, and interpersonal communication skills needed to ensure the safety of residents and to attend to their needs holistically. These attributes correspond to the instrumental and expressive caring behaviors identified in an earlier systemic review of quantitative studies (Papastavrou et al., 2011) and are consistent with Watson’s (2008) definition of caring as creating a supportive/protective/corrective environment and with the Quality-Caring Model (Duffy & Hoskins, 2003), which is based on the claim that effective caring requires nurses to initiate, cultivate, and sustain interdependent relationships with patients or families. Attributes of seeing generated in this study correspond to the process of being with in Swanson’s (1991) Caring Theory, to the unconditional acceptance concept in Nursing as Caring Theory (Boykin & Schoenhofer, 2001), and to the concepts of embracing altruistic values, being sensitive, instilling faith and hope, and honoring others in Watson’s
(2008) Caritas processes. To achieve the seeing attribute, caring must be delivered with respect and commitment (de Guzman et al., 2012) when dealing with people and handling their affairs. The personal traits required for an effective professional caregiver also include flexibility and sensitivity to individual needs. Some scholars have also proposed that an effective caregiver requires a strong moral foundation, such as a commitment to act benevolently, and that a caring attitude is an antecedent of caring (Finfgeld-Connett, 2008). Additionally, most studies agree that, for most residents of eldercare facilities, the main concern is the attitudes of their caregivers (Kydd, 2009; Xie, Gau, Li, & Xu, 2009; Yang & Shyu, 2001). The caring attributes that are important to institutionalized elders are interrelated and not mutually exclusive. Caring in nursing is a communicative discourse between nurses and clients, regardless of the service environment or culture, the diagnosed illness, or the debility of the client (Sumner, 2012). This view is consistent with studies such as Berglund (2007) and Sumner (2012), which indicated that the patient has an illness self whereas the nurse has a professional self. However, both parties also have a personal self. For example, clients must communicate their needs, and the staff must help to meet those needs. Such communicative action in nursing constitutes the moral part of caring and is bidirectional: The nurse gains satisfaction from providing care, whereas the patient gains satisfaction from receiving care. Interestingly, communication is important not only between the giver and receiver of care, but also between seeing and helping within the caregiver. Caring is not innate; it is developed through maturity and cultivation (Finfgeld-Connett, 2008). To handle patients and professional tasks effectively, caregivers require maturity and good professional skills, which can only develop over time. Facilities that provide elder care and schools that offer education in caring must devote adequate resources to cultivating helping and communicating skills in their employees and students. The objective is to establish a sensitive culture in which individual needs are understood and in which a multidisciplinary approach to caring is supported. Conclusion To account for the perspectives of both the care recipient and the caregiver, this study conceptualized the essential elements of caring (seeing, helping, and communicating) as an axle and two wheels. The axle and wheel is a strong metaphor for the interactive relationship between caregivers and recipients in an eldercare facility and can guide caregivers in delivering effective care in daily activities. For residents of eldercare facilities, caring is preceded by individual needs and organizational culture and is followed by well-being. Although the concept analysis did not provide a definite conclusion, it identified directions for 5
Caring for Residents of Eldercare Facilities: A Concept Analysis further study (Tofthagen & Fagerstrøm, 2010). This caring concept model requires further validation and testing. Specifically, the model should be compared using different methodologies and using subjects in different countries. Further studies are needed to validate the model by exploring how the antecedents of elder care and attributes affect quality of life. Further quantitative studies are also needed to explore how the characteristics of residents and characteristics of eldercare facilities affect wellness in both the recipients and givers of care. The proposed model of the institutional caring concept also needs further validation for use in developing interventions to assist managers of public and private eldercare facilities in achieving highquality care for elders. Relevance to Clinical Practice The institutional caring concept provides a language for discussing the roles of nurses and caregivers in aged care facilities and for discussing the development of knowledge in the field of long-term care. For professionals and paraprofessionals, this synthesis adds depth to the caring concept. For caregivers, clarifying this concept has several implications: (1) it improves understanding of the nature of caring in eldercare facilities; (2) it increases awareness of the contextual factors that affect the delivery and appraisal of care in eldercare facilities; (3) it provides a language that elders, their families, and their caregivers can use for an open discussion of care quality and other concerns; and (4) it can be used to educate administrators and policymakers in the elements of effective and comprehensive elder care policies. Acknowledgments. We would like to thank the Research Council of Taiwan Nurse Association for funding this study under grant number TWNA-1022023. References Abad-Corpa, E., Gonzalez-Gil, T., Martínez-Hernández, A., BarderasManchado, A. M., De La Cuesta-Benjumea, C., Monistrol-Ruano, O., & Mahtani-Chugani, V. (2012). Caring to achieve the maximum independence possible: A synthesis of qualitative evidence on older adults’ adaptation to dependency. Journal of Clinical Nursing, 21(21/22), 3153–3169. doi:10.1111/j.1365-2702.2012.04207.x Bedin, M., Droz-Mendelzweig, M., & Chappuis, M. (2013). Caring for elders: The role of registered nurses in nursing homes. Nursing Inquiry, 20(2), 111–120. doi:10.1111/j.1440-1800.2012.00598.x Berglund, A. (2007). Satisfaction with caring and living conditions in nursing homes: Views of elderly persons, next of kin and staff members. International Journal of Nursing Practice, 13(1), 46–51. doi:10.1111/j.1440172X.2006.00602.x Boykin, A., & Schoenhofer, S. (2001). Nursing as caring: A model for transforming practice. Sudbury, MA: Jones & Bartlett. Brilowski, G. A., & Wendler, M. C. (2005). An evolutionary concept analysis of caring. Journal of Advanced Nursing, 50(6), 641–650. Chao, S., & Roth, P. (2005). Dimensions of quality in long-term care facilities in Taiwan. Journal of Advanced Nursing, 52(6), 609–618. Cheng, S. T. (2009). The social networks of nursing-home residents in Hong Kong. Ageing and Society, 29(2), 163–178. Coffman, S. (2014). Ray’s Theory of Bureaucratic Caring. In M. Alligood (Ed.), Nursing theorists and their work (8th ed.). St. Louis: Mosby/Elsevier.
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Custers, A. F. J., Westerhof, G. J., Kuin, Y., & Riksen-Walraven, M. (2010). Need fulfillment in caring relationships: Its relation with well-being of residents in somatic nursing homes. Aging & Mental Health, 14(6), 731–739. doi:10.1080/13607861003713133 Duffy, J., & Hoskins, L. (2003). The quality-caring model: Blending dual paradigms. Advances in Nursing Science, 26(1), 77–88. Edwards, H. E., & Chapman, H. M. (2004). Contemplating, caring, coping, conversing: A model for promoting mental wellness in later life. Journal of Gerontological Nursing, 30(5), 16–21. Finfgeld-Connett, D. (2008). Meta-synthesis of caring in nursing. Journal of Clinical Nursing, 17(2), 196–204. Ganz, D. A., Fung, C. H., Sinsky, C. A., Shinyi, W., & Reuben, D. B. (2008). Key elements of high-quality primary care for vulnerable elders. Journal of General Internal Medicine, 23(12), 2018–2023. de Guzman, A. B., Santos, C. I. Q., Santos, I. B. A., Santos, J. A., Santos, J. E., Santos, J. M. S., & Santos, V. E. E. (2012). Concept of care, caring expectations, and caring frustrations of the elderly suffering from chronic illness. Educational Gerontology, 38(5), 299–313. doi:10.1080/ 03601277.2010.544586 Harrefors, C., Savenstedt, S., & Axelsson, K. (2009). Elderly people’s perceptions of how they want to be cared for: An interview study with healthy elderly couples in Northern Sweden. Scandinavian Journal of Caring Sciences, 23, 353–360. Haugan, G. (2014). Nurse-patient interaction is a resource for hope, meaning in life and self-transcendence in nursing home patients. Scandinavian Journal of Caring Sciences, 28(1), 74–88. doi:10.1111/ scs.12028 Haugan, G., Hanssen, B., & Moksnes, U. K. (2013). Self-transcendence, nursepatient interaction and the outcome of multidimensional well-being in cognitively intact nursing home patients. Scandinavian Journal of Caring Sciences, 27(4), 882–893. doi:10.1111/scs.12000 Huang, J. J., Lin, K. C., & Li, I. C. (2008). Service needs of residents in community-based long-term care facilities in northern Taiwan. Journal of Clinical Nursing, 17(1), 99–108. Hwang, H. L., Tu, C. T., Chen, S., & Wang, H. H. (2012). Caring behaviors perceived by elderly residents of long-term care facilities: Scale development and psychometric assessment. International Journal of Nursing Study, 49(2), 183–190. Hwang, H. L., Hsieh, P. F., & Wang, H. H. (2013). Taiwanese long-term care facility residents’ experience of caring: A qualitative study. Scandinavian Journal of Caring Sciences, 27(3), 655–668. doi:10.1111/j.14716712.2012.01082.x Juthberg, C., & Sundin, K. (2010). Registered nurses’ and nurse assistants’ lived experience of troubled conscience in their work in elderly care: A phenomenological hermeneutic study. International Journal of Nursing Studies, 47(1), 20–29. Kubiak, C., & Sandberg, F. (2011). Paraprofessionals and caring practice: Negotiating the use of self. Scandinavian Journal of Caring Sciences, 25(4), 653–660. doi:10.1111/j.1471-6712.2011.00875.x Kydd, A. (2009). The care and wellbeing of older people: A textbook for health care students. Exeter, UK: Reflect Press. Lee, Y. C. (2010). Social support: A study of elderly in nursing homes (Unpublished master’s thesis). Chung Shan Medical University, Taichun. Airiti GCScholar database. Lin, Y. H., Wang, L. S., Yarbrough, S., Alfred, D., & Martin, P. (2010). Changes in Taiwanese nursing student values during the educational experience. Nursing Ethics, 17(5), 646–654. doi:10.1177/0969733010373011 Liu, S. J. (2004). What caring means to geriatric nurses. Journal of Nursing Research, 12(2), 143–152. McGilton, K. S., Profetto-McGrath, J., & Robinson, A. (2013). Implementing the supportive supervision intervention for registered nurses in a long-term care home: A feasibility study. Worldviews on Evidence-based Nursing, 10(4), 238–247. doi:10.1111/wvn.12004 Nakrem, S., Vinsnes, A. G., & Seim, A. (2011). Residents’ experiences of interpersonal factors in nursing home care: A qualitative study. International Journal of Nursing Studies, 48(11), 1357–1366. Natan, M. B. (2008). Perceptions of nurses, families, and residents in nursing homes concerning residents’ needs. International Journal of Nursing Practice, 14(3), 195–199. Oxford Dictionaries. (2014). Language matter. Retrieved from http:// www.oxforddictionaries.com/definition/english/caring Papastavrou, E., Efstathiou, G., & Charalambous, A. (2011). Nurses’ and patients’ perceptions of caring behaviours: Quantitative systematic review of comparative studies. Journal of Advanced Nursing, 67(6), 1191– 1205. doi:10.1111/j.1365-2648.2010.05580.x Risjord, M. (2009). Rethinking concept analysis. Journal of Advanced Nursing, 65(3), 684–691. doi:10.1111/j.1365-2648.2008.04903.x
H. Hwang
Caring for Residents of Eldercare Facilities: A Concept Analysis
Rodgers, B. L. (2000). Concept analysis: An evolutionary view. In B. L. Rodgers & K. A. Knafl (Eds.), Concept development in nursing: Foundations, techniques, and applications (2nd ed., pp. 77–102.). Philadelphia: Saunders. Sumner, J. (2006). Concept analysis: The moral construct of caring in nursing as communicative action. International Journal for Human Caring, 10(1), 8–16. Sumner, J. (2012). Communication as moral caring in nursing: The moral construct of caring in nursing as communicative action. International Journal for Human Caring, 16(2), 20–28. Swanson, K. M. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161–166. Teeri, S., Leino-Kilpi, H., & Välimäki, M. (2006). Long-term nursing care of elderly people: Identifying ethically problematic experiences among patients, relatives and nurses in Finland. Nursing Ethics, 13(2), 116–129. Tofthagen, R., & Fagerstrøm, L. M. (2010). Rodgers’ evolutionary concept analysis—A valid method for developing knowledge in nursing science. Scandinavian Journal of Caring Sciences, 24, 21–31. doi:10.1111/j.14716712.2010.00845.x Tuckett, A., Hughes, K., Gilmour, J., Hegney, D., Huntington, A., & Turner, C. (2009). Caring in residential aged-care. Qualitative findings from an e-cohort sub-study. Journal of Clinical Nursing, 18(18), 2604–2612.
Turkel, M. C., & Ray, M. A. (2001). Relational complexity: From grounded theory to instrument development and theoretical testing. Nursing Science Quarterly, 14(4), 281–287. Wadensten, B. (2005). The content of morning time conversations between nursing home staff and residents. Journal of Clinical Nursing, 14, 84–89. doi:10.1111/j.1365-2702.2005.01283.x Wang, Y. (2009). From the point of adaptation to view employment and management foreign workers in long-term care facilities. Community Development Quarterly, 125, 472–485. Watson, J. (2008). Nursing: The philosophy and science of caring (2nd rev.). Boulder, CO: University Press of Colorado. Wolf, Z. R., Zuzelo, P. R., Goldberg, E., Crothers, R., & Jacobson, N. (2006). The Caring Behaviors Inventory for Elders: Development and psychometric characteristics. International Journal for Human Caring, 10(1), 49–59. Wu, S. C., White, A., Cash, K., & Foster, S. (2009). Nursing home care for older people in Taiwan: A process of forced choice. Journal of Clinical Nursing, 18(14), 1986–1993. doi:10.1111/j.1365-2702.2008.02697.x Xie, Y., Gau, G., Li, Y., & Xu, M. (2009). Overall service quality research in a long-term care facility in mid-Taiwan. Kuang Tien Medicine Journal, 4(7), 23–39. Yang, C. L., & Shyu, Y. I. (2001). Indicators of quality of care in nursing homes from the perspective of elderly residents. Journal of Nursing Research, 9(1), 53–62.
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