Human Caring: A Concept Analysis

Headnote

Keywords:

Analysis, Concept formation, Human caring, Nursing care

Abstract

Introduction: Human caring combines science, art, and humanity. Humanity is the heart of care and interpersonal interactions. Despite the critical emphasis on human caring and concern for nursing care without humanity, there is no clear definition for human caring in nursing. This study aimed to analyze the concept of human caring.

Methods: Walker and Avant's strategy for concept analysis was used. Electronic databases such as PubMed, Scopus, Ovid, Google Scholar, Magiran, Iran Doc, SID, and a number of dictionaries were searched without any limitation in date. Search keywords were "care", "caring", "human caring", "humanization", "patient care", "comprehensive care" and "nursing care". We searched all documents published before September 2020. In the initial search, 1637 articles were found but finally, 39 relevant articles remained in the study.

Results: The nine defining attributes of human caring were establishing therapeutic communication, presence at the patient bedside, empathy, providing scientific care, subjectivity, dynamicity, respecting the patient's rights and ethics of care, helping the patient achieve a feeling of well-being, and art and creativity. Antecedents of human caring were categorized into three categories namely, human, personal, and organizational factors. The consequences were also categorized into consequences related to nurse, profession, patient, and organization.

Conclusion: A theoretical definition and a conceptual model of human caring were developed. This concept should be included in the nursing curricula at all undergraduate and graduate levels and even in nurses' in-service training programs.

Introduction

Caring is an integral part of nursing.1 Quality of care is also a key issue for nurses and patients, and a major goal for patients, healthcare policymakers, and managers.2 Quality nursing care brings desirable health outcomes, for patients, nurses, and healthcare organizations.3 Quality nursing care necessities the nurses' responsiveness to the patients' physical, psychological, emotional, social, and spiritual needs, so that patients return to their healthy and normal lives and the satisfaction of both patients and nurses is achieved.4

The human nature of care and respect for human values are among the main feature of quality care.5 According to Jacobson, human caring involves the nurse's efforts to protect the clients' sublime human existence, to empower the clients, and bring them to a higher degree of harmony between mind, body, and spirit.6 In another definition, Watson defines human caring as an ideal moral practice that involves the unique use of self through movement, emotions, and touch to achieve unity between two individuals, in the light of which the client is healed and his inner strength and self-control flourishes.7 Jouzi et al also believe that human caring consists of good communication, a humanistic view of the patient, scientific caring, and patient safety.8 Another study also concluded that besides appropriate communication, human caring necessitates feeling accountable, using new methods in caring, and respect for sexual conformity in care.9 In a study, acceptance and understanding of patients, purposeful patient assessment and identification, and patient empowerment have been mentioned as the main components of human caring.10

Paterson & Zderad11 and Watson7 have also proposed theories on human caring. According to Paterson and Zderad human caring is an existential experience and "reciprocal call and response" in which the nurse and patient come together as human beings. The patient calls for the nurse with the expectation of being cared for and the nurse responds to the patient to meet his/her need of caring for another. Its purpose is a human response to human values beyond the mere concept of health.11 While defining human caring, Leininger and McFarland cited Watson's definition of human caring as the practice of loving-kindness and equanimity. It involves authentic presence, a deep belief in others, and the cultivation of one's spiritual practice toward wholeness of mind/body/ spirit. This type of care respects for individual's identity and values, supports the individual's uniqueness and independence, and helps people reach their maximum capacity.1

It is believed that human caring complements and balances the advanced healthcare technology,12 steps towards the humanization of the whole healthcare system, and promotes and develops the nursing profession.13

It is believed that human caring leads to respect for the patient's dignity, uniqueness, individuality, and humanity. It also enhances health care providers' empathy towards the patients, communication and bonding relationships, respect for patients' autonomy and involvement in the process of caring, and also promotes the development of rationality and Justice in the health system.14 However, there are still ambiguities about the concept. In a study of the meaning of 'being with the person cared for', O'Reilly and Cara emphasized that human caring is an ethical practice necessitating a humanistic relationship with the client, respecting for humanistic values, the individuality of the client, caring relationships, and the contextual complexities, in order to promote the bodysoul-spirit harmony of the person cared-for and the nurse.15 George emphasizes the conscious presence of the nurse,5 and Rudolfsson et al defines human caring as the nurse's physical and emotional closeness to the patients; an impersonal caring approach that affects the nurses' and healthcare systems' social and legal aspects.16 According to de Cássia Calegari et al human caring is a subjective and complex concept its meaning varies from person to person due to their cultural differences and individual values. Scholars have looked at human caring from different standpoints, and no concept analysis is available on this concept, though some studies have briefly referred to it.17

Analyzing Watson's theory of human caring, a study has referred to kindness, empathy, concern, and love for self and others as features of human caring and emphasized that all these features are influenced by childhood experiences, culture, beliefs, and art.18 Another study also cited respect, compassion, and empathy when discussed on the meaning of humanization of health care from the perceptive of nurses and physicians. However, it has been emphasized that organizational culture, managerial respect for professionals' autonomy, and workload can affect human caring.17 In a study on resources for nurturing human approaches in nurses, family upbringing, academic training, and culture were among the most important variables affecting human caring,12 however, a study reported that nurses' personality traits have little effect on human caring, but resources available for nurses and organizational support are among the most important factors affecting human caring.14

Although human caring is an important factor in care and treatment, it is not precisely and comprehensive defined. Also, no concept analysis of human caring was found. For the first time, in this study, we analyzed the concept of human caring. We used Walker and Avant's concept analysis method to analyze this concept. Concept analysis helps to update the knowledge framework about a concept, clarify the concept, and develop applicable guidelines for concept application through identifying the attributes, antecedents, and consequences of a concept.19 Clarifying the concept of human caring is expected to help caregivers provide high-quality humanistic care to their clients. Furthermore, concept analysis can help update the knowledge framework and clarify concepts.

Materials and Methods

This concept analysis was conducted using Walker and Avant's eight-step approach. This approach is clear and systematic and the most common for concept analysis and includes the following steps: 1- Selecting a concept for analysis; 2- Determining the purpose of the analysis; 3- Identifying all uses (definitions) of the concept; 4Determining the defining attributes of the concept; 5Constructing a model case; 6- Constructing borderline, related, contrary, invented, and illegitimate cases; 7Identifying the antecedents and consequences of the concept; and 8- Defining the empirical referents of the concept.19

Selecting the Concept and the Purpose of the Analysis

The first and second steps are selecting the concept for analysis and processing a theoretical basis and purpose of the analysis. Caring is the central concept in nursing.12 High-quality nursing care requires attention to the human dimension of care. Human caring maintains and promotes professional ethics, preserves human dignity, enhances the nurses' responsibility, and improves the bonding and empathy between nurses and patients.14 Human caring is a complex and abstract concept and people have different perceptions of it.17 Due to the ambiguities surrounding the concept of human caring, this concept was selected for analysis. The purpose of the analysis was to clarify and further develop the concept and propose a clear definition for it.

In the third step, we performed a literature review. We searched several books and online databases such as PubMed, Scopus, Ovid, Google Scholar, Magiran, Iran Doc, SID, and a number of dictionaries. Search keywords were "care", "caring", "human caring", "humanization", "patient care", "comprehensive care" and "nursing care". These keywords were searched in the title, abstract, and keyword section of the documents. The search was done without a time filter, and the Boolean operator "AND" and "OR" were used to combine search results (Table 1). The reference lists of all retrieved records as well as the available gray literature (such as books and dissertations) were also searched for additional records. All the records found were entered into the Endnote software to determine and remove duplicates.

Inclusion criteria were relevance to human caring, description of its aspects or its relationship with relevant concepts, publication in English or Persian, availability of the full-text, and containing materials on the definition, uses, attributes, antecedents, or consequences of human caring. We did not include editorials, commentaries, book reviews, and anonymous documents. At first, 1637 articles were found but after excluding the duplicates (n = 530), the number of the documents was decreased to 1107. After reviewing the titles and abstracts, 1068 items were excluded because they were irrelevant to human caring, were not in English or Persian languages, and were anonymous or predicate. Abstracts of the remaining studies were read, and studies were included in the final analysis if they had referred to at least one of the attributes, antecedents, consequences, definitions, contributing factors, and measurement techniques of human caring. Subsequently, 39 studies in the area of nursing or health sciences were included and analyzed (Figure 1). Two researchers independently extracted the relevant data on the definitions of human caring and its attributes, antecedents, consequences, contributing factors, and measurement methods from the included documents and wrote them on datasheets. Disagreements were resolved through group discussion.

Results

Results are presented as the uses of the concept, attributes, cases, antecedents, consequences, and empirical referents of the concept.

Uses of the Concept

The concept of human caring is a combination of the two concepts of caring and human. In the Oxford Dictionary, the concept of caring means caution, prudence, and serious attention or consideration applied to do something correctly. It also means feeling concern or interest; feeling affection or liking, attaching importance to something, and the provision of what is necessary for the health, welfare, maintenance, and protection of someone or something.20 Merriam-Webster's dictionary also defines the concepts of care and caring as painstaking, watchful attention, maintenance, supervision, regard coming from desire or esteem, and to feel interest, concern, and responsibility.21 Caring implies trying to discover the needs and limitations of patients.22,23 The concept of caring includes comprehensive attention to the patient, in accordance with his/her needs and mental, physical, emotional, psychological, and social conditions and is accompanied by respect, love, sense of commitment, responsibility, altruism.2,23 It necessitates a reciprocal relationship between caregiver and patient, and also an agreement between patients' expectations and caregivers' interpretation of these expectations.2,4,22,23

Human, in the Oxford Dictionary, is connected with human development/activity/behavior, contact with other people.20 Merriam-Webster's dictionary also defines the human concept with regard to human needs and emotions, within the range of human capacity and from a human point of view.21 The term human is a mental concept and can have different meanings due to cultural differences and individual values. Humanity is related to the concepts of respect, care, empathy, ethics and human rights.17

While human and humanity are interchangeably used to refer to concerns for other people.12 Human caring is also interchangeably used with humanistic care,8,13 humanizing care,10 humanized care,24 humanization of caring,14,17,25,26 caring,27 caring with dignity,6 and comprehensive care.28

Human caring is a process in which eminent values are preceded by all other measures in nurse-patient relationships.29 This process emphasizes the human components of caring and the moment-by-moment confrontation between the caregiver and the care receiver. The central idea of this concept is that human beings cannot be treated like objects and that human beings cannot be separated from themselves, others, nature, and the larger world. This concept rejects the mechanical and reductionist view of the world.30 It also includes a sense of responsibility towards oneself and others, responsible choices and emphasis on the role of man in one's own destiny, and comfort of others.17,30 It includes interactions between two people with different living conditions and phenomenological dimensions. This approach to caring is an ideal moral practice that includes the unique use of self to create unity between the two parties. It is also based on the interaction and healing of suffering, helping to promote the client's inner strengths and self-control and promoting the harmony between the patient's body and soul7 and brings the nurse physically and emotionally close to his/her patient. This approach results in mutual trust, commitment,16 understanding, and the ability to offer friendship, love, and acceptance.24 Factors such as a human relationship with the care receiver, attention to human values, uniqueness of caring experience, the spirituality ofthe patient and the nurse,15 and the conscious and authentic presence of the nurse5 are influential factors in this approach to caring.

The Defining Attributes of Human Caring

Defining the attributes of the concept is the core of concept analysis. According to Walker and Avant, attributes are a group of characteristics that have the strongest relationship with the concept, best explain the intended concept, help researchers differentiate the intended concept from similar or related concepts and allow the analyzer to obtain a deep insight. Concepts have more than an attribute. Therefore, it must be determined which attributes are more appropriate to describe the concept.19 The most common attributes of human caring are establishing therapeutic communication, presence at the patient bedside, having a human view of the patient, empathy with the patient, providing scientific care, observing the patient's rights and ethics of care, helping the patient achieves a feeling of well-being, art and creativity, subjectivity, and dynamicity of care.

Establishing Therapeutic Communication

Communication refers to the process of exchanging information between two or more people.31 But therapeutic communication, beyond mere communication, requires attention to human values and mutual trust8,31 and causes psychological and social comfort in patients, as well as increasing the employees' sensitivity and empathy with patients.25 Therapeutic communication requires the observance of communication etiquette, active listening,32 gaining the trust of the patients and their families, paying attention to the patient's culture,8 amiability while caring, and being responsive to the patient's needs.9

Presence at the Patient Bedside

Human caring requires the nurse's real presence at the patients' bedside.9 Presence is the core of nursing practice and is a state of bringing self to "being with" a person. Presence has been described as the process of being available with the whole of oneself and open to the experience of another through a reciprocal interpersonal encounter.11 It involves a spiritual connection that is felt when the nurse and patient share the experience of being together.33 Through presence, the nurse is available to the patient with the wholeness of his or her unique individual being and tries to bring integration and balance to the life of the patient.34

Empathy

Empathy is the ability of a person to understand another's feelings by placing oneself psychologically in that person's circumstance. Empathy has two dimensions: cognitive and emotional.35 Understanding the client's condition, needs and feelings is the basis of empathy and one of the foundations of human caring.36 Empathy requires attention, imagination, identification with patients, and human sensitivity. It is reflected in the nurse's empathetic behaviors and expressions and then leads to feedback and receiving mutual empathy from the patient.37

Providing Scientific Care

Human caring includes the nurse's effort to apply their scientific knowledge in comprehensive patient care. In human caring, the nurse tries to combine science and technology with human values, to meet the patients' needs, alleviate their problems, empower them,38 and evaluate the outcomes.8

Respecting the Patient Rights and Ethics of Care

Enjoying the best possible health care, regardless of race, religion, political opinion, financial or social status is among the basic rights of every human being.39 Training the patients, respecting patient privacy, and protecting their information within the framework of the law are among the fundamentals of patient rights and ethics of care.17 Privacy means that one draws a hypothetical line at accessibility to his or her physical and mental integrity, such as not allowing physical contact or not explaining his or her emotions and thoughts. People have physical, social, cognitive, and psychological privacy. Respect for privacy makes the patient feel safe and secure.40 Therefore, attention to patient privacy, patients' cultural values,8 and the need for being cared for by caregivers of the samesex9 are essential for human caring.

Helping the Patient Achieve a Sense of Well-being Well-being

is a concept beyond health. It is a state of feeling comfortable, healthy, and happy,41 and is considered the ultimate goal of nursing care. Human caring involves the nurse's efforts to instill a feeling of well-being. Creating a physical and psychological setting in which the patient feels comfortable can help him/her feel well. Mastery of the environment, positive relationships with others, autonomy, feeling a purpose in life and the ability to fulfill it, the realization of potentials, and self-acceptance also induce people a feeling of wellbeing.42

Art and Creativity

Human caring entails the nurse's artistic, creative, and purposeful use of self, skills, knowledge, and experiences in caring for, healing, and comforting the patient. Creative and artistic human caring is a relationshipcentered practice requiring human sensitivities, strong imagination, and skillful efforts in the use of empirical and metaphysical knowledge.43

Subjectivity

Human caring is a subjective concept that involves the understanding of patients' feelings, beliefs, conditions, attitudes, emotions, and expectations. It results in smart and responsible choices in special life situations.44

Dynamicity

Human caring is a dynamic and evolving concept because the ability to provide human caring develops over the nurses' life. It also develops during the nurse-patients relationship.10

Model Case

Model case is an example of the use of the concept and possesses all attributes of the intended concept.19

Ms. M., a 53-year-old woman, with a history of type 1 diabetes and a medical diagnosis of acute myocardial infarction, was admitted in the cardiac intensive care unit 2 days ago. Ms. A. is her nurse in the evening shift. She greets the patient, introduces herself, and writes her name on the board next to the patient's bed. She noticed the patient's sad face and her rapid heart rate. The patient tries to hide his tears. The nurse monitors her blood pressure that is 165/100, raises the bedrails, and starts talking to the patient. She kindly asks the patient to talk to her. The patient states that the doctor requested an angiography for her but she does not know how angiography is performed and what its side effects are. The nurse takes the patient's hands after permission, looks into the patient's eyes, and explains about angiography. She also sends from her cellphone an educational video about angiography to the patient's mobile phone. Then they watch it together and while watching, the nurse explains some points to the patient and replies to the patient's questions. The patient was also worried about her 9-year-old daughter not seeing her for 2 days. She said this to the nurse with tearful eyes. The nurse listened to her worries, asked her if she wishes to talk with her daughter, and then, in coordination with the patient's spouse, she provides the possibility of a video contact with the patient's daughter. After that, the patient took the nurses hand and said: "Thank you. You taught me very well. I wish you were always here. I am very happy for seeing my daughter's face and hear her voice. I will never forget your kindness."

In this example, the nurse was really present and noticed the patient's worries. She tried to communicate the patient, listened to the patient carefully and empathetically, establishing proper communication with the patient, and explained angiography to the patient in a scientific, artistic and creative way. To protect the patient's rights, she provided scientific education the opportunity for her. The nurse also empathized with the patient and respected her privacy by asking her before taking her hands. The nurse instilled in the patient a feeling of psychological well-being through training and video calls with her daughter.

Other Cases

Borderline Case

Borderline case is an example that contains most but not all of the defining attributes of the intended concept.19

Ms. F., a 50-year-old, illiterate woman, was admitted to the medical ward with a medical diagnosis of a transient ischemic attack. Ms. P was her nurse on the evening shift. After starting the shift, the nurse entered the patient's room, greeted the patient, introduced herself, and wrote her name on the board above the patient's head. She instructed the patient to use the alarm ring if needed. She discovered that the patient had not yet taken her medication. She requested the patient to take it and remained until she did so. The patient complained of constipation and the nurse gave her a laxative that had been prescribed as as needed.

The patient had an order for a contrast medium injection and was worried about it. She did not know the time or the method. The nurse gave her some explanations about the CT scan procedure and informed her that she should be transferred to the radiology department at 5:00 pm. The nurse handed over a CT scan training pamphlet to one of the relatives of the nearby patient and asked her to explain the contents to Ms. F. and said to the patient: I am here if she has any further questions. At 5:00 pm, the nurse entered the patient's room and asked her to be ready for transfer to the radiology department for the CT scan. After two minutes, the nurse came back with her assistant, covered the patient's body with a sheet, raised her bedrails, and transferred the patient to the radiology department. The patient requested that her son accompany them during the transfer and the nurse agreed. While the patient was being transferred, the nurse tried to relieve her stress and listened to her. The nurse documented all the transportation procedures in the patient's file before and after transportation. After the procedure, the nurse assistant returned the patient to her room. The nurse came to her and asked her: Are you OK? Do you have any problems? I am here at the nursing station. Please use the alarm ring if you need anything. The patient said that your words calmed me down a lot. Then, at 19:30 pm the nurse handed over the patients to the next shift. In this case, the nurse assessed the patient's problems, greeted her, and agreed to her request. She had good communication with the patient. She also maintained the subjectivity and dynamically of care and tried to respect the patient's rights and ethics of care, and took steps to train the patient. She was physically present and empathetic to the patient during transport and tried to do everything on time. She tried to develop a sense of calm in the patient. However, her conduct lacked art and creativity.

Contrary Case

Contrary case apparently fulfills none of the defining attributes of the intended concept. The contrary case can be expressed as something that is not known as the intended concept.19

Mr. J. 52-year-old man was admitted to the coronary care unit with a medical diagnosis of angina pectoris. Mr. M. is his nurse in the morning shift. The nurse came to the patient's bedside to take an ECG of him. He greeted the patient but did not introduce himself. Without mentioning the relevant procedure and using a screen, asked the patient to expose his chest and then started taking an ECG. The patient is very worried about seeing the wires connected to his body. The nurse only told him: "don't be afraid, and do not move". After the procedure, the nurse gave him a few Kleenex and said: now you can clean your skin and arrange your clothing. Then, he leaves the patient without informing the patient of the ECG result. He wrote the patient's name on the ECG and attached it to the patient file.

In this case, the nurse did not provide any human caring. There was no therapeutic communication, empathy, scientific caring, respect for patient privacy and patient right, art, and creativity, or instilling a feeling of well-being.

Identifying the Antecedents and Consequences of the Concept

Identifying the antecedents and consequences of a concept can lead us to the social contexts in which the concept is used. Antecedents are events or factors that come before the occurrence of the intended concept.19

Antecedents of Human Caring

Antecedents of human caring can be categorized into three categories namely: human, personal, and organizational antecedents. Having a human view of the patients is the most important human antecedent of human caring.

The human view is in fact caring for the patient as a human being, not as a patient. This view leads to a comprehensive view of the patient and would lead the nurse to design a comprehensive care plan for all the patient's physical, psychological, social, and spiritual problems and needs.8 The human view of the patient is a sign of the nurse's humanitarian and benevolent thinking towards the patients.26 It causes kindness, empathetic behaviors, concern, and love for oneself and others,18 protects and supports the sublime human existence of the patient,7 and preserves the personality and dignity of both the patient and the nurse.35 Other human antecedents of human caring include loving others and having sublime purposes in life.7

Personal antecedents of human caring include having professional nursing knowledge, the ability to understand the needs and situation of the patient,24,35 having personal experiences of patient care and working in clinical settings,12,17 enjoying a good family upbringing based on high human values,12 and feelings of responsibility and commitment to the needs of the others.45

Organizational antecedents of human caring include the existence of sufficient human and material resources,14,46 having a balanced workload,14 having good role models,12 and an organizational culture supporting quality care, teamwork,17 and holding courses on human caring for nurses.30

Consequences of Human Caring

Consequences are conditions or events which appear due to the intended concept.19 The consequences of human caring can be categorized into four main areas related to the nurse, the nursing profession, the patient, and the organization.

Nurse-related consequences of human caring include increased professional satisfaction,43,46 feeling of success, and increased interactions with patients and colleagues,46 increased self-esteem and personal growth,2,43 and further development in their commitment, holistic view of human beings,46 and the ability of artistic caring.2

The nursing profession-related consequences of human caring include improved quality of nursing care,44,46 further orderliness of care plans,44 and the appearance of an increased number of empowered and creative nurses who can play as role models for human caring.2 All these can eventually improve the public image of nursing.8

Patient-related consequences of human caring include increased patient satisfaction and participation in process of health care,44,46 improved feelings of esteem, dignity, autonomy, and reduced anxiety, a better acceptance of care, increased comfort46 and safety,47 reduced hospital stay and costs44 and achieving a feeling of well-being.43

The organization-related consequences of human caring include reduced rates of nosocomial infections, reducing hospital costs,44 improved productivity, care quality, and developing an organizational climate appropriate for human caring.46

Defining the Empirical Referents of the Concept

Empirical referents are the detectable characteristics of a concept, the manifestation of which indicates the presence of the concept. The main aim of defining the empirical referents of a concept is to facilitate its measurement. As abstract concepts have abstract defining attributes, finding and defining their empirical referents are difficult.19

A number of instruments are available that might be used for the measurement of human caring, including the Humanized Care Assessment Tool (HCAT), developed by Galvin et al. This scale has 114 items asking respondents how often on an average day their work environments enabled various humanizing behaviors. Items are in eight dimensions of care namely: sense-making-loss of meaning, personal journey-loss of personal journey, uniqueness-homogenization, togetherness-isolation, embodiment-reductionist view of the body, insidernessobjectification, sense of place-dislocation, and agencypassivity.48 The Hospitality Axiological Scale (HAS) was also developed by Galán González-Serna et al to evaluate the humanization of nursing care. This scale has 17 items and 4 dimensions of respect, responsibility, quality, and transpersonal care.45 An empathy scale (Interpersonal Reactivity Index) has also been developed by Davis for the assessment of empathy among faculty members. However, it might be used as a guide for assessing empathy in clinical settings. This 28-item scale assesses empathy in 4 dimensions of adopting a perspective, imagination, personal distress, and empathetic attention.49 Yet, further studies are needed to develop more comprehensive scales for the measurement of human caring.

Discussion

In this study, we analyzed the concept of human caring. Accordingly, it can be said that human caring is the result of nurses' effort to dynamically care for their clients through a combination of science, art, and spirituality. This type of care is somewhat subjective and necessitates transpersonal and moral interactions between a nurse and another person as two human beings with different conditions. This type of care is a unique use of self through movements, emotions, and touch, and in the light of humanitarian values to form a bond between two people. Human caring promotes harmony between body and soul, and develops spirituality in both the one who receives the care and the caregiver (i.e. the patient and the nurse), provides maximum welfare and comfort for the client, and increases the empathy and respect for the patient's rights, privacy, and safety, and promotes the ethics of care.

The most important attributes of human caring are: establishing therapeutic communication, presence at the patient bedside, empathy with the patient, providing scientific care, observing the subjectivity and dynamicity of care, respecting the patient's rights and ethics of care, and using the art of nursing and creativity to induce a sense of well-being in the patient. Human caring has human, personal and organizational antecedents.

Human caring originates from the nurse's specific worldview, who gives people a high priority.12 Human values and humanity are at the focus of the nurse while providing human caring. Human caring implies concern for the centrality of human values in all aspects of professional activity. This concern focuses on respecting for an individual's freedom, dignity, values, and beliefs. This type of care represents a sensitive, friendly, and empathetic way of addressing some human problems or needs.13

Human caring is the provision of comprehensive care in a friendly environment. With this type of care, the patient is recognized as a unique and complete being with different aspects. Nurses who provide such comprehensive care actively listen to patients, inform them well sufficiently, respect them, pay special attention to them, try to satisfy their needs and protect their rights, and encourage them to take an active part in the care process.10 Human caring is in line with patients' needs and wishes and is based on mutual respect and participatory knowledge.45 The nurse and patient develop a more respectful relationship and feelings of hope and trust for the effectiveness of the treatment are strengthened.46

According to Umenai et al human caring is mainly based on communication in care and leads to selftransformation, feelings of empathy and interaction with other people.50,51 This approach empowers individuals and groups.43

A nurse's performance in human caring reflects an understanding of some human potential that goes beyond the precise concept of health. Therefore, nursing should be implemented both as a profession and as a valuable technique. Strengthening and enhancing the human dimension of nursing care not only preserves the life of the profession but can also be a step towards humanizing the entire health system.12,52

Human caring appears to be a platform for cultivating excellent human attributes. Having a human outlook, a loving and purposeful attitude,17,24 and respect for the beliefs, values, feelings,14 culture, and individuality of patients17 are cornerstones of human caring. Interdisciplinary collaboration, professional knowledge, and organizational culture are among the factors that facilitate human caring. In human caring, the nurse's activities are planned based on the ancestors of the patients.51 and the care is not merely physical. It should be noted that a high workload can confine human caring, and limits the nurses' capability to focus on all patient's needs and expectations.17,53

It can be concluded that human caring is a growing and evolving art in nursing23 that brings the knowledge, ethics, art and creativity, skills, experience, and aesthetics together in order to bring the patient to a state of wellbeing and satisfaction with the life.54

In the present study, we only reviewed studies that had been published in English or Persian and their full texts were available. Although we tried to include all relevant articles in our review, due to the researchers' lack of access to some databases, there were likely articles that the researchers did not include in the study.

Conclusion

Human caring is the main pillar of clinical nursing and aims at increasing the quality of nursing care. Clarification of the concept of human caring and identification of its attributes, antecedents, consequences, and empirical references can broaden nurses' understanding in this regard and provide guidelines for nursing practice, research, and education. By the provision of required resources and organizational support, nursing managers should provide a suitable context for human caring. Also, to become more familiar with the concept of human caring, this concept should be included in the nursing curricula at all undergraduate and graduate levels and even in nurses' in-service training programs. Further quantitative and qualitative studies are recommended to more explore the impacts of human caring on care recipients and caregivers. Furthermore, studies are recommended to develop valid and reliable tools to measure human caring and its different aspects.

Acknowledgments

The authors would like to thank all the people who supported them during this study.

Authors' Contributions

LGHA: Designed the review protocol and developed the search strategy and drafted the protocol; LGHA, MAH: Participated in searching, data selection and extraction; MAH, MD: Provided critical points on the first draft of the manuscript; LGHA: Has involved in data analysis and interpretation of the results; LGHA, MAH and MD: Have read and approved the final manuscript

Funding

Not applicable.

Data Accessibility

All data generated or analysed during this study are included in this published article.

Ethical Issues

This project is a concept analysis and did not require an ethical approval as no direct intervention was performed on humans.

Conflict of Interests

No conflicts of interest have been declared by the authors.

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Article Info

Article History:

Received: November 10, 2021

Accepted: February 17, 2022

e-Published: August 16, 2022

Research Highlights

What is the current knowledge?

Human caring is one of the principal foundations of clinical nursing. There are many different definitions of human caring. Yet, no concept analysis is available on human caring.

What is new here?

So far, the concept of human caring has not been analyzed. Human caring can have different definitions and meanings for nurses. The present study showed human caring definitions, attributes, antecedents, and consequences.

Footnote

*Corresponding Author:

Mohsen Adib-Hajbaghery,

Email: [email protected]

References

References

1. Leininger MM, McFarland MR. Culture Care Diversity and Universality: A Worldwide Nursing Theory. USA: Jones & Bartlett Learning; 2005.

2. Ghafari S, Mohammadi F. Concept analysis of nursing care: a hybrid model. J Mazandaran Univ Med Sci. 2012; 21 (1): 153-64. [Persian]

3. Khaki S, Esmaeilpourzanjani S, Mashouf S. Nursing cares quality in nurses. Sci J Nurs Midwifery Paramed Fac. 2018; 3 (4): 1-14. doi: 10.29252/sjnmp.3.4.1

4. Pazargadi M, Zagheri Tafreshi M, Abed Saeedi Z. Nurses' perspectives on quality of nursing care: a qualitative study. Research in Medicine. 2007; 31 (2): 147-53. [Persian]

5. George JB. Nursing Theories: The Base for Professional Nursing Practice. 6thed. London: Pearson; 2010.

6. Jacobson N. Dignity and health: a review. Soc Sci Med. 2007; 64 (2): 292-302. doi: 10.1016/j.socscimed.2006.08.039

7. Watson J. Nursing: the philosophy and science of caring (revised edition). In: Smith MC, Turkel MC, Wolf ZR, eds. Caring in Nursing Classics: An Essential Resource. New York: Springer Publishing Company; 2008. p. 243-64. doi: 10.1891/9780826171122.0016

8. Jouzi M, Vanak Z, Mohammadi E. The essence of nursing students clinical competency in internship period: humanistic patient-centered care. Educ Ethics Nurs. 2013; 2 (4): 51-9. [Persian]

9. Mohammadhossini S, Gheibizadeh M, Saki Malehi A, Zarea K. Burn patients' need for human caring: content analysis study. Armaghane Danesh. 2019; 24 (3): 358-72. [Persian]

10. Cheraghi MA, Esmaeili M, Salsali M. Seeking humanizing care in patient-centered care process: a grounded theory study. Holist Nurs Pract. 2017; 31 (6): 359-68. doi: 10.1097/ hnp.0000000000000233

11. Paterson JG, Zderad LT. Humanistic nursing. 2nd ed. New York: Libro Electrónico; 2008.

12. Khademi M, Mohammadi E, Vanaki Z. The origins of the education of humanistic nursing approaches in nurses: a qualitative study. Nurs Midwifery J. 2012; 10 (5): 630-9. [Persian]

13. Dellasega C, Milone-Nuzzo P, Curci KM, Ballard JO, Kirch DG. The humanities interface of nursing and medicine. J Prof Nurs. 2007; 23 (3): 1 74-9. doi: 10.1016/j.profnurs.2007.01.006

14. Busch IM, Moretti F, Travaini G, Wu AW, Rimondini M. Humanization of care: key elements identified by patients, caregivers, and healthcare providers. A systematic review. Patient. 2019; 12 (5): 461-74. doi: 10.1007/s40271-019003 70-1

15. O'Reilly L, Cara C. "Being with" the person cared for in a rehabilitation context: a profound, therapeutic and transformative human relationship. Rech Soins Infirm. 2010; (103): 46-66. doi: 10.3917/rsi.103.0046

16. Rudolfsson G, von Post I, Eriksson K. The expression of caring within the perioperative dialogue: a hermeneutic study. Int J Nurs Stud. 2007; 44 (6): 905-15. doi: 10.1016/j. ijnurstu.2007.02.007

17. de Cássia Calegari R, Massarollo MC, Dos Santos MJ. Humanization of health care in the perception of nurses and physicians of a private hospital. Rev Esc Enferm USP. 2015; 49 Spec No: 42-7. doi: 10.1590/s0080-623420150000800006

18. Watson J. Watson's theory of human caring and subjective living experiences: carative factors/caritas processes as a disciplinary guide to the professional nursing practice. Texto Contexto Enferm. 2007; 16 (1): 129-35. doi: 10.1590/s010407072 007000100016

19. Walker L, Avant K. Strategies for Theory Construction in Nursing. 6th ed. London: Pearson; 2018.

20. Dictionary OE. Oxford English dictionary online [Internet]. USA; 2004. Available from: https://www. oxfordlearnersdictionaries.com/definition/english/caring. Accessed June 20, 2022.

21. Webster M. Learner's dictionary [Internet]. USA; 2016. Available from: https://www.merriam-webster.com/ dictionary/human. Accessed June 20, 2022.

22. Granger BB, Moser D, Germino B, Harrell J, Ekman I. Caring for patients with chronic heart failure: The trajectory model. Eur J Cardiovasc Nurs. 2006; 5 (3): 222-7. doi: 10.1016/j. ejcnurse.2006.02.001

23. Karaöz S. Turkish nursing students' perception of caring. Nurse Educ Today. 2005; 25 (1): 31-40. doi: 10.1016/j. nedt.2004.09.010

24. Beltrán Salazar OA. Impersonal care or humanized care: a decision made by nurses? Hourglass model. Invest Educ Enferm. 2016; 34 (3): 444-55. doi: 1 0.1 7533/udea.iee. v34n3a03

25. Facioli AM, Amorim FF, de Almeida KJ. A model for humanization in critical care. Perm J. 2012; 16 (4): 75-7. doi: 10.7812/tpp/12-044

26. Luiz FF, Caregnato RCA, da Costa MR. Humanization in the intensive care: perception of family and healthcare professionals. Rev Bras Enferm. 2017; 70 (5): 1040-7. doi: 10.1590/0034-7167-2016-0281

27. Pajnkihar M, McKenna HP, Štiglic G, Vrbnjak D. Fit for practice: analysis and evaluation of Watson's theory of human caring. Nurs Sci Q. 2017; 30 (3): 243-52. doi: 10.11 77/089431841 7708409

28. de Medeiros AC, de Siqueira HC, Zamberlan C, Cecagno D, Dos Santos Nunes S, Thurow MR. Comprehensiveness and humanization of nursing care management in the intensive care unit. Rev Esc Enferm USP. 2016; 50 (5): 816-22. doi: 10.1590/s0080-623420160000600015

29. Sourial S. An analysis and evaluation of Watson's theory of human care. J Adv Nurs. 1996; 24 (2): 400-4. doi: 10.1046/j.1365-2648.1996.19524.x

30. Khademi M, Mohammadi E, Vanaki Z. Appraisal of the applicability of humanism based nursing theories. Iran J Med Ethics Hist Med. 2012; 5 (3): 33-46. [Persian]

31. Brittain AC, Carrington JM. A concept analysis of organizational health and communication. Nurs Adm Q. 2019; 43 (1): 68-75. doi: 10.1097/naq.0000000000000331

32. Hasani P, Nikfarid L. Assessment of nursing students' of Azad Islamic university of Saveh' percpective about amount of important caring behavours based on caring model of Watson. Iran J Nurs Res. 2014; 9 (1): 8-16. [Persian]

33. Hessel JA. Presence in nursing practice: a concept analysis. Holist Nurs Pract. 2009; 23 (5): 276-81. doi: 10.1097/ HNP.0b013e3181b66cb5

34. Snyder M, Brandt CL, Tseng YH. Use of presence in the critical care unit. AACN Clin Issues. 2000; 1 1 (1): 27-33. doi: 10.1097/00044067-200002000-00005

35. Cuff BMP, Brown SJ, Taylor L, Howat DJ. Empathy: a review of the concept. Emot Rev. 2016; 8 (2): 144-53. doi: 10.1177/1754073914558466

36. Girón M, Gómez-Beneyto M. Relationship between empathic family attitude and relapse in schizophrenia: a 2-year followup prospective study. Schizophr Bull. 1998; 24 (4): 619-27. doi: 10.1093/oxfordjournals.schbul.a033353

37. Pohling R, Bzdok D, Eigenstetter M, Stumpf S, Strobel A. What is ethical competence? The role of empathy, personal values, and the five-factor model of personality in ethical decisionmaking. J Bus Ethics. 2016; 137 (3): 449-74. doi: 10.1007/ s10551-015-2569-5

38. Ceribelli C, Nascimento LC, Pacífico SM, de Lima RA. Reading mediation as a communication resource for hospitalized children: support for the humanization of nursing care. Rev Lat Am Enfermagem. 2009; 17 (1): 81-7. doi: 10.1590/s010411692009000100013

39. Ivanov LL, Oden TL. Public health nursing, ethics and human rights. Public Health Nurs. 2013; 30 (3): 231-8. doi: 10.1111/ phn.12022

40. Ozturk H, Bahçecik N, Ozçelik KS. The development of the patient privacy scale in nursing. Nurs Ethics. 2014; 21 (7): 812-28. doi: 10.11 77/0969733013515489

41. Keeman A, Näswall K, Malinen S, Kuntz J. Employee wellbeing: evaluating a wellbeing intervention in two settings. Front Psychol. 2017; 8: 505. doi: 1 0.3389/fpsyg.201 7.00505

42. Dodge R, Daly AP, Huyton J, Sanders LD. The challenge of defining wellbeing. Int J Wellbeing. 2012; 2 (3): 222-35. doi: 10.5502/ijw.v2i3.4

43. Finfgeld-Connett D. Concept synthesis of the art of nursing. J Adv Nurs. 2008; 62 (3): 381-8. doi: 10.1111/j.13652648.2008.04601 .x

44. Sajadi SA, Mahmoudi H. Review of the human care theory. Journal of the School of Army Nursing. 2018; 17 (1): 32-44. [Persian]

45. Galán González-Serna JM, Ferreras-Mencia S, ArribasMarín JM. Development and validation of the hospitality axiological scale for humanization of nursing care. Rev Lat Am Enfermagem. 2017; 25: e2919. doi: 10.1590/15188345.1767.2919

46. de Melo R, Costa PJ, Henriques LVL, Tanaka LH, Queirós PJP, Araújo JP. Humanitude in the humanization of elderly care: experience reports in a health service. Rev Bras Enferm. 2019; 72 (3): 825-9. doi: 10.1590/0034-7167-201 7-0363

47. Lee SE, Scott LD, Dahinten VS, Vincent C, Lopez KD, Park CG. Safety culture, patient safety, and quality of care outcomes: a literature review. West J Nurs Res. 2019; 41 (2): 279-304. doi: 10.11 77/019394591 7747416

48. Galvin KT, Sloan C, Cowdell F, Ellis-Hill C, Pound C, Watson R, et al. Facilitating a dedicated focus on the human dimensions of care in practice settings: development of a new humanised care assessment tool (HCAT) to sensitise care. Nurs Inq. 2018; 25 (3): e12235. doi: 10.1111 /nin.1 2235

49. Davis MH. Interpersonal Reactivity Index (IRI). APA PsycTests; 1980. doi: 10.103 7/t01093-000

50. Umenai T, Wagner M, Page LA, Faundes A, Rattner D, Dias MA, et al. Conference agreement on the definition of humanization and humanized care. Int J Gynaecol Obstet. 2001; 75 Suppl 1: S3-S4. doi: 10.1016/s0020-7292 (01)00508-2

51. McCormack LA, Treiman K, Rupert D, Williams-Piehota P, Nadler E, Arora NK, et al. Measuring patient-centered communication in cancer care: a literature review and the development of a systematic approach. Soc Sci Med. 2011; 72 (7): 1085-95. doi: 10.1016/j.socscimed.2011.01.020

52. Kvande ME, Angel S, Højager Nielsen A. "Humanizing intensive care: a scoping review (HumanIC)". Nurs Ethics. 2022; 29 (2): 498-510. doi: 10.1 177/0969733021 1050998

53. Dall'Ora C, Ball J, Reinius M, Griffiths P. Burnout in nursing: a theoretical review. Hum Resour Health. 2020; 18 (1): 41. doi: 10.1186/s12960-020-00469-9

54. Suárez-Baquero DFM, Champion JD. Expanding the conceptualisation of the Art of Caring. Scand J Caring Sci. 2021; 35 (3): 860-70. doi: 10.1111 /scs.12903