Analysis of Nursing Concept using McKenna Approach

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


INTRODUCTION
Development of the model of nursing education based on the explanation of the role of nurses in the health system will not be possible without analyzing the nursing concept and its infrastructures.Nursing concept is a dynamic concept and constantly evolving in response to the new health needs of the patients.It is clear that providing a single definition for the nursing concept is too limited to be able to cover all aspects of this profession.By analysing the nursing concept we can achieve the three following objectives: To analyze the nursing concept, the McKenna method (McKenna, 1997) was used and according to it the concept was analyzed in the following 9 steps: 1.
Select the nursing concept 2.
Define the goals of the analysis of the nursing concept 3.
Identify the meanings of the nursing concept 4.
Determine the defining features of the nursing concept 5.
Identify a model case or a specific example 6.
Introduce alternative cases (what is not nursing) 7.
Identify antecedents and consequences of nursing 8.
Consider context and values of nursing concept 9.
Identify empirical indicators of nursing concept.
Step 1: Selecting the concept of interest In this step we answer the question "what arethe elements and structures of nursing concept?" Concepts incorporated within a theory or separate from it, explain and describe a phenomenon.Therefore, if a concept is obscure it must be described in the form of propositions.Nursing is also a broad concept that can be examined at three levels (McKenna 1997):

Global concepts of nursing
These are concepts represented by metaparadigm and include person, health, environment, and care.

Middle-range concepts of nursing
Include the expansion of nursing global concepts through nursing theories and models that are defined under systemic, interactive, evolutional, and behavioral paradigms.

Empirical concepts of nursing
These concepts are much more accurate and their boundaries can be determined.Each intermediate concept could include a wide range of these concepts.

Step 2: Stating the aim of nursing concept analysis
The outcome of a successful analysis of a concept includes the identification of reliable indicators to inform us of the various aspects of a concept.Until the structure of the nursing concept is not accurately analyzed, it cannot be clearly defined.Therefore, at this step the aim is to explain the elements and structures of the nursing concept according to the theories and models of nursing.spiritual development, and must pass through various stages.The role of the nurse is to encourage positive development and to eliminate obstacles to development.The theories under this paradigm are called humanistic theories (Humanistic T.) and the most important paradigms under this paradigm are Peplau's interpersonal model, Travelbee's interpersonal aspects of nursing model, and Betty Newman's healthcare system model.

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

Expanding Global Concepts of Nursing (Middlerange Concepts) through Nursing Theories and Models
To develop the global concepts of nursing, four concepts of human, health, environment, and nursing were studied from the viewpoint of nineteen nursing theorists (McKenna 1997, Kim and Kollak 2006, Meleis 2012).Summary of these definitions are as follows: Nursing is the practice of helping individuals to use the power within to achieve higher levels of knowledge, and to evaluate the potential effects of the environmental stressors, and to act in relationto them.

Person/Man
Nursing guides human beings in finding the meaning of circumstances, choosing methods for creating health, and real and lively presence in everyday life. Step

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

Step 4-Determining the Representative Features of Nursing Concept
At this step, after reviewing the fields related tothe nursing concept, a new classification in eight areas was established.Thus, eighth subconcepts, along with classifications related to each of them, were provided to illustrate different aspects of nursing.Accordingly, the representative features of the nursing concept can be summarized as following: 1.
focus of nursing care 3.
nursing professional values 4.
audience of nursing care 5.
fields of nursing care 6.
features of the providers of nursing care 7.
level of education of the providers of nursing care 8.
role of nurses in providing nursing care In the following, each of these features will be discussed in details.

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

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

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

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

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

Improvement of the patient's quality of file
It means health counselingwithpatients in order to achieve the highest level of heath, preventing illness and disability, and facilitating access, and maintaining the best possible quality of life until the end of life (Cherie et

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

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

Interactions between individual and environment
Meaning the optimization of the environment and coordination of the physiological, psychological, social, and therapeutic interaction between the individual and the environment to promote health and recovery (Dossey, 2008

Nursing is a profession committed to the following values Human dignity
It means belief in the dignity and value of the patient, respect for independence and attention to the nature of man, and maintaining peace and dignity of the patients in deathbed.

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

Professional commitment
It meansresponsibility to human health andprofessional performance, as well as accountability to decisions and professional performance.

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

Participation in patient care
It meansdecentralization of decisionmaking and sharing decision-making with the health care team and patient along with respect for acknowledgment of the importance of the work of all members of the health care team.

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

Professional behavior
It means commitment to professional values and standards and obligation to provide nursing services within the ethical and legal framework of the professional performance during the period of service(Carey, 2000, Cherie et

Nursing care is provided in the following areas Patient's environment
Meaning home, temporary hospice and housing center, nursing home, and mentally ill institution.

Healthcare centers
It means hospitals and clinical centers

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

Features of Nursing care providers (nurses) Mood features
Meaning philanthropy, empathy, having good temper, having confidence in providing professional nursing services, and the ability to turn these emotional features into compassionate, sensitive, and appropriate care.

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

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

Professional behavior features
It means having professional expertise, commitment to professional values, abiding the law, accountability and responsibility, being supportive of the physiological, psychological, and spiritual needs of the patient, and having educational and researching role (

T provider of nursing care (nurse) has the following educational degrees Work certification
It mean the certificate for a graduate of nursing that shows he/she has the abilities necessary tocare nursing patients.

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

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

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

PhD: Nursing Doctor of Philosophy
It is a doctorate degree (doctorate of The relationship between health care professionals and to partnership (DC) their patients should be one of mutual collaboration.People who provide health care intervene on behalf of the adult patient only when he asks for their help or when his health needs cannot be fully satisfied.

Nature of nursing C1
(DN) philosophy) that is a three-year program, which seeks to prepare students to combine scientific research with nursing roles and usually includes performing a research.

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

Nursing provides the following roles by nurse Creating the background for providing the care
It means creating an appropriate care environment by providing appropriate care grounds and delivering independent and collaborative care services and maintaining the continuity of care and patient support.

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

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

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

Nursing is a profession that: Necessity
1 Provides its services to patient/patients from all age groups, illor healthy, P and during their whole life 2 Its focus is on the nursing care of the patient, healthpromotion, and interaction P between the individual and environment 3 It is committed to human dignity, comprehensive patient care, professional P commitment, respect for patient rights, involvement in patient care, adoption of good manners, and professional commitment.4 Is committed to addressing patient needs, maintaining security, care, care P follow-up, contribution in achieving independence , and improving the quality of life of the patient 5 Provides its services in the areas of the living environment of the patient, P healthcare centers, community, academic centers, or legal services 6 Is provided by people with features of good manner, leadership / management P / planning of change, problem-solving / decision-making, and professional behavior 7 Its providers have academic education and work certification P 8 Its role is to provide care, establish communication, design and implement the P nursing process, leadership/management/planning of changes in patient care, evaluation/follow-up of patient care, counseling/education, prevention/ rehabilitation, and research

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

Jointpatient care
Meaning consultation and joint decisionmaking with other members of the health care team to provide health care and at the same time engage the patient and family in the care

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

Evaluation/follow-up of the patient care
It means evaluation of providing nursing services, reporting changes in health condition, evaluating the outcomes the expectedfrom the patient, and following up with the care after patient discharge.

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

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

Research
Meaning participation in research activities related to health problems, and contribution to the development of health policies (Cherie et

Screening Test of Necessity of the Features Explaining Nursing Concept
Summing up the features representative of nursing concept, we can define the nursing as follows: "Nursing is a profession that provides its services to patients of all age groups, ill or healthy, during their whole life, and its focus is on nursing care for patient, health promotion, and interaction between the individual and environment.Nursing is committed to human dignity, comprehensive patient care, professional commitment, respect for patient's rights, and participation in patient care; and is committed to the safety, follow-up care, giving assistance for gaining independence, and improving the quality of life of the patient.This profession provides its services in the areas of patient's living environment, society, academic centers, or legal centers by people who have the features of good moral, leadership/management/ planning of change, problem-solving/decisionmaking, and professional behavior, and also have university degree and work certificate.The role of nursing is providing care, establishing communication, designing and implementing nursing process, leadership/management/ planning changes in the care of the patient, evaluation/follow-up of patient's care, counseling/ education, prevention/rehabilitation, and research.
In case a profession lacks any of these features, it cannot be called nursing.The features of the nursing profession are shown in detail in the following table

Step 5) Identifying a "Model Case"
A model is a pure example that the nursing concept is used in it and should have all the features of the concept.It can be written in one or two paragraphs as a hypothesis: summary of a narrative that represents a real life event, or a clinical example that carefully explains a concept.According to McKenna, by giving an example from real life as a "model case" that covers all the features of the concept, the degree of transparency and credibility of the concept increases.Therefore, the model should include all the representative features of the concept (McKenna 1997).

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

Country Case
These are cases that do not cover the nursing concept, and sometimes their difference is obvious and clear to individuals.Thus, if an individual acts this way his performance cannot be considered nursing:

•
Obviating the health needs of the patients is not one of his goals.

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

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

Invented Case
Invented cases include cases that show the nursing concept out of its natural and normalcontext.These include cases that are not considered nursing but are tagged as nursing.
• providing any early clinicalservices to the patient(nursing assistance services) • Injection services (without any knowledge and just doing injection)

Illegitimate Case
It includes improper use of nursing concept in real life.

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

Step 7) Identify Antecedents and Consequences of Nursing Concept
The importance of this step is in analysis of afield in which the concept is normally used.Antecedents are the events that come before the occurrence ofthe concept.They cannot be considered synonymous with causality.Antecedent may help the occurrence of the concept, it may be associated with the occurrence of the concept or its existence may be necessary for the presence of this concept (falling out of balance).Walker and Avant (1995) believe that nothing can be both an antecedent and a feature at the same time.Consequences are those events and outcomes that take place after the occurrence of the concept (return to balance) (McKenna 1997).

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

The culture of the relations between doctors and nurses in Iran
Summing up the findingsof seven studies performedon this topic, it seems that more efforts are neededfor training of both physicians and nurses to improve communication and collaborative care within the healthcare team (Namazi et al

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

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

Islamic Context of Nursing
The holy prophet of Islam in this regard says: everyone who tries to meet the needs of a patient, if satisfies or even if ceases to satisfy them, will be relieved of his/her sins like the day that was born.Among careers that people pursue there are professions which their material and economic aspects are insignificant and are considered holy and spiritual.The choice of these careers, in a way, is an indication of dedicated effort, spirit of selfsacrifice and selflessness, and mentality of patience and perseverance among people employed in these professions.The nursing is one those noble professions (Heydari-zadeh, 1993).
In conclusion, considering Iranian contexts and values, it is clear that Iranian-Islamic culture is influential on the value-centered and behavioral indicators of the nursing concept; therefore, these effects should be added to the previously mentioned parameters.
Step 9) IdentifyingEmpirical Indicators "These include explicit references to measure or evaluatethe existence of the concept.It is this step that is often considered as the operationalization of a concept.When, equipped with these indicators, we can see a concept "beyond a shadow of a doubt".However, regarding Walker and Avanet (1995) sometimes the concept is so abstract that even the defined indicators are also abstract and therefore, cannot be good empirical indicators.Such indicators are useful for research and performance, since they can provide criteria by which a concept can be measured.Empirical indicators can be measured relatively easy to identify tangible concepts.However, it is possible to specify such indicators even for abstract concepts" (McKenna 1997).

Empirical indicators of nursing conceptare as follows:
1.
Providing services topatient/patients, from all age groups, sick or healthy, and during their whole life 2.
Focusing on nursing care for patient, healthpromotion, and interaction between the individual and environment.

3.
Commitment to human dignity, comprehensive care for patient, professional commitment, respect for patient's rights, cooperation in care for patient, and adoption of good manners and professional behavior with regard to Islamic values 4.
Commitment to address the needs of the patient, maintaining security, care, follow-up care, assistance for achieving of independence, and promoting the quality of life of the patient.

5.
Providing services in the areas of: the living environment of the patient, health care, communities, academic centers , or legal services centers 6.
Providing services by people with good moral, leadership/management/planning of change, problem-solving/decision-making, and professional behavior features 7.
Providing services by people with academic education, and nursing certification 8.
Providing care, establishing communication, design and implementation of the nursing process, leadership/management/planning change in patient care, evaluation/follow-up of the patient care, counseling/education, prevention/rehabilitation, and research • To describe nursing to people who do not understand and have no knowledge about it • To shed light on the role of nurses in a multidisciplinary health care team • To expand nursing curriculum Therefore this study was designed to analyze, explain elements and infrastructures, and identify the empirical indicators of the nursing concept using McKenna (1997) approach.

. A is doing is nursing. Step 6) Identifying Alternative Cases of Nursing Concept
Alternative cases include examples of what is not the nursing concept.They include contrary cases, related cases, borderline cases, invented cases, and illegitimate cases.