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Concept identification and definition

Open Posted By: highheaven1 Date: 13/09/2020 High School Research Paper Writing

To prepare

  • Reflect on the phenomenon of interest and concepts you identified in the Week 2 Discussion. Based on insights you have gained this week, would you like to make any modifications to your phenomenon and/or concepts? If so, you may do so before posting to this Discussion.
  • Although you will identify more than one concept for your research, select one primary concept on which to focus for this Discussion. Your concept should be one word or a very short phrase (e.g., “quality of life”).
  • Review the literature to see how this concept is defined in various sources. Remember to look at literature across all disciplines in which this concept may be used. Also search for all known definitions of the word in an unabridged dictionary.
  • As you do this, consider the following: 
    • Has the concept been developed directly from nursing or health care research or practice, or has it been borrowed or derived from another discipline?
    • To what degree is the concept abstract or concrete?
    • How suitable is this concept for your intended use?
  • Formulate a definition of the concept that aligns with your intended research. (Your definition may continue to evolve as you complete your concept analysis for the Assignment introduced this week. In addition, you will likely make adjustments as you proceed through this course and/or later in this PhD program if you continue to address the concept.)

By Day 3 

Post your selected concept and provide a definition of it, as well as context to help your colleagues understand what you are addressing. Summarize at least one article that addresses the concept and discuss how the information presented relates to your own definition of the concept.

Category: Business & Management Subjects: Human Resource Management Deadline: 12 Hours Budget: $150 - $300 Pages: 3-6 Pages (Medium Assignment)

Attachment 1

Isolation: A Concept Analysis Heather M. Gilmartin, MSN, RN, FNP, Patti G. Grota, PhD, RN, CNS-M-S, and Karen Sousa, PhD, RN, FAAN

Heather M. Gilmartin, MSN, RN, FNP, is Adjunct Clinical Faculty, College of Nursing, University of Colorado, Aurora, CO; Patti G. Grota, PhD, RN, CNS-M-S, is Assistant Professor of Nursing, Schreiner University, Kerrville, TX; and Karen Sousa, PhD, RN, FAAN, is Professor and Associate Dean for Research and Extramural Affairs, College of Nursing, University of Colorado, Aurora, CO.

Keywords Communicable disease, concept analysis, nursing theory

Correspondence Heather M. Gilmartin, MSN, RN, FNP, College of Nursing, University of Colorado, Aurora, CO E-mail: [email protected] ucdenver.edu

Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.Conflict of Interest Statement: No conflicts of interest have been declared by the authors.

TOPIC. Concept analysis of isolation. PURPOSE. This article uses Walker and Avant’s methodological approach in distinguishing the concept of isolation between the normal, ordinary language usage and the scientific usage of the concept. BACKGROUND. The importance of social contact has long been recog- nized as a fundamental need for humans. The concept of isolation is used throughout the lay and scientific literature and has a primarily negative connotation for humans. The experience is sometimes severe enough to result in serious reductions in adaptation and performance. DATA SOURCES. The Medline, CINAHL, and Google Scholar databases were searched using the key terms of concept analysis, human, and isolation with no restriction on the year of publication. English language reports were used exclusively. CONCLUSION. Three attributes were identified: sensory deprivation, social isolation, and confinement. Antecedents included individual per- ception and situational dimensions. Consequences included anxiety, depression, mood disturbances, anger, loneliness, and adverse health events. Through this concept analysis, isolation has been theoretically defined as a state in which an individual experiences a reduction in the level of normal sensory and social input with possible involuntary limi- tations on physical space or movement. Systematic studies of isolation using this concept can ultimately enhance nurses’ knowledge base and contribute to the quality of life for isolated persons.

Introduction

It is generally recognized that humans are social animals whose behavior is significantly determined by their needs and reactions to other people. This social aspect of human existence is nowhere more evident than when he or she is isolated from others (Haythorn, 2008). People have been subjected to isolation for centuries, as evidenced through accounts of solitary confinement in the penal system, Arctic explorers, and ocean sailors (Haney, 2003; Laing & Crouch, 2009; Zubek, 2008). Isolation has also been used as a tool to prevent the spread of infectious disease through the physical separation of those infected from the popula- tion (Abad, Fearday, & Safdar, 2010; Gensini, Yacoub, & Conti, 2004). Isolation is now being recognized as an

outcome for those with mental, physical, infectious, and age-related issues that limit a person’s ability to connect with their social network (Abad et al., 2010; Furr et al., 2007; Hagedoorn & Molleman, 2006; Maunder, 2004; Nicholson, 2009; Trout, 1980; Victor, Scambler, Bond, & Bowling, 2000).

The anecdotal literature, field, and laboratory studies indicate that isolation is stressful to many indi- viduals and that the stress is sometimes severe enough to result in serious reductions in adaptation and per- formance (Catalano et al., 2003; Haythorn, 2008). This article attempts to distinguish the normal, ordi- nary language usage of the concept of isolation and the scientific usage, and develop an operational defi- nition of isolation using the methods of Walker and Avant (2011) because of its ease and straightforward

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approach. The key procedures in the concept analysis include identifying definitions, defining attributes, related cases, model, borderline and contrary cases, and empirical referents.

Uses of the Concept

Ordinary

The Merriam-Webster Dictionary defines isolation as the condition of being alone (Isolation, 2011c). WordNet.com (Isolation, 2011d), a word-defining Web site, adds, “A state of separation between persons or groups and a feeling of being disliked or alone,” and etymology.com (Isolation, 2011b), an online etymol- ogy dictionary, identifies the origin of isolation as the Latin insulatus, or “made into an island.” The popular literature has described isolation in song, such as Iso- lation by John Lennon (1970), literary essays, such as Papillion (Charriere, 2006), The Scarlet Letter (Haw- thorne, 1999), and The Colony: The Harrowing True Story of the Exiles of Molokai (Tayman, 2007). These works tell the stories of persons forced into isolation because of their social situation, as a penalty or because of fear of contagion. A consistent theme among the ordinary use of isolation is a physical or emotional separation that is negatively experienced by the individual or group.

Scientific

The term isolation is defined in the field of chemistry as the separation of a pure chemical substance from a compound or mixture; in computer science, it is defined as the ability of a logic circuit having more than one input to ensure that each input signal is not affected by any of the others; in evolution, it is defined as the restriction or limitation of gene flow between distinct populations because of barriers to interbreed- ing; in health care, it is defined as the separation of an individual with a communicable disease from other, healthy individuals; in microbiology, it is defined as the separation of an individual strain from a natural, mixed population; in physiology, it is defined as the separation of a tissue, organ, system, or other part of the body for purposes of study; and in psychology, it is defined as the dissociation of a memory or thought from the emotions or feelings associated with it (Iso- lation, 2011a). Science uses the concept of isolation as a separation of one object or individual from another.

Defining Attributes

To distinguish isolation from other related concepts, it is essential to identify its defining characteristics (Walker & Avant, 2011). Three major attributes of human isolation have been identified in the scientific literature: sensory deprivation, social isolation, and confinement (Rasmussen, 2008; Sells, 2008; Zucker- man, Persky, & Link, 1968). Studies have indicated that these attributes, when experienced in combina- tion, are stressful to many individuals and that the stress is sometimes severe enough to result in serious decrements in adaptation and performance (Haythorn, 2008).

Sensory Deprivation

Sensory deprivation, or the removal of reception and/or perception of human stimuli (Chodil & Will- iams, 1970), is noted to be disturbing to many indi- viduals. The importance of continued, varied sensory input is a noted necessity for the maintenance of normal, intelligent, and adaptive behavior in humans (Bexton, Heron, & Scott, 1954). The experience of sensory deprivation has been tested in lab studies by the complete restriction of communication, sights, and sounds from the external world (Bexton et al., 1954; Zubek, 2008). In the field, sensory deprivation has been described through the practice of solitary con- finement in the penal system (Haney, 2003), for hos- pitalized patients in isolated environments (Abad et al., 2010; Barratt, Shaban, & Moyle, 2010; Gammon, 1999), and for persons with restriction on one or many of their senses because of injury or treat- ment (Chodil & Williams, 1970).

In laboratory studies, the outcomes of sensory and stimulus deprivation were summarized by researchers into three themes: tedium stress, reflecting concern with the boredom and monotony of isolation; unreal- ity stress, concerned with the novel and frightening reactions to stimulus reduction; and positive contem- plation, reflecting the positive reactions of some indi- viduals to the opportunity that isolation provides for thinking about one’s life and the meaning of things (Haythorn, 2008). These themes have been validated in observational and qualitative studies in the health- care literature with patients in source isolation for infectious disease and protective isolation for cystic fibrosis and cancer reporting boredom, stress, fear, and positive reactions to the experience (Abad et al., 2010; Barratt et al., 2010; Bolin, 1974; Campbell, 1999;

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Gammon, 1999; Knowles, 1993; Madeo, 2001; Russo, Donnelly, & Reid, 2006; Skyman, Sjostrom, & Hell- strom, 2010; Ward, 2000; Wassenberg, Severs, & Bonten, 2010).

In addition, Wexler, Mendelson, Leiderman, and Solomon (1958) summarized the outcomes of previ- ous studies on experimental sensory deprivation, stating that subjects in these studies demonstrated an inability to tolerate or adapt to the stress of sensory isolation; subjects attempted to obtain extrinsic physi- cal and social stimuli during the experience; and the progressive failure, in certain subjects, of reality contact led to the emergence of pathological thought processes and behaviors. In essence, sensory depriva- tion acts as a stressor for humans for it jeopardizes a subject’s hold on external reality because of the chal- lenges to the person’s reality orientation. Negative outcomes, such as anxiety, depression, and hallucina- tions, have been reported by subjects (Abad et al., 2010; Bexton et al., 1954; Gammon, 1999; Vernon & McGill, 1957; Wexler et al., 1958; Zuckerman et al., 1968).

Social Isolation

Social isolation emphasizes the separation of persons from significant others, groups, activities, and social situations that subsequently impairs a person’s social processes (Biordi & Nicholson, 1995; Sells, 2008). There have been no direct laboratory studies testing the separate effects of social isolation from those of confinement and sensory deprivation, but Haythorn (2008) supports the hypothesis that social isolation by itself is a significantly stressful condition for at least a substantial number of people and that the reactions to it are distinguishable from those of confinement and sensory deprivation. Observational studies in the healthcare literature have described social isolation as an alienating, lonely experience with negative health consequences for all ages (Nicholson, 2009; Skipper, Leonard, & Rhymes, 1968; Trowbridge, 2008). Social isolation ranges from the voluntary isolate who seeks disengagement from social intercourse to those whose isolation is involun- tary or imposed by others (Biordi & Nicholson, 1995).

Isolation can occur at four layers of the social concept. The first social layer is the larger community, such as peer groups, next is organizations, such as school and work, followed by confidantes, such as friends and family, and last is the inner person’s ability to apprehend and interpret relationships (Lin, 1986).

In a concept analysis of social isolation in older adults, Nicholson (2009) identified five attributes that define social isolation in this population: number of contacts, feeling of belonging, fulfilling relationships, engagement with others, and quality of network members. In addition, Biordi and Nicholson (1995) have described social isolation to have three additional attributes: the experience of alienation, loneliness, and aloneness. In summary, the experience of social isolation has been well defined in the literature and is noted to lead to negative health consequences for all ages.

Confinement

Confinement connotes a forced, or involuntary, limitation in the amount of physical space and/or restraint on actual physical movement for a person. Confined subjects report emotional overreactions and physical discomfort because of the experience (Haythorn, 2008). Researchers have attempted to isolate the experience of confinement, but they have reported challenges due to the overlapping experi- ences of social isolation and sensory deprivation that occur during confinement (Haythorn, 2008; Zubek, 2008). Because of these challenges, confinement has been broadly defined as a physical concept that then can lead to the psychological concept of isolation, through a combination of social isolation and/or sensory deprivation (Rasmussen, 2008).

Confinement is practiced in the penal system through solitary confinement, where a prisoner is physically segregated from the rest of the prison popu- lation and is excluded from normal programming and collective activities (Haney, 2003). Confinement through geography is seen with travel to distant or isolated locations (Laing & Crouch, 2009) and in geo- graphically isolated populations (Haggard, 2008). Confinement is seen in health care through the use of source and protected isolation, where patients are not permitted to leave their rooms (Abad et al., 2010; Campbell, 1999; Catalano et al., 2003; Gammon, 1998, 1999; O’Connell, 1984; Russo et al., 2006) and in persons who are bedridden because of pregnancy (Schroeder, 1996) or illness (Ishizaki et al., 1994).

Definition of Isolation

Taking into account the attributes, the following definition of isolation is suggested: a state in which an

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individual experiences a reduction in the level of normal sensory and social input with possible invol- untary limitations on physical space or movement. It is not possible to state which of the attributes must be present for a person to be defined as isolated because the balance of each attribute varies on the individual’s perception or segment of society the person is func- tioning at.

Related Concepts

Related cases are instances of concepts that are related to the concept being studied but that do not contain all of the defining attributes (Walker and Avant, 2011). However, the concept of isolation is often interchanged with the concept of solitude. Soli- tude, historically, has had a more purposeful, positive, and healthful definition (Phelps, 1966). Solitude is defined as a state of being alone without being lonely and can lead to self-awareness through a positive and constructive state of engagement with oneself (Marano, 2003). Solitude, at times, is desirable and can replenish the soul (Marano, 2003). Throughout history, many philosophers, spiritual leaders, and artists have attested to the benefits of solitude (Long & Averill, 2003).

In addition, seclusion and privacy are related to isolation. The Merriam-Webster Dictionary (2011) defines seclusion as being screened or hidden from view and privacy as the quality or state of being apart from company or observation. These three concepts have similar descriptions, but in opposition to the proposed definition of isolation, they are acts of willing sensory and social reduction with voluntary limitations on space or movement.

Antecedents and Consequences

Walker and Avant (2011) describe antecedents as those events or incidents that must occur or be in place prior to the occurrence of the concept and con- sequences as the events or incidents that are an outcome of the concept (see Table 1). An understand- ing of the individual and the group or segment of society in which the person is functioning is necessary to shed light on the social contexts of isolation (Ras- mussen, 2008). In addition, the situational dimensions that have significant implications on isolation can help define the experience. Situational dimensions include the voluntary versus involuntary nature of the event; the purpose, or instrumental reason; the planning and preparation permitted prior to; the duration of isolation; whether isolation occurs to an individual or as a group; if confinement is severe; if there is a sub- jectively viewed threat from isolation; current social and support conditions; and lastly the environmental variability during isolation (Sells, 2008). The conse- quences, or outcomes, of isolation have been reported in the ordinary and scientific literature as anxiety, depression, mood disturbances, anger, loneliness, and adverse health effects (Abad et al., 2010; Bekhet, Zauszniewski, & Nakhla, 2008; Catalano et al., 2003; Gammon, 1998; Kennedy & Hamilton, 1997; Kuni- tomi et al., 2010; Tarzi, Kennedy, Stone, & Evans, 2001).

Model Case of Isolation

Walker and Avant (2011) define a model case as an example of the use of the concept that demonstrates all of the defining attributes of the concept. An

Table 1. Isolation: A Concept Analysis

Concept Attributes Antecedents Situational dimensions Consequences

Isolation Sensory deprivation Individual perception Voluntary versus involuntary Anxiety Social isolation Situational dimension Instrumental versus obstructive Depression Confinement Planned versus unplanned Mood disturbances

Duration Anger Individual versus group Loneliness Space restriction Adverse health events Threat Social conditions Support conditions Environmental variability

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example of isolation would be a person with multi- drug resistant tuberculosis that requires strict airborne isolation. This young man lives in a single 8-square meter space with no windows to view the outdoors. The room has a thick metal door with a 1 ¥ 1 meter window that faces the hallway. The young man is required to be in this room at all times, except for periodic examinations. His activity is limited to actions within his room. He is permitted a television for stimu- lus and has control over the lights in the room, but he is deprived of natural sounds, such as activities in the building or outdoors. Visitation is permitted but strictly limited. His mandated time in isolation will be 6 months.

Borderline Case of the Concept

Borderline cases are those examples or instances that contain most of the defining attributes of the concept being examined, but not all of them (Walker and Avant, 2011). Sarah is undergoing a bone marrow transplant and will be placed in protective isolation for 2 weeks during the treatment and recovery phase. She will be alone in a special room with the door closed at all times. She is not permitted to leave the room, except for special circumstances. She is permitted to have visitors, but they will be required to wear gloves, gowns, and masks during their time in the room. She and her parents have met with a recreation counselor to plan for activities and schoolwork to keep her mind active and entertained during her isolation. She is scared, but she and her parents are ready for the isolation because they know that it will help her heal, and it will protect her from illness when she is most susceptible.

Contrary Case of the Concept

Contrary cases are clear examples of what is not the concept (Walker and Avant, 2011). An example is a mystic who electively separates herself from others and confines herself to small spaces with the goal of inducing a mode of consciousness that permits clarity, relaxation, and internal assessment. She limits her movements to those essential for existence. She is emotionally, physically, and socially isolated from the world. She is not isolated though because she elec- tively enters into isolation to achieve her goals, and she is free to return to her normal life at any time.

Empirical Referents

Empirical referents are classes or categories of actual phenomena that by their existence or presence dem- onstrate the occurrence of the concept itself (Walker and Avant, 2011). After an extensive review of the literature, no empirical referents of the concept of isolation were found, but tools to assess the outcomes of isolation have been reported. Anxiety, depression, mood disturbances, anger, and loneliness have been assessed using instruments, such as the University of California, Los Angeles Loneliness Scale; the Hospital Anxiety and Depression Scale; the Hamilton Anxiety Rating Scale; the Hamilton Depression Rating Scale; the Health Illness Questionnaire; the Self-Esteem Scale; the Consumer Assessment of Healthcare Provid- ers and Systems; the Beck Depression Inventory; the State Anxiety Inventory; the Profile of Mood States; the Abbreviated Mental Test Score; the Barthel Index; the Geriatric Depression Scale; and the Crown-Crisp Experiential Index (Abad et al., 2010; Catalano et al., 2003; Gammon, 1998; Kennedy & Hamilton, 1997; Stelfox, Bates, & Redelmeier, 2003; Tarzi et al., 2001; Wassenberg et al., 2010)

Discussion

The limitations of this concept analysis include the interpretation of the research and potential for not locating source references. Although the literature was used to guide the process, any interpretation is subjective in nature. An extensive search was under- taken, but it is unlikely that this was all-inclusive.

This concept analysis presents an opportunity to develop nursing theory through the adoption of a theoretical model that supports the concept of isola- tion. Nicholson (2009) proposed Roy’s adaptation model as a nursing conceptual model that fits well with social isolation. This will require further study to determine if the model will encompass all the attributes of isolation.

According to Walker and Avant (2011), after con- structing an operational definition of a concept, the location of a research instrument is necessary to con- struct and test theoretical relationships between isola- tion and outcome variables. There is a need for more research to explore implications of the suggested defi- nition. Further clarification is needed to revise and test the attributes of isolation in clinical situations. System- atic studies of isolation can ultimately enhance nurses’

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knowledge base and contribute to the quality of life for isolated persons.

Conclusion

Being alone does not make a person isolated. The state of isolation that can lead to negative experiences and outcomes requires a combination of psychological and physical factors to experience the deleterious effects. The research presented here has identified and examined important characteristics of isolation. Isola- tion is defined as a state in which an individual expe- riences a reduction in the level of normal sensory and social input with possible involuntary limitations on physical space or movement. Nursing has an impor- tant role to play in recognizing isolation and in acting to minimize the event on their patient’s behalf.

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Isolation: A Concept Analysis H. M. Gilmartin et al.

60 © 2013 Wiley Periodicals, Inc Nursing Forum Volume 48, No. 1, January-March 2013

Attachment 2

CONCEPT ANALYSIS

Migration: a concept analysis from a nursing perspective

Michelle Freeman, Andrea Baumann, Jennifer Blythe, Anita Fisher & Noori Akhtar-Danesh

Accepted for publication 17 September 2011

Correspondence to M. Freeman:

e-mail: [email protected]

Michelle Freeman MSN RN

Doctoral Student

School of Nursing, McMaster University,

Hamilton, Ontario, Canada,

and Lecturer

Faculty of Nursing, University of Windsor,

Ontario, Canada

Andrea Baumann PhD RN

Associate Vice-President,

Global Health, Faculty of Health Sciences,

and Scientific Director

Nursing Health Services Research Unit

(NHSRU), McMaster Site, Hamilton,

Ontario, Canada

Jennifer Blythe PhD

Associate Professor (part-time)

School of Nursing, Research Associate

NHSRU, McMaster University, Hamilton,

Ontario, Canada

Anita Fisher PhD RN

Associate Professor

School of Nursing and Senior Researcher

NHSRU, McMaster University, Hamilton,

Ontario, Canada

Noori Akhtar-Danesh PhD

Associate Professor of Biostatistics

School of Nursing, McMaster University,

Hamilton, Ontario, Canada

FREEMAN M., BAUMANN A., BLYTHE J. , F ISHER A. & AKHTAR-DANESH N.FREEMAN M., BAUMANN A., BLYTHE J. , FISHER A. & AKHTAR-DANESH N.

(2012)(2012) Migration: a concept analysis from a nursing perspective. Journal of

Advanced Nursing 68(5), 1176–1186. doi: 10.1111/j.1365-2648.2011.05858.x

Abstract Aim. This article is a report of a concept analysis of nurse migration.

Background. International migration is increasing and nurse migrants are active

participants in this movement. Migration is a complex term and can be examined

from a range of perspectives. Analysis of nurse migration is needed to guide policy,

practice and research.

Data sources. A literature search was undertaken using electronic literature indexes,

specific journals and websites, internet search engines and hand searches. No

timeframe was placed on the search. Most literature found was published between

2001 and 2009. A sample of 80 documents met the inclusion criteria.

Method. Walker and Avant’s approach guided the analysis.

Discussion. Nurse migration can be defined by five attributes: the motivation and

decisions of individuals; external barriers and facilitators; freedom of choice to

migrate; freedom to migrate as a human right, and dynamic movement. Antecedents

of migration include the political, social, economic, legal, historical and educational

forces that comprise the push and pull framework. The consequences of migration

are positive or negative depending on the viewpoint and its affect on the individual

and other stakeholders such as the source country, destination country, healthcare

systems and the nursing profession.

Conclusion. This concept analysis clarified the complexities surrounding nurse

migration. A nursing-specific middle-range theory was proposed to guide the

understanding and study of nurse migration.

Keywords: concept analysis, human right, middle-range theory, migration, nurse

migration

Introduction

People have always migrated, either voluntarily in search of a

better life or involuntarily, because of war, famine or

persecution. International migration is a reality in our global

community with the number of migrants doubling in the last

four decades [International Organization for Migration

(IOM) 2005]. An important proportion of these migrants

1176 � 2011 Blackwell Publishing Ltd

J A N JOURNAL OF ADVANCED NURSING

are professional healthcare workers, specifically Registered

Nurses (RNs) (Kingma 2007).

As one of the defining issues of the twenty-first century (IOM

2009), migration is an important area on which to focus

attention. The IOM describes migration as ‘an essential,

inevitable and potentially beneficial component of the

economic and social life of every country and region’ (IOM

2009). As the world is faced with a critical shortage of nurses,

nurse migrants are of great interest nationally and internation-

ally. These ‘on the move’ nurses, migrate each year in search of

better pay and working conditions, professional development,

personal safety, or adventure (Kingma 2006a, 2007). Although

there is a great deal of published literature on nurse migration

in the past 10–15 years (Khaliq et al. 2009), the topic has

received limited attention from the nursing community.

Migration is a complex term with many meanings that can

be examined from a range of perspectives. Definitions have

been described as vague, controversial, or contradictory and

vary by country (IOM 2004, p. 3). Although migration

theories have been evolving for many years, there are few

examples of their use in research on nurse migration.

Migration theories focus on various levels of analysis: micro

levels concentrate on individual migration decisions, macro-

levels on aggregate explanations, and the meso-level exam-

ines household and community level influences on migration

(Hagen-Zanker 2008). The theory most frequently used to

explain nurse migration is the push pull theory (Meija et al.

1979, Kline 2003, Kingma 2006a, Bach 2007). This micro-

level framework offers an explanation of why nurses migrate

but not the individual’s decision-making. It has also been

criticized for its inability to explain why people decide not to

migrate (De Jong & Fawcett 1981, Arango 2000). These

limitations affect our ability to describe, study and/or address

issues related to increasing rates of nurse migration.

This article presents a concept analysis of nurse migration.

Two aims guided this analysis: to understand how the

concept of migration is used in nursing and to propose a

middle-range theory to guide the study of nurse migration.

Background

A concept is a mental image of a phenomenon, an idea, a

person, or an object (King 1988, Walker & Avant 2005). A

concept analysis is a formal, linguistic exercise that examines

the elements of a concept, its usage and how it is similar to or

different from other related words (Walker & Avant 2005,

p. 63). It is useful in clarifying words that are vague or

overused so that everyone subsequently using the word will

be speaking about the same thing (Walker & Avant 2005,

p. 64). In addition, they give precise definitions for use in

theory and research (p. 74). Since concepts are dynamic and

change over time, a concept analysis should never be

regarded as a ‘finished product’ (p. 64) but only as one

defining its attributes at the current time.

Migration is a commonly used word with explicit meaning

and an unusual topic for a concept analysis in nursing. An

analysis is usually done on abstract concepts such as quality

of life (Haas 1999). Penrod and Hupcey (2005) state,

however, that an everyday concept with explicit meaning is

inadequate for scientific inquiry. There is also no guarantee

that everyday concepts are similarly understood. ‘Definitions-

and this is true of all terminology, not only that related to

migration- may vary according to a given perspective or

approach’ (IOM 2004, p. 3). Since the concept analysis

process includes the identification of antecedents and conse-

quences of nurse migration, it will contribute to a more

complete understanding of the concept.

Conducting a concept analysis requires similar skills and

level of rigour as other research methods (Baldwin & Rose

2009). The concept analysis method developed by Walker

and Avant (2005) was used for this analysis. This approach

involves eight sequential steps to be used iteratively: selecting

the concept; determining the aim purpose of the analysis;

identifying all uses of the concept; determining defining

attributes; developing model cases; constructing additional

cases (e.g. borderline, related, contrary, invented, and illegit-

imate cases); identifying antecedents and consequences; and

defining empirical referents. This method was chosen because

it is the most widely used in the literature (Hupcey et al.

1996), and is systematic (Brennan 1997, Xyrichis & Ream

2008). The first two steps of the process, choosing the

concept and purpose, have been described. The analysis will

continue with describing data sources and selection.

Data sources

In the past decade, there has been an explosion of interest in

international migration (Favell 2008, p. 259). This presented

a major challenge for this analysis given the constraints of

time and space and therefore required the development of

clear inclusion criteria. An extensive literature review was

conducted. All uses of the term migration were examined by

reading as many different sources as possible since ignoring

some uses could bias findings (Walker & Avant 2005).

Searches were performed on the general topic of migration

and the specific subject of nurse migration. No limit was placed

on the timeframe for the search. Electronic literature indexes

and specific journals were searched using keywords such as

‘migration’, ‘immigration’, ‘emigration’, ‘nurse migration’,

‘internationally educated nurses’ and ‘healthworkermigration’

JAN: CONCEPT ANALYSIS Concept analysis nurse migration

� 2011 Blackwell Publishing Ltd 1177

in full and truncated forms. Indexes included CINAHL,

PubMed, SCOPUS, Sociological Abstracts and PsychINFO.

Reference lists (ancestry searching) were used to locate relevant

sources and specific journals and websites focusing on migra-

tion were searched. A Google search was also performed using

the terms migration, nurse migration and human migration.

Definitions of migration were sought in dictionaries, migration

specific glossaries and in all the retrieved literature.

Data selection

The literature represented diverse disciplines including nurs-

ing, law, human resources, psychology, sociology, anthro-

pology, geography, demography, economics, statistics,

political science, and policy and professional groups. Most

publications on nurse migration were written during the last

8 years (2001–2009). Approximately 500 articles, documents

and books were initally scanned for inclusion based on the

following criteria: (a) English language; (b) contribution to

understanding of the concept of migration; (c) contribution to

the definition, attributes, antecedents and/or consequences of

nurse migration; (d) focus on out of country rather than

internal migration; and (e) reference to a professional RN in

his/or her home country. Using these criteria approximately

150 documents were identified. All documents were read in

full and excluded if they did not meet criteria.

The final sample of 80 documents included articles,

research, grey literature and books. An inductive content

analysis approach was used to organize the information (Elo

& Kyngas 2007). Each document was reviewed and infor-

mation was tracked by using sticky notes. The information

was transferred to a data tracking form and summarized in a

matrix to extract defintions and themes. Tracking is not

usually explicitly described and/or done but it was critical to

ensuring the integrity of this complex analysis.

Results

Identifying uses of the concept of migration and nurse

migration

The third step in the process was to identify all uses of the

concept. According to the Merriam-Webster dictionary

(2009) the meaning of migration is ‘to move from one

country, place, or locality to another’; ‘to pass usually

periodically from one region or climate to another for feeding

or breeding’; ‘to change position in an organism or sub-

stance’. Migration, therefore, describes the movement of

individuals, groups, organisms or objects such as humans,

birds, insects, animals, planets, cells and data.

Since the focus of this concept analysis is human migration,

definitions focusing on humans were explored. Migration,

according to the Glossary on Migration (IOM 2004, p. 41), is

‘A process of moving, either across an international border, or

within a State. It is a population movement, encompassing

any kind of movement of people whatever its length,

composition, and causes; it includes migration of refugees,

displaced persons, uprooted people, and economic migrants’.

Migrant is described in the same source as having no

universally accepted definition but ‘‘usually understood to

cover all cases where the decision to migrate is taken freely by

the individual concerned for reasons of ‘personal convenience’

and without intervention of an external compelling factor’’

(p. 40). Even these two explanations, from the same source,

present conflicting views with one including forced movement

(e.g. refugees); the second a decision to move taken freely.

Similar confusion was found in literature on nurse migration.

A specific definition of migration was ‘… the crossing of the boundary of a political or administrative unit for a certain

minimum period of time’ and includes the ‘movement of

refugees, displaced persons, uprooted people as well as

economic migrants’ [United Nations Educational, Scientific

and Cultural Organization (UNESCO) 2005]. It is interesting

that this definition does not specify the individual leaving the

home country and timeframes are vague.

Migration is also described using a variety of terms that

attempt to categorize and describe migrants (see Table 1).

These include (a) movement (e.g. external), (b) motivation

(e.g. economic), (c) freedom of choice (e.g. voluntary), (d)

length of time of migratory period (e.g. temporary), (e)

frequency of moves (e.g. circular), (f) status of migrant (e.g.

skilled) and (g) legal status.

These terms were not standardized. For example, Brettel

and Hollifield (2008, p. 21) used migration to describe

movement within borders, immigration to describe crossing

national borders but identified that some disciplines prefer

the term mobility to migration. Out-migration was an

alternative term found in the nurse migration literature for

emigration (Buchan et al. 2005).

No definition of nurse migration was found in the search.

Presumably authors assumed a common understanding of the

term. A number of different terms were used to refer to the

nurse migrant (see Table 2).

They included ‘foreign’ (Kline 2003, Brush et al. 2004),

‘foreign-educated’ (Aiken et al. 2004, Aiken 2007), ‘nurse

recruits’ (Brush et al. 2004), ‘Canadian trained’ (Pink et al.

2004), and ‘overseas qualified’ (Hawthorne 2001). The

decision of the authors about the choice of labels was not

explicit. Some of these terms, however, identified nurse

migrants as outsiders or aliens and could have important

M. Freeman et al.

1178 � 2011 Blackwell Publishing Ltd

consequences for their acceptance and treatment. Kingma

(2006a, p. 70) has identified racism and discrimination as the

most serious problem that migrant nurses encounter. She

paints a sad reality where migrants’ are bullied, their

professional skills are undermined and they are discriminated

against in promotion and continuing educational opportuni-

ties. Other terms used such as trained vs. educated commu-

nicate a different view and valuing of the nursing profession.

In summary, although there was no single definition of

nurse migration, attributes recurred in the literature and will

be described in the next section.

Defining attributes

The fourth step in the process was to describe the attributes,

the cluster of characteristics most frequently associated with

the concept in the literature (Walker & Avant 2005).

Tracking and summarizing the characteristics required multi-

ple revisions. As shown in Figure 1, five attributes were

identified: (a) the motivation and decisions of an individual,

(b) external barriers and facilitators, (c) freedom of choice,

(d) migration as a human right and (e) movement is dynamic.

A brief overview of each follows.

Migration is determined by the motivation and decisions of

an individual

Motivation to migrate is a key characteristic associated with

nurse migration. It has been described as a subjective deci-

sion-making process (Fawcett 1985) influenced by push and

pull factors (Pink et al. 2004, Brush 2008, Kingma 2008,

McGillis Hall et al. 2009). Motivation can be both intrinsic

and extrinsic. Many theories and models have been offered to

explain it including Equity Theory, Maslow’s Hierarchy of

Needs, Expectancy Theory (Winkelmann-Gleed 2006, p. 42),

behavioural models (Fawcett 1985) and economic and social

network theories (Teitelbaum 2008). Motivations driving

nurse migration are multifaceted and no theories have yet

been developed to explain them (Kingma 2006a).

Table 1 Categories and terms for migrants/migration.

Categories and terms

(a) Movement

*Internal

*External

*Emigration

*Out-migration

*Immigration

*Cross-border commuters

*Commuter migration

*Shuttle migration

*Cross-industry

*Geographical

(b) Motivation

*Economic migrant

*Quality-of-life migrant

*Career-move

*Partner

*Adventurer

*Holiday workers

Student

*Family reunification

(c) Freedom of choice

*Voluntary

Involuntary, forced, population transfer

Impelled, reluctant or imposed

Survival

(d) Length of time of migratory period

Seasonal

*Temporary

*Permanent

(e) Frequency of moves

*Carousel

*Step

*Chain

*Return

*Circular

(f) Status of migrant

*Skilled or highly skilled

(g) Legal status

*Legal

Illegal, irregular or undocumented

*Indicates terms found in nurse migration literature.

Table 2 Terms used for nurse migration/nurse migrants in literature.

Term Source

Overseas nurses Troy et al. (2007)

Overseas qualified nurses Hawthorne (2001)

Overseas trained nurses Allan et al. (2008)

Foreign-educated nurses Aiken et al. (2004),

Aiken (2007)

Foreign nurses Brush et al. (2004),

Kline (2003)

Nurse recruits Brush et al. (2004)

Internationally Educated Nurses Baumann et al. (2006)

Internationally recruited nurses Buchan et al. (2006)

International health worker Ray et al. (2006)

Global nursing migration Keatings (2006), Brush (2008),

Khaliq et al. (2009)

International Registered Nurses North (2007)

International nurses Buchan et al. (2005)

International nurse migration Kline (2003), Kingma (2008)

Non English Speaking

Background Source Countries

(NESB) and English Speaking

Background Source

Country (ESB)

Hawthorne (2001)

Canadian trained nurses Pink et al. (2004)

JAN: CONCEPT ANALYSIS Concept analysis nurse migration

� 2011 Blackwell Publishing Ltd 1179

Migration is influenced by external barriers and facilitators

Barriers and facilitators to nurse migration, a recurrent theme

in the literature, were classified as external when they were

not under the control of the migrant. Major barriers to

migration were language competency and inadequate

educational preparation (Kingma 2006a, 2008). Facilitators

of nurse migration assumed many forms. Nurse migrants, as

professional or highly skilled migrants, were granted prefer-

ential treatment for admission to some host countries (IOM

2004). For example, labour mobility clauses in trade agree-

ments between countries, such as the North American Free

Trade Agreement (NAFTA), were written to facilitate

migration (Blouin 2005, Aiken 2007). Countries’ immigra-

tion policies have been modified to allow additional visas for

skilled professionals, such as nurses (Aiken 2007). Improving

access to the writing of licensing exams is another strategy.

For example, the American exam (NCLEX-RN) has been

made available since 2005 in many different countries to

lessen the financial burden on qualified nurses who want to

migrate to the US (Aiken 2007).

Entrepreneurs have emerged to facilitate nurse migration,

now described as big business (Kingma 2006a). These include

international nurse recruiting agencies that link nurses with

jobs for profit (Brush et al. 2004, Perrin et al. 2007); govern-

ments, such as China, which organize groups of nurses to

work in other countries and charge handling fees (Fang 2007);

and the development of new nursing schools to train nurses for

export (Lorenzo et al. 2007). Barriers and facilitators in the

complex global environment are constantly changing and

evolving. Economic downturns and international events such

as 9/11 can quickly result in new policies that limit immigra-

tion or make it more difficult (Kingma 2006a, Buchan 2007).

Freedom of choice to migrate

Freedom of choice in nurse migration can be described as a

continuum from completely voluntary (taken freely), to

reluctant (impelled), to completely involuntary (forced). All

these forms are described in the literature on nurse migration.

Although many nurses view migration as voluntary, Kingma

(2006a, p. 5) questioned, ‘Is migration a matter of choice or is

it imposed on nurses as an obligation or [as a result of]

constraint?’ She and others stress that migration does not

occur without strong push factors from the home country.

‘‘Without both sets of [push and pull] forces operating in

unison, little migration would occur. In other words no

matter how strong the ‘pull’ forces, large scale migration will

not take place from countries where strong ‘push’ factors do

not exist’’ (Meija et al. 1979, p. 102). For example, the lack

of full time work in Canada acted as a strong push factor

resulting in Canadian nurses migrating for full time work in

the United States (McGillis Hall et al. 2009), a move that

would not be considered truly voluntary.

Freedom to migrate is a human right

Nurse migration is characterized by the human right of

freedom of movement. This right is articulated in Article 13

of the Universal Declaration of Human Rights which states

‘Everyone has the right to leave any country, including his

own, and to return to his country’ (United Nations 1948).

This right is supported by the International Council of Nurses

(2007) who state that all nurses have the right to migrate as a

function of choice, regardless of their motivation. Although

concerns were expressed in the literature about the negative

consequences of nurse migration on some countries, no one

recommended that the rights of nurses to migrate be denied

(Buchan et al. 2005, 2006, Chikanda 2005, Kingma 2006a,

2008, Thupayagale-Tshweneagae 2007).

Movement is dynamic

Nurse migration is dynamic, characterized by movement that

is unpredictable and ever changing and not, as often por-

trayed, as a ‘one-way linear brain drain’ (Buchan et al. 2005,

• Forces influencing motivation to migrate (push and pull):

• Political • Social (personal) • Economic • Legal • Historical • Educational

Antecedents

• Motivation and decisions of individuals

• External barriers and facilitators

• Freedom of choice to migrate

• Freedom to migrate as a human right

• Dynamic movement

Attributes Consequences

• Positive and/or negative dependig on view point of:

• Individual (and family)

• Stake holders (source country, destination country, health care system/organization and nursing profession)

Figure 1 Concept of nurse migration: antecedent, attributes and consequences.

M. Freeman et al.

1180 � 2011 Blackwell Publishing Ltd

p. 5, Humphries et al. 2008). Movement is influenced by

both country-specific and broader global issues and the length

of migratory periods and patterns of movement (e.g. circular;

commuter) are diverse (Bach 2004, Buchan et al. 2005). The

varieties of countries of origin, different demographic profiles

and individual motivations and career goals contribute to the

dynamic patterns of movement (Buchan 2004, Buchan et al.

2006, Perrin et al. 2007).

Model case to illustrate the concept of nurse migration

The next step in the concept analysis is to construct a model

case that illustrates all these attributes. The case can be

constructed from real life, found in the literature or invented

(Walker & Avant 2005) although it is recommended that

cases be identified rather than constructed whenever possible

(Rodgers 1989). A model case, adapted using elements from a

study by Perrin et al. (2007) and others found in the literature

is used.

Jeanette is a 24 year old who graduated from a university

in the Philippines with a bachelor’s degree in nursing. She has

just taken her licensing exams, now offered in her home

country, to work as a nurse in the US. She does not want to

leave her family but there are no jobs at home. She will make

$4000 per month in the US, compared to $69 per month in

the Philippines. This will allow her to send money home to

support her family. She knows nurses are trained for export

in her country but hoped that there would be job openings by

the time she finished school. She is recruited through an

agency that found her a job and arranged her travel. She

migrates to the US, plans to obtain a graduate degree and

work in other countries, such as Great Britain or Canada,

before returning home.

All attributes occur in this case and illustrate the complex-

ity of the concept. Jeanette demonstrated individual motiva-

tion in her decision to migrate. Her migration was facilitated

by the availability of US exams, jobs, higher income and

recruiters. She had the right to migrate but her decision was

made reluctantly, rather than freely, because of lack of work

in her home country. Her migration path will be dynamic

involving moves to other countries but it will be influenced by

her motivations.

Since the development of other cases (e.g. borderline) does

not contribute to concept clarification, Walker and Avant

(2005) support omitting them.

Antecedents and consequences

The identification of antecedents and consequences is the

next step in the process. The push and pull model is the

dominiant framework for explaining nurse migration (Bach

2007). The antecedents for nurse migration are the political,

social (personal), economic, legal, historical and educational

forces that comprise this framework (Meija et al. 1979, Kline

2003, Kingma 2006a). The pull factors are conditions in the

destination country that attract and facilitate the migration of

nurses; the push factors are conditions that encourage nurses

to leave their own country (Kingma 2006a, p. 19). These

factors usually mirror each other; for example, a nurse from a

country making a low salary will be pulled to a country

offering higher wages (Kingma 2006a, p. 19). The main pull

factor is the world-wide shortage of nurses with countries

competing for scarce resources. Common factors are the

desire for better incomes and benefits, full time work, healthy

work environments, professional development opportunities,

better resourced health systems and safe and supportive work

environments (Pink et al. 2004, Buchan et al. 2005, Interna-

tional Centre on Nurse Migration (ICNM) 2008, McGillis

Hall et al. 2009). Other pulls include a shared language,

appropriate nursing qualifications and family, historical and

trade ties to the destination country (Ross et al. 2005,

Kingma 2006a, Winkelmann-Gleed 2006). Newly emerging

pull factors include aggressive recruitment agencies who

receive large payments per nurse and encourage migration by

funding the move and linking nurses with jobs (Brush et al.

2004), the Internet which has increased awareness of oppor-

tunities around the world for nursing skills, and the growing

big business of educating nurses for export (Kingma 2006b,

Lorenzo et al. 2007).

Nurse migration can be considered both positive and

negative depending on the viewpoint and their affect on the

individual and stakeholders. Stakeholders include the source

country, destination country, healthcare systems and the

nursing profession. For example, positive consequences for

the individual (e.g. a well paying secure job) may produce

negative consequences for the home country (e.g. loss of a

scarce nursing resource). The growing mobility of nurses has

been criticized as occurring without a careful analysis of the

implications of this movement on the nurses and on health-

care delivery systems that both send and receive them (Brush

et al. 2004). One consequence for source countries is a brain

drain that diminishes nursing resources for their population

(Meleis 2003, Pink et al. 2004, Perrin et al. 2007, Kingma

2008, McGillis Hall et al. 2009).

There are social costs to the individual who migrates

(Kingma 2006a, 2006b). Adapting to a new country, a new

culture and an unfamiliar healthcare environment, with or

without a support network can be a monumental task. Often

these nurses, who may have children in their home country,

are responsible for financially supporting their families. In

JAN: CONCEPT ANALYSIS Concept analysis nurse migration

� 2011 Blackwell Publishing Ltd 1181

addition, they frequently experience discrimination and

exploitation by agencies and institutions in the destination

country (Hawthorne 2001, Allan et al. 2008, Kingma 2008).

There are also positive consequences. In many countries in

the world, a nursing licence is viewed as a ticket to a better

life (McCarthy 2009). Remittances sent home improve the

family life in the home country through redistribution of

global wealth (ICNM 2007, Kingma 2008). There is

improved personal and professional safety and empowerment

for some migrants (Meleis 2003, Kingma 2008) who leave

unsafe environments and countries with gender inequities

(Hawthorne 2001, Meleis 2003, Buchan et al. 2005, Buchan

2006, Thomas 2006, Allan et al. 2008, Bourgeault & Wrede

2008).

Although the Philippines has had the most success in

training nurses for export and benefited as a country from the

remittances sent home, it serves as an example of unexpected

negative consequences. The ease of nurse migration has

resulted in physicians retraining as nurses to migrate, a waste

of an already limited health human resource (Brush et al.

2004). The country also experienced a decrease in the quality

of nursing education as evidenced by high exam failure rates

as a result of schools being pressured to educate large

numbers of nurses for both foreign and domestic markets

(Perrin et al. 2007).

Nurse migration has consequences for the nursing profes-

sion, some known and others which are emerging. There

appears to be an attitude in many countries that a supply of

nurses exists somewhere in the world waiting to be enticed to

migrate to their country. As a result, many developed

countries are not educating enough nurses to meet their

needs and instead, rely on the recruitment of nurses from

other countries to address shortages (Buchan 2006). Institu-

tions have also been accused of recruitment from abroad

rather than raising salaries and improving working environ-

ments to retain nurses (Brush et al. 2004). Nurse migrants

also stress health systems resources if they require language

competency training, orientation to vastly different health-

care systems and, to autonomous professional nursing roles

(Hawthorne 2001, Buchan et al. 2005). A positive outcome is

that nurses from different cultures and countries contribute to

making the nursing profession more culturally aware (Meleis

2003, Kingma 2008). Finally, the uncontrolled growth in the

business of exporting nurses for profit presents unknown

consequences for the profession.

Defining empirical referents

The final step in the concept analysis is to determine the

empirical referents. In this step, the question is asked, ‘If we

were to measure this concept or determine its existence in the

real world, how do we do so?’ (Walker & Avant 2005, p. 73).

While nurse migration, the actual movement of nurses, can be

measured in many ways, it has been a challenge for most

researchers. Data come from a variety of sources and are

collected by different organizations for different uses (Diallo

2004). The lack of data accuracy is usually identified as a

limitation in most studies.

The attributes of nurse migration, and its antecedents and

consequences can be examined using a combination of

qualitative, quantitative and mixed methods. For example,

a survey in combination with focus groups could be used to

explore motivations for migration, perceptions of freedom of

choice and human rights and explore the facilitators, barriers

and dynamic nature of the process. The challenge for the

researcher is to understand the complex nature of these

characteristics to ensure a robust research design to capture

the many variables of interest.

One instrument was found that measures immigration-

specific distress. The Demands of Immigration Scale, devel-

oped by Aroian et al. (1998), was created for use with other

populations but tested with nurse migrants (Tsai 2002,

Beechinor & Fitzpatrick 2008). Standardized measures and

approaches would contribute greatly to the understanding of

nurse migration and allow findings to be compared to or

generalized in different contexts and countries.

Discussion

Conducting this concept analysis was a challenging exercise

which began with choosing a model. Although there were

publications on specific models, examples of applications of

models and articles criticizing the approaches and/or use of

concept analysis in nursing (Paley 1996, Hupcey & Penrod

2005, Beckwith et al. 2008) there was no guidance to assist in

the choice. To advance this scientific process, it is recom-

mended that several models be used concurrently to analyse

the same concept. This would test the strength and limita-

tions of different models and allow for examination of the

findings through the use of different approaches.

The concept analysis process was found to be a challenging

undertaking requiring the same skills and level of rigour as

any research method (Baldwin & Rose 2009). Walker and

Avant’s (2005) process, presented as simple steps, was found

to be overly simplified related to the scope of the literature

review and organizing and synthesizing the findings.

Although they state that a review of the literature helps

support and validate the attributes, they provided no direc-

tion on how to organize a review except by extensive reading

in as many different sources as possible. Therefore, the first

M. Freeman et al.

1182 � 2011 Blackwell Publishing Ltd

hurdle to clear was the huge volume of literature on the topic

of migration and determining relevant literature from irrel-

evant. The search involved not just the usual sources, but also

a large number of websites dedicated to the topic of

migration; for example the Migration Policy Institute,

Mobility of Health Professionals, Global Migration Group,

and International Centre on Nurse Migration (to name only a

few). This increased the complexity of the literature review.

Since a concept analysis involves examining all uses of the

concept, it was a challenge to conduct a comprehensive

review and not get lost in the process.

Another hurdle was organizing the findings. Defining

attributes, the heart of the concept analysis process, has been

criticized as an arbitrary process (Paley 1996). Examining

other methods and reviewing information on qualitative

content analysis were necessary to develop a method for

collecting, organizing and managing the data and distilling

defining attributes (Paley 1996, Elo & Kyngas 2007). These

insights on the challenges are meant to contribute to improv-

ing the process and offer some guidance to novice analysts.

Regardless of these challenges, this concept analysis on

nurse migration has contributed to nursing in several ways.

The first aim was to understand how the concept of migration

is used in nursing. The results can inform nurses in education,

administrative and research positions who are involved

directly and indirectly with nurse migration. It has not only

deepened the understanding of the characteristics related to

this complex concept, but it has also clarified some of the

misunderstandings related to human rights, freedom of

choice and characteristics of nurse migration. It has also

alerted nursing leadership that nurse migration is a complex

and dynamic process and that there will be no simple

solutions to the issues surrounding it (Buchan et al. 2006). An

unexpected contribution was that through this analysis of the

literature, awareness was raised that authors need to choose

the labels for nurse migrants with caution as they may be

unwittingly contributing to the alienation of and discrimina-

tion against this group. This is an important caution and

reminder about the use of language and labels in our research

and writings.

The second aim was to generate a discipline-specific theory

to guide the study of nurse migration. A middle-range theory

is a set of related ideas with suggested relationships among

the concepts depicted in a model (Smith & Liehr 2003). It is

narrower in scope than a grand theory and comprised of

concepts that are empirically measurable (Fawcett 1997). The

identification of the attributes, antecedents and consequences

represents a framework for a middle-range theory of nurse

migration. Although requiring testing and further develop-

ment, this theory is more robust than the push pull theory

which focuses only on the forces influencing the decision to

migrate (antecedents). It offers a more complete and explicit

model of this complex concept to guide policy and research.

For example, understanding that the consequences of nurse

migration should be examined through the eyes of all

stakeholders is important for policy makers. This theory

could also guide the development of a predictive model of

nurse migration to guide nursing human resource planning.

Conclusion

This article provided unique insights into conducting a

concept analysis. The analysis suggested that nurse migration

What is already known about this topic

• Nurse migration is a growing global phenomenon as a result of the RN shortage in most countries.

• Migration is a complex term with many meanings that can be examined from a range of perspectives.

• Walker and Avant’s concept analysis methodology is a standardized approach for clarifying antecedents,

attributes and consequences.

What this paper adds

• The antecedents are the political, social (personal), economic, legal, historical and educational forces that

comprise the push pull theory.

• The attributes include: the motivation and decisions of individuals; external barriers and facilitators; freedom

of choice to migrate; freedom to migrate as a human

right, and dynamic movement.

• The consequences of nurse migration can be positive or negative and depend on its affect on the individual, the

family and other stakeholders such as the source

country, destination country, healthcare systems and the

nursing profession.

Implications for policy and/or practice

• The identification of attributes, antecedents and consequences can guide the development of research

instruments to study nurse migration.

• Categories of terms used to describe nurse migration in the literature reflect its complexity.

• Terms that label nurse migrants as outsiders such as ‘foreign nurses’ should be used carefully because they

could influence the acceptance and treatment of these

nurses.

JAN: CONCEPT ANALYSIS Concept analysis nurse migration

� 2011 Blackwell Publishing Ltd 1183

is a human right, characterized by dynamic movement and a

continuum of freedom of choice, not only guided by

individual motivation and decision-making but influenced

by external barriers and facilitators. Nurse migration is on

the rise. The consequences of this movement will affect

nursing practice and health care throughout the world.

Although there has been a growing interest in nurse mobility

in the past 10 years, there is little primary research and

therefore, little evidence to guide practice, policy, or research

(Haour-Knipe & Davies 2008, McGillis Hall et al. 2009).

This concept analysis proposes a middle-range theory of

nurse migration to guide this much needed research.

Funding

This research received no specific grant from any funding

agency in the public, commercial or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

MF, AB, JB, AF and NA-D were not only responsible for the

study conception and design, but also made critical revisions

to the article for important intellectual content. They also

provided administrative, technical or material support and

approved the final version for publication. MF performed

data collection, data analysis and was responsible for the

drafting of the manuscript. AB supervised the study.

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Attachment 3

CONCEPT ANALYSIS

Perceived HIV symptom manageability: synthesis of a new use for

a known concept

Katharina Fierz, Dunja Nicca & Rebecca Spirig

Accepted for publication 19 May 2012

Correspondence to R. Spirig:

e-mail: [email protected]

Katharina Fierz MNS RN

Scientific Collaborator

Institute of Nursing Science, University of

Basel, Switzerland, and

Department of Nursing and Allied Health

Professions, University Hospital Basel,

Switzerland

Dunja Nicca PhD RN

Scientific Officer

Institute of Nursing Science, University of

Basel, Switzerland, and

Department of Infectious Diseases, Cantonal

Hospital St. Gallen, Switzerland

Rebecca Spirig PhD RN

Head of Department

Institute of Nursing Science, University of

Basel, Switzerland, and

Center of Clinical Nursing Science,

University Hospital Zurich, Switzerland

F I ERZ K . , N ICCA D . & SP IR IG R . ( 2 0 1 3 ) Perceived HIV symptom manageabil-

ity: synthesis of a new use for a known concept. Journal of Advanced Nursing

69(1), 229–241. doi: 10.1111/j.1365-2648.2012.06068.x.

Abstract Aim. To report the synthesis of the concept of perceived symptom manageability.

Background. Common symptom assessment parameters fail to address concerns

about the impact of symptoms on everyday life, overall functioning, or threats to

individuals living with the human immunodeficiency virus. We claim that the

concept of ‘perceived symptom manageability’ integrates these important

dimensions of the patients’ experience of their symptoms.

Data sources. Online databases, thesauri, and dictionaries were accessed in

January 2012. A free search was performed scanning the PubMed, CINAHL, and

PsycINFO databases for entries from 2001–2011 using ‘manageability’ in the title

or abstract as a search term.

Design. Text-based analysis.

Review methods. We followed the steps delineated by Walker and Avant for

concept synthesis. Uses of the concept ‘manageability’ were identified and listed,

meaningful usage clusters were generated, and a preliminary working definition

was created.

Results. Social resources and individual interpretation were relevant in view of

managing a difficult situation, thus positioning ‘manageability’ in a social and

interpretational context that exceeded objective control. We preliminarily defined

perceived symptom manageability as ‘the extent of the perceived ability to bring

social and personal resources into play to successfully deal with or control

symptoms, despite difficulties’.

Conclusion. We believe that our working definition represents a promising start

to understand and address the manageability problems that individual patients

face regarding particular symptoms and may serve as a basis to identify not only

symptoms but also areas of intervention that are of most concern to individual

patients.

Keywords: concept analysis, human immunodeficiency virus, manageability, nurs-

ing, symptoms

© 2012 Blackwell Publishing Ltd 229

JAN JOURNAL OF ADVANCED NURSING

Introduction

In countries where antiretroviral therapy is available and

affordable, human immunodeficiency virus (HIV) is

acknowledged as a long-term illness. As with many other

chronically ill populations, persons living with human

immunodeficiency virus (PLWH) can be challenged by a host

of symptoms due to comorbidities, the illness itself, and the

side effects of medications in the course of their illness tra-

jectory. Identifying symptoms that need management from

the patients’ perspective is, thus, an integral part of clinical

follow-up visits in any social or political context. In a

research project conducted to better understand the mecha-

nisms underlying the symptoms and medication management

of PLWH (Nicca et al. 2011), we realized that the ability to

manage symptoms in their daily routine is of great impor-

tance to this population and that this perceived manageabil-

ity of symptoms is crucial to the overall experience of

symptoms by PLWH. We also realized that the symptom

experience parameters commonly used by providers to iden-

tify symptoms needing management, i.e. symptom frequency

and severity/intensity, bother, or distress, failure to address

the concerns of PLWH about integrating their symptoms

into everyday life, and overall functioning (Willard 2006,

Hobbs 2009). Disagreement on symptoms needing manage-

ment may occur (Apollo et al. 2006, Edelman et al. 2010).

Therefore, we postulate that the parameters used to identify

symptoms needing management ought to incorporate the

individual interpretation of PLWH related to their daily liv-

ing with symptoms and propose ‘perceived symptom man-

ageability’ to be such a term. To our knowledge, the term

‘manageability’ has not been described or used in the context

of symptoms to date; therefore, an exploration and descrip-

tion of the concept are needed. Our aim was to explore ‘per-

ceived symptom manageability’ and establish a working

definition of this concept.

Background

As the collaboration between PLWH and healthcare providers

has become a core issue in healthcare encounters and is partic-

ularly important in the field of HIV care (Fehr et al. 2005), we

conducted a mixed methods research project (Nicca et al.

2011) in an effort to better understand the collaboration

between providers and patients in view of medication and

symptom management. We based our thinking on the Com-

mon SenseModel (CSM) of Leventhal et al. (1992) and specif-

ically on its adaptation for PLWH suggested by Spirig et al.

(2005), which provides an advanced framework for the care

of PLWH. While conducting interviews for this project, we

discovered that PLWH are actively involved in designing and

negotiating symptom management strategies; however,

patients and healthcare providers do not always agree on the

symptoms needing management (Apollo et al. 2006, Edelman

et al. 2010). This divergence may impede effective illness

management and diminish the quality of the healthcare

encounter (Jackson&Kroenke 2001).

To understand potential sources of disagreement in view

of the symptoms needing management, subjective illness

theories such as the CSM (Leventhal et al. 1980, 1984) and

specifically its adaptation by Spirig et al. (2005) are useful

frameworks. These theories underscore the individuality

inherent in the interpretation of an illness and its symp-

toms. In the CSM, Leventhal et al. (1980, 1984) state that

first, internal and external stimuli generate an individual,

cognitive representation of the problem and emotions. Emo-

tions and representation are cues that lead to separate, yet

intertwined, coping actions and the evaluation of outcomes

in both dimensions, which feed back into representations

and generate further emotions, finally representing a self-

regulatory system. Both processing tracks, i.e. the emotional

and the cognitive, are influenced by self and the social con-

text. To understand the drivers of patient behaviour, it is

crucial for healthcare providers to be aware of a patient’s

illness representation, which, in turn, shapes their actions

to confront the illness and form the basis for outcome inter-

pretation. Disagreements may occur within the attributes of

illness representation, i.e. identity, time-line, consequences

(physical, social, and economic), antecedent causes, and the

potential for cure and/or control of a threat. Furthermore,

according to the authors, diverging notions of problem

space (i.e. the representation-coping-evaluation pathways),

culturally diverging interpretations of the illness, or incon-

sistencies with an individual’s personality may result in

divergence between patients and providers regarding treat-

ment. In fact, the lay interpretation of the cause, effect, and

controllability of an illness or symptom determines how

people react to the threat and cope with the unpleasant sit-

uation (Leventhal et al. 1992). As the self-regulatory system

is coherent in itself and consistent for an individual patient,

it is crucial that providers are aware that a patient’s inter-

pretations of their emotional and cognitive representation-

coping-evaluation pathways (i.e. the patient’s problem

space) may differ from state-of-the art interpretations and

cannot be altered without acknowledging its consistency for

the patient.

For PLWH, social support has been established as being

crucial to successful symptom and illness management (Spi-

rig et al. 2005) and was integrated as a core determinant

for successful symptom management by these authors into

230 © 2012 Blackwell Publishing Ltd

K. Fierz et al.

the CSM. Furthermore, symptom manageability was intro-

duced as a variable representing the cognitive and emo-

tional evaluation of individual symptom management

endeavours by addressing the overall success of these

actions as perceived by the patient, which will, eventually,

affect further actions, health-related quality of life, clinical

parameters, and adherence.

We suggest that discrepancies between providers and

PLWH about symptoms needing management occur due

to their different perspectives when evaluating symptom

management outcomes. PLWH and providers are both

concerned about identifying those symptoms that need

management and to initiate management actions and a

reduction in symptom severity (intensity), and their fre-

quency of occurrence is commonly interpreted as manage-

ment success. However, this perspective fails to address

the challenges posed by the symptoms (Hobbs 2009),

which are subject to the patient’s individual evaluation. In

a recent study investigating adherence and attitudes

towards haemodialysis in patients with end-stage renal dis-

ease, Karolich and Ford (2010) found that the subjective

meaning attributed to the illness greatly influenced how

patients understand and manage their chronic condition.

Furthermore, there is evidence that interventions based on

a patient’s illness representation can successfully promote

their well-being (Hill et al. 2007) and adherence to medi-

cation (Phillips et al. 2012). Integrating a concept that

addresses a patient’s lived experience of managing their

symptom(s) in addition to ‘objective’ criteria to identify

symptoms needing management may contribute to mutual

understanding and improved satisfaction with the health-

care encounter (Jackson & Kroenke 2001). On the basis

of our clinical observation that PLWH often use ‘manage-

able’ when describing their symptoms, we considered ‘per-

ceived symptom manageability’ as a concept that expands

the focus of symptom assessment from mere symptom

expression to a comprehensive understanding of the prob-

lem space perceived by PLWH, as depicted by Spirig et al.

(2005).

Data sources

If a concept is already used, but not described in a specific

area or context, concept synthesis is deemed especially

useful (Walker & Avant 2005). By exploring broadly as

many current uses of a concept as possible, summarizing

core aspects of the concept and translating it to a new

area of use may add a new perspective to this specific

area. According to these authors, concept synthesis

precedes the well-known approach of concept analysis,

which is used if a concept is common knowledge, has

been used in different areas in many situations, became

blurred, or needs sharpening. Concept synthesis also com-

plements the process of concept derivation, where a con-

cept is transferred from one domain to another where it

has not yet been used (e.g. from industry to nursing). To

expand and target the use of ‘manageability’ to HIV

symptoms and to preliminarily define ‘perceived symptom

manageability’, we employed concept synthesis as

described by Walker and Avant (2005).

Our concept synthesis is based on online data sources.

The steps to perform concept synthesis, as described by

Walker and Avant (2005) and how the steps were followed,

are summarized in Table 1. As a first step in concept syn-

thesis and to achieve familiarity with the topic, Walker and

Avant (2005) suggest the use of all possible sources of

information to detect as many current uses of the concept

as possible. Our sources were PubMed, CINAHL, Psy-

cINFO (entries within the last 10 years (2001–2011), ‘man-

ageability’ in the title or abstract); the Google search engine

(entries within 24 months; search term ‘manageability’ in

the title), and online versions of dictionaries and thesauri

which were scanned using the search terms ‘to manage’,

‘manageability’, ‘ability’, and ‘manageable’ (Table 1). To

allow a broad perspective on concept use, the search was

not limited to any area of use.

In a second step, we listed the uses of ‘manageability’, ‘to

manage’, and ‘manageable’ as retrieved from online the-

sauri and dictionaries. Similar uses were grouped and same

uses were discarded. Abstracts retrieved from online data-

bases (PubMed, CINAHL, and PsycINFO) were scanned

for the use of ‘manageability’ and emerging groups of uses

were compared with the categories identified in online the-

sauri and dictionaries and assigned accordingly. Abstracts

were then scanned in each semantic group and included in

our synthesis if the use of ‘manageability’ provided infor-

mation on the meaning of the concept from a person’s/

patient’s perspective, if the use of the concept was either

related to health or a condition or was transferable to the

health context. The meaning of manageability was summa-

rized in each group of uses.

To extend the information on the uses of the concept

to non-scientific sources, the Google search engine was

employed and citations were scanned for additional uses

of the concept. In the next step, we combined the core

information from summarized evidence and a working

definition of the use of the concept with symptoms was

created.

© 2012 Blackwell Publishing Ltd 231

JAN: CONCEPT ANALYSIS Perceived symptom manageability

Results

Steps 1 and 2: Achieve familiarity with the topic and

identify current uses of the concept; list the uses and

combine them into meaningful clusters

Online versions of English dictionaries and a thesaurus

We accessed four different online dictionaries and one the-

saurus: Wiktionary (http://en.wiktionary.org/wiki/Manage,

http://en.wiktionary.org/wiki/manageability), Merriam-Web

ster Online Dictionary (http://www.merriam-webster.com/

dictionary), Merriam-Webster Online Thesaurus (http://

www.merriam-webster.com/thesaurus), Oxford English Dic-

tionary (http://www.oed.com), and Houghton-Mifflin Online

Dictionary (http://ahdictionary.com/word/search.html): All

electronic sources were accessed on 2 January 2012. ‘Manage-

ability’ was referred to as ‘the quality or condition of being

manageable’ (http://www.oed.com) and not further discussed

in any of the sources as a noun. Therefore, we performed all

further steps using the descriptions of ‘to manage’, mainly

described as a transitive verb with some intransitive uses

(Table 2). Uses were summarized into four broad semantic

categories: ‘to act as a manager’, ‘to control the movements or

actions of something (tool)’, ‘to exert one’s authority: control

someone (animal or human)’, and ‘to succeed in accomplish-

ing or achieving, especially with difficulty’ (Table 2). As the

only source to do so, the Oxford English Dictionary listed the

specific use of ‘to manage’ in the healthcare setting as follows:

‘to control or relieve (a disease or disorder); to look after

(a patient, case, or client) as appropriate. Also especially in

later use: to provide or coordinate (a suitable course of action

for the care of such a person)’ (http://www.oed.com).

Literature search PubMed (National Library of Medicine),

CINAHL, and PsycINFO

The literature search of PubMed, CINAHL, and PsycINFO

was performed for the years 2001–2011 with ‘manageabil-

ity’ in the title or abstract. A total of 320 abstracts were

listed, of which 86 were identified as duplicates and were

discarded, resulting in 234 abstracts for closer inspection.

Six citations were additionally discarded because ‘manage-

ability’ was not in their title or abstract. Finally, 228

abstracts were checked for the use of the term ‘manageabil-

ity’ and clustered according to the use of this term. Table 2

provides an overview on the combined uses of the concept

in dictionaries and the assignment of abstracts retrieved

from PubMed, CINAHL, and PsycINFO.

Open internet search using the Google search engine

The Google search returned 777 links when ‘manageability’

was entered. These were compatible with the already dis-

covered uses and no new uses were detected.

Table 1 Steps of the concept synthesis.

Steps described by Walker

and Avant (2005) Data source Action Process

Step 1: achieve familiarity

with the topic; identify

current uses of the

concept

Online versions

of thesauri and dictionaries

Search term: ‘to manage’,

‘manageability’, ‘ability’,

and ‘manageable’

Results of step 1

inform step 2

PubMed, Cinahl

and PsycINFO

Search term: ‘manageability

[Title and Abstract]’

Google search engine Search term:

‘manageability’

Step 2: list and combine

uses of the concept

Results from

step 1: abstracts

and definitions

Clustering of uses listed in

dictionaries and thesaurus;

reviewing abstracts, listing of

uses of manageability in

abstracts and clustering

of abstracts presenting

similar uses

Results of step 2

inform the definition

of the new use

Steps 3a and 3b: definition

of the new use

Reduced uses

(results from

step 2)

Summarizing meaning of

manageability within

semantic clusters; transfer

of uses to symptoms and

creation of the preliminary

working definition

232 © 2012 Blackwell Publishing Ltd

K. Fierz et al.

T a b le

2 S te p 2 : L is ti n g a n d co m b in in g th e u se s o f th e co n ce p t in

d ic ti o n a ri es , a ss ig n m en t o f cl u st er ed

a b st ra ct s, a n d a rt ic le s in te g ra te d in

sy n th es is .

In tr a n si ti v e u se s

C a te g o ri es

o f ‘m

a n a ge a b il it y ’

u se

li st ed

in d ic ti o n a ri es

S ea rc h re su lt s: cl u st er ed

a b st ra ct s (n u m b er

o f

a b st ra ct s)

A rt ic le s in te g ra te d in

th e w o rk in g d efi n it io n ,

re p o rt in g p er ce iv ed

m a n a g ea b il it y

T o d ir ec t a ff a ir s o r in te re st s,

b e in

ch a rg e o f (m

a n a g e a

co m p a n y )* ,†

T o lo o k a ft er

a n d m a k e d ec is io n s a b o u t‡

A ls o : to

h a n d le

o r d ir ec t w it h a d eg re e o f sk il l§

T o co n d u ct , ca rr y o n , su p er v is e,

co n tr o l‡ ,* *

‘A ct

a s m a n a g er ’

IT a n d e- le a rn in g (9 )

P ro je ct

(5 )

P ro ce ss es , n o n -m

ed ic a l (5 )

S er v ic es

(1 1 )

H a ir

(8 )

R is k (1 2 )

E k lo f (2 0 0 2 ), P et er s- G u a ri n et

al . (2 0 1 2 ), S a n n e (2 0 0 8 ),

S ta v e et

al . (2 0 0 6 )

M ed ic a l p ro ce ss es

(2 4 )

A ra p a k is et

al . (2 0 0 5 ), B er g k et

al . (2 0 0 4 ),

P er io li et

al . (2 0 0 9 )

O cc u p a ti o n a l d em

an d s

(8 )

T o h a n d le , w ie ld

(a to o l, w ea p o n )*

T o d ir ec t o r co n tr o l th e u se

o f, h a n d le

(a m a ch in e to o l) †

T o co n tr o l th e m o v em

en ts

o r a ct io n s o f (s o m et h in g )

(= co n tr o l) ¶

T o h a n d le , w ie ld , o r m a k e u se

o f* *

T o co n tr o l th e m o ve m en ts

o r

a ct io n s o f so m et h in g (t o o l) ;

M a te ri a l fo r cl in ic a l u se

(1 0 )

M ed ic a l d ev ic e (7 )

– –

T o m a k e su b m is si v e to

o n e’ s a u th o ri ty , d is ci p li n e,

o r

p er su a si o n †

T o co n tr o l th e b eh a v io u r o f (a

ch il d o r a n im

a l) †, * *

T o tr a in

o r d ir ec t* *

T o ex er t o n e’ s a u th o ri ty :

co n tr o l so m eo n e (a n im

a l o r

h u m a n )

T ra it in

ch il d re n (9 )

P ri so n er s (3 )

W o rk er s (1 )

D is a b le d p er so n s (1 )

H o rs es

(5 )

O th er

(2 )

– – – – – –

T o h a n d le

o r co n tr o l (a

si tu a ti o n o r jo b )*

T o su cc ee d in

d o in g , a cc o m p li sh in g , o r a ch ie v in g

so m et h in g , es p ec ia ll y w it h d if fi cu lt y ; co n tr iv e o r

a rr a n g e†

T o d ea l o r co p e w it h (s o m et h in g ) u su a ll y sk il fu ll y o r

ef fi ci en tl y (m

a n a g ed

th e cr is is )‡ ,* *

W it h in fi n it iv e:

to b e su cc es sf u l o r sk il fu l en o u gh

to d o

so m et h in g , u su a ll y w it h d if fi cu lt y o r in

th e fa ce

o f

a d v er si ty * *

T o su cc ee d in

a cc o m p li sh in g o r

a ch ie v in g , es p ec ia ll y w it h

d if fi cu lt y

C o n d it io n , si tu a ti o n ,

il ln es s (2 9 )

Jo h a n ss o n et

al . (2 0 0 7 ), K a ro li ch

a n d F o rd

(2 0 1 0 ),

O ls so n O za n n e et

al . (2 0 1 2 ), P o w er

et al . (2 0 1 0 ),

S u n v is so n a n d E k m a n (2 0 0 1 ), W

ik lu n d (2 0 0 8 )

S O C

(7 5 )

St ru ct u re : B er n a b e et

al . (2 0 0 9 ), B en gt ss o n -T o p s et

al .

(2 0 0 5 ), Z im

p ri ch

et al . (2 0 0 6 ), F le n sb o rg -M

a d se n et

al .

(2 0 0 5 , 2 0 0 6 )

P at ie n ts

w it h sp ec ifi c co n d it io n s: Je n se n (2 0 0 1 ),

M a lt er u d a n d H o ll n a g el

(2 0 0 4 ), N y m a n et

al . (2 0 1 2 ),

S tr a n g a n d S tr a n g (2 0 0 1 )

U se

in sc a le

(4 )

A n to n o v sk y (1 9 8 7 ); K en n ed y et

al . (2 0 0 9 );

V in ce n zi

et al . (2 0 0 9 ); R ee ce

et al . (2 0 1 0 ),

H o ll u b et

al . (2 0 1 1 )

T o ta l

2 2 8

In tr an

si ti ve

u se s

© 2012 Blackwell Publishing Ltd 233

JAN: CONCEPT ANALYSIS Perceived symptom manageability

Step 3a: Review and summarize the uses

The uses of ‘manageability’ in the abstracts basically repre-

sented the substantiated transitive uses of ‘to manage’ listed

in the online thesaurus and dictionaries and ‘manageability’

as part of the sense of coherence (SOC) (Table 2).

Finally, 21 articles corresponded to the inclusion criteria

for the concept synthesis and represented a patient/person

experience in the healthcare setting or experiences that

were transferable to this setting. Four articles referred to

the use of the concept as part of a scale. Only one study

group included PLWH (Reece et al. 2010, Hollub et al.

2011). The following paragraphs provide a summary of

concept uses in semantic clusters.

To act as a manager

From two subgroups of this cluster, i.e. risk management

and management of medical processes, we extracted

qualitative information that could be transferable to our

envisioned use of ‘manageability’.

Risk management: The authors investigating the risk-

taking behaviour of fishermen (Eklof 2002) and farmers

(Stave et al. 2006) found that the interviewees engaged in

preventive actions (safety work) if they perceived the

manageability of a risk as low. The finding was that the

interviewees generally underestimated the risk or overesti-

mated their ability to manage such a threat. After group

interventions, both groups perceived risks as less manage-

able. In another qualitative study, communities in the

Philippines were questioned about their perception of flood

hazards. Communities perceived the manageability of a

flood hazard in relation to the community’s capacity and

available coping mechanisms (Peters-Guarin et al. 2012). In

a study on the risk-taking behaviour of railway workers,

Sanne (2008) found that risk-taking was not only related to

the workers’ appraisal of risk manageability but also their

duty to provide a functioning railway to the public.

Manageability in medical processes comprised user-

friendliness, as viewed by the researchers, such as non-

invasive, frameless, and self-adhesive for an X-ray surgery

procedure (Arapakis et al. 2005). Bergk et al. (2004) found,

in a quantitative study, that the frequency and severity of

drug interactions may not be adequate dimensions to assess

the potential risk/harm. The authors state that measuring

potential outcomes irrespective of their manageability may

overestimate the risk arising from drug interactions.

In sum, manageability of a risk or threat, as applied to

studies of fishermen, railway workers, and farmers, was the

perceived ability to deal or cope with a difficult situation.

However, the concept was connected to influencing factors

T a b le

2 (C

o n ti n u ed ).

In tr a n si ti v e u se s

C a te g o ri es

o f ‘m

a n a ge a b il it y ’

u se

li st ed

in d ic ti o n a ri es

S ea rc h re su lt s: cl u st er ed

a b st ra ct s (n u m b er

o f

a b st ra ct s)

A rt ic le s in te g ra te d in

th e w o rk in g d efi n it io n ,

re p o rt in g p er ce iv ed

m a n a g ea b il it y

T o m ee t o n e’ s d a y -t o -d a y n ee d s‡

T o b e a b le

to li v e o r to

d o w h a t is

n ee d ed

b y u si n g w h a t

y o u h a ve

ev en

th o u g h y o u d o n o t h a v e m u ch

T o co p e o r g et

b y ; to

co n tr iv e to

g et

o n w it h so m et h in g

w h ic h is

b a re ly

a d eq u a te * *

T o su cc ee d (d es p it e d if fi cu lt ie s)

in a cc o m p li sh in g a

ta sk * *

In tr a n si ti v e u se

T o co n ti n u e to

ge t al o n g ; ca rr y o n

T h er e w er e n o in tr a n si ti v e u se s in

th e ci te d a b st ra ct s

* W

ik ti o n a ry .

† H o u g h to n -M

if fl in

O n li n e D ic ti o n a ry .

‡ M

er ri a m -W

eb st er

O n li n e T h es a u ru s.

§ M

er ri a m -W

eb st er ’s L ea rn er ’s

D ic ti o n a ry .

¶ M er ri a m -W

eb st er

O n li n e D ic ti o n ar y .

* * O x fo rd

E n g li sh

D ic ti o n a ry .

234 © 2012 Blackwell Publishing Ltd

K. Fierz et al.

such as personal values and social desirability. Moreover,

solely weighting the quantifiable expression of an

occurrence may underestimate the role of manageability.

Procedure manageability was used in the sense of user-

friendliness as viewed by non-patients. The semantic clus-

ters ‘to control the movements or actions of something

(tool)’ and ‘to exert one’s authority: control someone

(animal or human)’ did not provide relevant information

for our purpose.

To succeed in accomplishing or achieving, especially with

difficulty

Under this group of concept uses we assigned articles that

were related to dealing with an illness, condition, or diffi-

cult situation. For patients living with amyotrophic lateral

sclerosis, the constant fluctuation between opportunities

and limitations in an individual’s abilities made managing

the life situation challenging and difficult (Olsson Ozanne

et al. 2012). Creating a new frame of reference for inter-

preting life facilitated the manageability of the illness and

for these patients comprised developing one’s own strategies

to accept the situation, living in the present and the felt

presence and assistance from a supportive network and

authorities. For people living with a substance use disorder,

manageability of their situation was supported by

experiencing coherence in their life, confirmation and

acceptance, and gaining a sense of community and attach-

ment (Wiklund 2008). Connectedness and interactions with

a social network were also fundamental for patients with

myocardial infarction to manage their situation (Johansson

et al. 2007). Being part of a social context and meeting

adequate physical challenges were important factors

supporting the perceived manageability of the illness

situation in patients with Parkinson’s disease (Sunvisson &

Ekman 2001).

In sum, perceiving symptoms may be experienced as chal-

lenging and the main factors supporting the perceived man-

ageability of the situation were connectedness, functional

relationships, and interaction with the social environment.

Furthermore, the ability to constantly develop strategies to

adapt to the fluctuating and unpredictable physical and

mental changes due to a long-term illness emphasized the

volatility and difficulty of the situation.

Use of ‘manageability’ as part of questionnaires

There were 4 questionnaires distinctly employing the con-

cept: The Orientation to Life Questionnaire (Antonovsky

1987), The Perceived Manageability Scale (PMnac) (Ken-

nedy et al. 2009), the Multi-factor Attitude Towards Con-

doms Scale (MFACS) (Reece et al. 2010, Hollub et al.

2011), and the HIV-Symptom Manageability Scale (HIV-

SMS) (Vincenzi et al. 2009).

The Orientation to Life Questionnaire was developed to

measure the sense of coherence, which represents an indi-

vidual’s global attitude towards life and basically describes

what keeps people healthy in a hostile environment. The

SOC encompasses three explanatory concepts: making sense

of what is going on (meaningfulness), understanding (com-

prehensibility), and manageability, which is defined as ‘the

extent to which one perceives that resources are at one’s

disposal which are adequate to meet the demands posed by

the stimuli that bombard one’ (Antonovsky 1987, p. 17).

This global definition of manageability refers to life in gen-

eral and remains abstract. In the questionnaire, manageabil-

ity was operationalized as the perceived ability to trust in

oneself, trust in others, and act and control or overcome an

unpleasant situation. The Orientation to Life Questionnaire

has been employed and evaluated in diverse healthcare con-

texts and countries for many years (Abu-Shakra et al.

2006, Nabi et al. 2008, Wiesmann & Hannich 2011).

Validity evidence in terms of the structure of the question-

naire, however, is inconclusive. The 3-factor structure, as

suggested by Antonovsky, has been examined by numerous

authors: in the Finnish general population, a 1-factor solu-

tion seemed the most adequate (Bernabe et al. 2009),

whereas in patients with schizophrenia, a 4-factor solution

emerged (Bengtsson-Tops et al. 2005). Zimprich et al.

(2006) explored 1107 Swiss students, for which a 2-factor

solution was found, combining ‘manageability’ and ‘com-

prehensibility’. While the construct ‘sense of coherence’ and

the three components of comprehensibility, manageability,

and meaningfulness are well accepted, the operationaliza-

tion of the construct has been criticized and an adaptation

of scale items was suggested (Flensborg-Madsen et al.

2005, 2006).

Perceived manageability in the SOC. Patients with chronic

fatigue syndrome described their lives as increasingly cha-

otic, with lower manageability, comprehensibility, or mean-

ingfulness scores than persons diagnosed with other

enduring illnesses (Jensen 2001). Patients newly diagnosed

with a brain tumour reported that they achieved manage-

ability by actively seeking social support and information.

Despite their insecure situation, these patients constructed

comprehensibility mainly by their own theories and

thoughts (Strang & Strang 2001). Feeling part of the care

process and having personal and social resources at one’s

disposal facilitated coping with health problems among

patients attending a general practice or persons with sub-

stance use disorder (Malterud & Hollnagel 2004, Nyman

© 2012 Blackwell Publishing Ltd 235

JAN: CONCEPT ANALYSIS Perceived symptom manageability

et al. 2012). In sum, although the kind of support may dif-

fer between populations, creating a new frame of reference

to interpret life, the experience of coherence in life, and

being embedded in a community were elements contribut-

ing to the perception of manageability for all groups. The

PMnac was developed by Kennedy et al. (2009) and based

on Antonovsky’s concept to assess the manageability of

spinal cord injury, emphasizing (successful) control as the

core dimension of manageability.

The HIV-SMS (Vincenzi et al. 2009) encompasses a list

of 82 HIV-specific symptoms, medication side effects, and

non-specific symptoms that occur frequently in PLWH. To

assess their perceived ability to manage a specific symptom,

the participants were asked to rate their perception of

symptom manageability for each symptom that occurred

during the prior week on a Likert-type scale that provided

options from 1 ‘very poorly’–6 ‘very well’. However, there

was no information on the definition of perceived symptom

manageability used in the scale. The scale was piloted a few

years ago and preliminary validity evidence on the response

process and test content was established, and the generation

of further validity evidence is underway.

The MFACS (Reece et al. 2010, Hollub et al. 2011)

was developed to fill a gap in previous research on con-

dom use, which had been conducted for specific contexts

or outcomes, e.g. preventing a pregnancy or the transmis-

sion of a disease. The MFACS specifically measures con-

dom use. It encompasses 3 dimensions and covers

cognitive and emotional aspects: perceived effectiveness,

affective issues, and manageability. Condom manageability

not only refers to the actual handling of condoms but also

addresses less clearly defined issues such as dealing with

embarrassment and being a difficult topic between sex

partners.

Step 3b: Creation of the working definition

The group of uses listed in dictionaries and the thesaurus,

‘achievement of something despite difficulties’ or ‘coming to

terms/dealing successfully with difficult situations’ where a

focused, skilfully performed activity with the ultimate goal

of success was described, allowed the application of the

concept to symptoms. Symptom manageability, thus, could

then be summarized as ‘the ability to successfully handle or

deal with symptoms with a degree of skill’.

Uses of the concept identified in empirical evidence

across diverse populations emphasized the importance of

connectedness with a supportive network as a resource to

deal with a condition or a difficult situation. Moreover, the

evidence supported the individuality of the frame of refer-

ence providing the basis to evaluate the manageability of a

situation and the notion that personal strategies to meet a

constantly changing condition influenced its perceived man-

ageability.

The inspection of questionnaires using the concept accen-

tuates the relevance of ‘being in control’ of a condition or

illness situation (Kennedy et al. 2009) and the importance

of emotions and cognition (Reece et al. 2010, Hollub et al.

2011). The generic and abstract formulation of Antonov-

sky’s (1987) definition of manageability presented above

allows the concept to be concretized for its use with symp-

toms. Therefore, ‘the extent to which one perceives that

resources are at one’s disposal which are adequate to meet

the demands posed by the stimuli that bombard one’ (Anto-

novsky 1987, p. 17), served as the basis for our working

definition. The uses of the concept in diverse realms

revealed that the activation of social and personal resources

contributed substantially to the perceived manageability of

a complex situation. By integrating these aspects, our work-

ing definition of ‘perceived HIV symptom manageability’

unfolds as follows. The extent of the perceived ability to

bring social and personal resources into play to successfully

deal with/control symptoms, despite difficulties.

Discussion

There are limitations to the present study. In the almost

complete absence of evidence relating to ‘manageability’ in

PLWH, the transfer of ‘manageability’ to symptoms per-

ceived by PLWH was based on evidence from other chroni-

cally ill populations, even from areas that were not related

to symptoms or illnesses. Moreover, aspects contributing to

the manageability of a challenging situation were investi-

gated in relation to illnesses, but not to symptoms. Thus, its

adaptation to symptoms involves a certain degree of insecu-

rity and interpretation. The working definition is prelimin-

ary and needs further exploration. As it was developed

theoretically, it may be incomplete; therefore, the interpre-

tation of the concept by PLWH and the verification of the

definition relating to symptoms in this population are

important next steps. Further work needs to be done to

relate the value and position of perceived symptom manage-

ability in the broader conceptual model, integrating contex-

tual and outcome variables such as quality of life,

adherence, and social support, as conceptualized by Spirig

et al. (2005).

We undertook this concept synthesis because we realized

that the concerns of PLWH in view of living with symptoms

go beyond alleviation and that commonly used parameters to

measure management success do not sufficiently capture the

236 © 2012 Blackwell Publishing Ltd

K. Fierz et al.

patients’ perspective in view of integrating symptoms into a

daily routine and maintaining a normal life. Our working

definition of ‘perceived symptom manageability’ clearly

exceeds symptom management, which represents a provider

view (Kendall et al. 2011), by focusing on symptom control

as measured by the severity and frequency of symptoms.

‘Deal with’, as formulated in our working definition, explic-

itly integrates the possibility not only to be ‘in control of’

symptoms but also to negotiate, handle, cope with, or learn

to live with symptoms. PLWH often perceive symptoms as

fluctuating and unpredictable, creating difficult situations

that require a high degree of flexibility from PLWH and their

network (Wilson et al. 2002). The working definition of per-

ceived symptom manageability addresses this aspect by

incorporating the degree to which an individual perceives

that they have symptom management strategies at their dis-

posal and the skills to use them to live at ease with their

symptoms. Perceived symptom manageability may be espe-

cially important for symptoms that often involve a person’s

environment or threaten personal integrity. For instance, fati-

gue or vomiting (Chubineh & McGowan 2008, Jong et al.

2010) may impede social contacts or working capacity. Some

patients manage well, some do not, often unrelated to the

severity or frequency of symptoms. Also for skinny arms and

legs, both symptoms attributable to HIV treatment, and the

individual perception of manageability is only partly related

to severity or frequency. Dealing with these symptoms may

be challenging because of the stigma attached to HIV and the

threat to individual integrity inherent in unwanted disclosure

(Power et al. 2003, Reynolds et al. 2006). Assessing the

ability of a PLWH to manage these symptoms may

elucidate symptom-related areas for intervention that

complement symptom alleviation as measured by severity or

frequency.

We claim that ‘manageability’ can be defined for symp-

toms, integrates the subjective evaluation of emotional and

cognitive processes in the face of symptoms, as depicted by

Spirig et al. (2005) and Leventhal et al. (1992), and that it

can be a useful concept to identify symptoms needing man-

agement as perceived by PLWH. The use of the concept in

questionnaires targeting different populations, as well as

the different semantic usages identified in our database

search, provide evidence for the flexibility of the concept

and that its use with symptoms lies within the scope of the

concept. Although the concept is not yet used with PLWH,

there is some evidence that PLWH interpret some HIV

symptoms as threats (Power et al. 2003, Reynolds et al.

2006) or as difficult to deal with (Chubineh & McGowan

2008, Jong et al. 2010), which may impede symptom

manageability. Therefore, we claim that the concept can

also be used with PLWH to identify symptoms needing

management and negotiate strategies, which increase their

perceived ability to manage symptoms.

What is already known about this topic

● Persons living with the human immunodeficiency virus

(HIV) can be confronted with burdensome symptoms

due to the illness itself, medication side effects, and

co-morbid conditions.

● Symptoms needing management in persons living with

HIV are identified using parameters exploring the

expression of symptoms, e.g. frequency, severity/inten-

sity, and bother/distress.

● Although patients often use the expression ‘I manage

well (not well)’ when asked about their life with symp-

toms, the concept of ‘perceived symptom manageabil-

ity’ has not yet been explored.

What this paper adds

● The concept of ‘manageability’ has been used generi-

cally and specifically, but not with regard to symp-

toms; however, manageability is a concept that can be

used with symptoms.

● Manageability of health challenges is consistently asso-

ciated with the availability of a supportive social envi-

ronment and the use of personal resources.

● A working definition of ‘perceived symptom manage-

ability’, based on an open internet search and concept

synthesis, i.e. the extent of the perceived ability to bring

social and personal resources into play to successfully

deal with/control symptoms, despite difficulties.

Implications for practice and/or policy

● ‘Perceived symptom manageability’ represents a prom-

ising complement to the parameters commonly used to

identify symptoms needing management, but should

not be used without inquiring the patients’ interpreta-

tion of the concept.

● Further research exploring attributes of perceived

symptom manageability from the patients’ perspective

is needed to substantiate or refine the working defini-

tion.

● Inquiring the patients’ perception of symptom manage-

ability may elicit concerns not captured by commonly

used parameters assessing symptom severity (intensity)

and frequency and facilitate satisfactory and more

effective patient–provider interactions.

© 2012 Blackwell Publishing Ltd 237

JAN: CONCEPT ANALYSIS Perceived symptom manageability

The importance of a supportive network is evident in the

descriptions of manageability (Sunvisson & Ekman 2001,

Johansson et al. 2007, Wiklund 2008) and thus verifies the

framework suggested by Spirig et al. (2005). Healthcare

providers, among others, represent an important source of

information and support for PLWH (Holzemer 2002). Under-

standing the patient’s interpretation of a symptom by address-

ing its manageability in daily life – the aspect of dealing/living

with symptoms of the working definition –may create an envi-

ronment where healthcare providers and PLWH can establish

a true collaboration. Addressing and discussing patient wor-

ries seemed to facilitate successfully dealing with a symptom,

even if there were limited treatment options (Jenkin et al.

2006, Reynolds et al. 2006). Moreover, studies in HIV popu-

lations have shown that a positive appraisal of illness-related

phenomena supports living successfully with this chronic con-

dition (Bova 2001, Fleishman et al. 2003). However, it is

important to note that merely using ‘manageability’ will not

make the difference and the interpretation of the concept by

providers may still be different from its use by patients (Arapa-

kis et al. 2005, Perioli et al. 2009) and needs exploration. The

manageability of treatable or untreatable and visible or invisi-

ble symptoms would be an interesting area for future research

using the concept.

Emerging evidence that the perception of control and the

ability to deal with symptoms might be relevant to several

outcome measures, e.g. the quality of life or adherence,

points to the importance of our concept for future research,

and patient care. In previous studies of long-term illness

management, perceived control moderated the improvement

of self-efficacy (Jerant et al. 2008), whereas a perceived lack

of control was associated with decreased quality of life

(Sarna et al. 1999), self-care behaviour (Lovejoy et al.

1991), medication adherence (Evans et al. 2000), and

increased distress (Pergami et al. 1993).

Conclusion

The concept synthesis procedure guided our process to

explore the concept of ‘manageability’ and translate its gen-

eric use to a symptom-specific use. Our working definition of

perceived symptom manageability combines symptom con-

trol with two dimensions relating to the continuing challenge

of living with HIV symptoms: (1) the availability of social

resources; and (2) the notion of successfully dealing with

and, thus, integrating emotional and cognitive aspects. Inte-

grating perceived manageability into symptom assessment in

addition to using objective measures focusing on physiologi-

cal state represents, in our opinion, is an interesting approach

for negotiating symptoms that need management in PLWH

and identifying new, patient-defined areas for intervention.

While further research is needed, our working definition is a

promising starting point in developing a measure that might

help to improve the care of PLWH.

Acknowledgements

Mary Beth Happ, PhD, RN, FAAN, for ongoing consulta-

tion and editorial assistance; Manuel Battegay, MD, and

Jacqueline Martin, MNS, for thoughtful reviews and valu-

able input; Professors Kimberly Moody, PhD, RN, and San-

dra Engberg, PhD, RN, FAAN, for process supervision and

continuing feedback.

Funding

This work was supported by unrestricted educational grants

from Nora van Meeuwen-Haefliger Stiftung, Glaxo-Smith-

Kline AG, Merck Sharp & Dohme-Chibret, Roche Pharma

AG, Bristol-Myers Squibb GmbH, Boehringer Ingelheim, the

Swiss National Science Foundation Grant Nr 3346-100884,

and Swiss National Science Foundation Grant Nr 33CSCO-

108787, which supported the Swiss HIVCohort Study.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

All authors meet at least one of the following criteria (rec-

ommended by the ICMJE: http://www.icmje.org/ethi-

cal_1author.html) and have agreed on the final version:

● substantial contributions to conception and design, acqui-

sition of data, or analysis and interpretation of data;

● drafting the article or revising it critically for important

intellectual content.

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JAN: CONCEPT ANALYSIS Perceived symptom manageability

Attachment 4

CONCEPT ANALYSIS

Work engagement in nursing: a concept analysis

L. Antoinette Bargagliotti

Accepted for publication 17 September 2011

Correspondence to L. Antoinette Bargagliotti:

e-mail: [email protected]

L. Antoinette Bargagliotti DNSc RN FAAN

Professor

University of Memphis Loewenberg

School of Nursing, Memphis, Tennessee,

USA

ANTOINETTE BARGAGLIOTTI L. (2012)ANTOINETTE BARGAGLIOTTI L. (2012) Work engagement in nursing: a

concept analysis. Journal of Advanced Nursing 68(6), 1414–1428. doi: 10.1111/

j.1365-2648.2011.05859.x

Abstract Aim. This article is a report of an analysis of the concept of work engagement.

Background. Work engagement is the central issue for 21st century professionals

and specifically for registered nurses. Conceptual clarity about work engagement

gives empirical direction for future research and a theoretical underpinning for the

myriad studies about nurses and their work environment.

Method. Walker and Avant’s method of concept analysis was used. Nursing,

business, psychology and health sciences databases were searched using Science

Direct, CINAHL, OVID, Academic One File, ABI INFORM and PsycINFO for

publications that were: written in English, published between 1990 and 2010, and

described or studied work engagement in any setting with any population.

Results. Work engagement is a positive, fulfilling state of mind about work that is

characterized by vigour, dedication and absorption. Trust (organizationally,

managerially and collegially) and autonomy are the antecedents of work engage-

ment. The outcomes of nurses’ work engagement are higher levels of personal

initiative that are contagious, decreased hospital mortality rates and significantly

higher financial profitability of organizations.

Conclusion. When work engagement is conceptually removed from a transactional

job demands-resources model, the relational antecedents of trust and autonomy

have greater explanatory power for work engagement in nurses. Untangling the

antecedents, attributes and outcomes of work engagement is important to future

research efforts.

Keywords: autonomy, concept analysis, nurses work engagement, trust

Introduction

Work engagement in nursing is becoming strategically

important as three important factors converge: a global

shortage of nurses who are the largest group of healthcare

providers; political resolve to restrain the growth of rising

healthcare costs in industrialized nations; and a medical error

rate that threatens the health of nations. Since nurses report

low levels of work engagement (Fasoli 2010) by scoring

lower than other hospital groups (Blizzard 2005a) on

measures of work engagement, understanding engagement

is important. While the concept of work engagement emerges

from the new ‘positive psychology’ (Luthans et al. 2007,

p. 541) that focuses on human strengths, rather than

limitations, work engagement has captured global research

attention because it is amenable to change (Luthans et al.

1414 � 2011 Blackwell Publishing Ltd

J A N JOURNAL OF ADVANCED NURSING

2007). The purpose of this concept analysis is to clarify the

concept of work engagement in nursing.

Work engagement has been studied by the disciplines of

nursing, psychology, education and business in more than

one million people. The participants for these studies have

been nurses and other professionals in the US (Mackoff &

Triolo 2008a,b, Simpson 2009b, Palmer et al. 2010), Canada

(Spence-Laschsinger et al. 2006), the Netherlands (Brake

et al. 2007), South Africa (Rothman 2008), Australia (Parker

& Martin 2009), Ireland (Freeney & Tiernan 2009), Norway

(Andreassen et al. 2007, Vinje & Mittlemark 2008), Finland

(Hakanen et al. 2008a), China (Lu et al. 2011) and Spain

(Jenaro et al. 2010).

Work engagement contributes to a distinctive body of

nursing knowledge because it theoretically underpins the

actions of nurses and nurse managers as they create a practice

environment that either supports safe and effective care or

does not. According to the IOM (2003) report, the US nurses’

work environment is a threat to patient safety. Lake’s (2007)

review of 54 nursing studies of the practice environment, and

Cummings et al.’s (2010) review of 53 studies of the effects of

nursing leadership on nursing practice attest to an enduring

nursing interest in creating a practice environment that

supports safe and effective care.

Background

Clarifying the concept of work engagement is important in

nursing because as Rafferty and Clark (2009) noted, ‘The

danger with concepts like engagement is that they can

become unwieldy, fuzzily-defined terms invoked as panaceas

for the dilemmas of workforce management’ (p. 876).

Simpson’s (2009a) nursing review of the research on work

engagement concluded that there is an essential need to

differentiate the antecedents from defining attributes because

these have been interchangeably used. This conceptual

confusion has prompted four distinctive lines of research:

personal engagement, burnout/engagement, work engage-

ment and employee engagement (Simpson 2009a).

Fasoli (2010) characterized work engagement as the fifth

line of inquiry emerging from the American Academy of

Nursing’s Magnet study of the characteristics of hospitals

that attract and retain nurses (McClure et al. 1983). The

original MagnetTM study gave empirical evidence for what

came to be known as the essentials of magnetism (clinical

competence, RN/MD relationships, autonomy, support for

education, nurse manager support, cultural values and

adequacy of staffing). According to Fasoli (2010) the original

magnet research in the US was followed by a second wave

that shifted the focus to patient outcomes, a third wave that

compared Magnet designated hospital outcomes to their non-

Magnet cohorts, a fourth wave that focused on measuring the

professional environment and now an emerging fifth wave

focused on work engagement. Engagement moves beyond

retention to the strategic question of how to engage nurses in

their professional practice (Wagner 2006, Fasoli 2010). The

related concept of embeddedness points out why engagement

may or may not be related to retention. Embeddedness is an

enduring attachment to a job and work setting that occurs

because of the constellation of factors that keep a person in

one job. Links, person-job fit and the sacrifices that leaving

would entail are factors that grow over time to cause

embeddedness (Halbesleben & Wheeler 2008). In contrast,

work engagement is directly related to the work itself that

could be done in multiple settings.

A model of work engagement (Bakker & Demerouti 2008)

that is intuitively appealing and one that has captured

important research attention is one that is based on job

resources and demands (JD-R).

The job demands-resources model

The JD-R model (Bakker & Demerouti 2008) posits that in

all jobs, there are demands and varying resources to meet

those demands. Demands are the job requirements that

require employee effort to achieve. Resources are aspects of

the job that either enable the work to be done, ameliorate

work demands, reduce the personal cost of doing work, or

develop the work-related skill sets of the person (Demerouti

et al. 2001). The JD-R model posits that burnout occurs

when resources are inadequate and work engagement occurs

when resources are high. Subsequently, in a JD-R model, high

resource levels become the antecedent of work engagement.

The JD-R model is conceptually rooted in Lazarus and

Folkman’s (1984) transactional model of stress and coping

that describes stress as the outcome of situations where

demands (stressors) exceed available resources (coping).

However, as Hobfoll (1989) cogently noted, the inherent

flaw in all transactional or balance models of stress and

coping is the tautology that neither side of the equation

(demands or resources) has meaning without the other.

Conceptualizing the antecedents of work engagement as

personal and organizational resources that mediate or are

mediated by job demands has mixed empirical support as

noted in Tables 2 and 3. However, the JD-R model fails to

explain how work engagement occurs in adverse conditions

when demands are extraordinarily high and resources are

scarce as in an emergency or natural disaster. Moreover, this

transactional approach means that nurses’ work engagement

is solely dependent on the dubious outcome of a balancing act

JAN: CONCEPT ANALYSIS Engagement

� 2011 Blackwell Publishing Ltd 1415

between demands/resources. Subsequently, this relegates the

dedication of nurses, a distinguishing characteristic of the

profession (Fagermoen 1997, Pask 2005, O’Connor 2007), to

being a transactional commodity that occurs because some-

one else dispenses resources. And, work engagement becomes

externally controlled.

Method

Walker and Avant’s (2010) model of concept analysis was

used. Their eight-step model includes selecting the concept

for analysis, determining the aim, identifying uses of the

concept, determining defining attributes, constructing cases,

identifying the antecedents and consequences of the concept

and defining the empirical referents for the concept.

Data sources

The Cumulative Index of Nursing and Allied Health

(CINAHL), Science Direct, OVID (Lippincott), Academic

One File, ABI INFORM and PsycINFO were systematically

searched using the keywords: work engagement, engagement,

work engagement in nursing. The inclusion criteria included:

written in English, published between 1990and 2010, and

described or studied work engagement in any setting with any

population. Because Kahn (1990) first described work

engagement in 1990, all articles between 1990 and 2010

were reviewed against the inclusion criteria of theoretical

work or empirical studies of work engagement.

Results

The results of the concept analysis include the uses of the

concept, the definitions of engagement and work engage-

ment, the attributes, three constructed cases, the antecedents,

the consequences and the empirical referents.

Uses of the concept

The Encarta World English Dictionary North American

Edition (2009) defined engagement as: ‘agreement to marry,

commitment to attend, short job, battle, and an active or

operational state’. Engagement connotes encounter when

used in the phrase the ‘rules of engagement’. For example,

Laurence (2007) described his ostracism by soldiers when his

news reports violated their ‘rules of engagement’ or unspoken

rules of conduct about reporting from a battlefield.

Nursing has used the term ‘engagement’ as engaged

scholarship, civic engagement and clinical engagement.

Engaged scholarship describes the work of faculty who

engage students as active learners in real world settings

(engaged pedagogy), collaborate with practice colleagues to

conduct community-based research and collaborate in

practice (Burrage et al. 2005). Civic engagement refers to

the political activism of nurses to shape health policy at local,

state, national and international levels (Gehrke 2008). At a

micro level, Ellefson and Kim’s (2005) qualitative study of

Norwegian nurses revealed that clinical engagement

included: nursing approaches and movements in time, space

and perspectives; involvement as in knowing the patient; and

clinical actions that were therapeutic, caring and efficient.

Definitions of work engagement

The empirical and theoretical definitions of work engagement,

as noted in Tables 1–3, have focused either on the person/

organization interaction or on the experience of the person

who is engaged in work. Tying the efforts of the person to

organizational goals can be found in two similar definitions of

work engagement: ‘the harnessing of organizational member

selves to their work roles’ as a way of self-expression in work

(Kahn 1990, p. 694) and working collegially to meet organi-

zational goals (Seymour & Dupre 2008). However, when the

focus is shifted to the experience of the person, work

engagement is defined as a ‘positive, fulfilling work-related

state of mind’ (Schaufeli et al. 2002, p. 465) and well-being at

work that is ‘characterized by vigour, dedication, and

absorption’ (Schaufeli & Bakker 2003).

Vinje and Mittlemark’s (2008) qualitative study of com-

munity health nurses’ work engagement defined work

engagement as ‘searching for, experiencing, and holding on

to the meaningful work that enables one to lives one’s values’

(p. 200). Alternatively, Maslach and Leiter (1997) defined

engagement as the polar opposite of burnout and Shimazu

and Schaufeli (2008) as the antithesis of burnout. Efforts to

differentiate work engagement from burnout using Warr’s

(2002) four dimensions of work well-being in a study of

South African police officers did not conceptually untangle

the two concepts (Rothman 2008). For the purposes of this

analysis, Schaufeli et al.’s (2002) earlier definition of work

engagement as a ‘positive, fulfilling work-related state of

mind’ (p. 465) is used.

Defining attributes of work engagement

The defining attributes are those characteristics of the

concept that both define and differentiate the concept

(Walker & Avant 2010). ‘‘The employment and expression

of the person’s ‘preferred self’ in task behaviors that promote

connections to work and to others, personal presence.... and

L. Antoinette Bargagliotti

1416 � 2011 Blackwell Publishing Ltd

active, full role performance’’ (Kahn1990, p. 770), being

‘emotionally connected to each other’ (Harter et al. 2002a)

and ‘cognitively vigilant’ (Harter et al. 2002a) have been

described as attributes of work engagement.

Vigour, dedication and absorption (Schaufeli & Bakker

2004) have been commonly used attributes in work engage-

ment research. When work engagement is conceptualized as

the antithesis of burnout, the attributes of work engagement

become energy, involvement and efficacy as the polar

opposites of burnout (Maslach & Leiter 1997). Vigour is

the energy and enthusiasm that the person brings to the work

setting. Dedication is being devoted, inspired and believing

that the work has a purpose. Absorption is being immersed in

the work to the extent that it is difficult to leave and time

becomes less relevant (Schaufeli & Bakker 2004).

Most recently, Vinje and Mittlemark (2008) described

three inter-related attributes of nurses’ work engagement:

having a ‘calling’ (p. 198) which provides the path to

meaningfulness; zest which happens when experiencing

meaningfulness in work; and vitality, which is the ability to

hold onto meaningfulness in work. The two most commonly

agreed on dimensions of work engagement are high levels of

energy and identification with work (Bakker et al. 2008).

Vigour, absorption and dedication (Schaufeli & Bakker

2004) were selected as defining attributes of work engage-

ment because as indicated in Table 3 they have been widely

used in work engagement research (Schaufeli & Bakker 2003,

Wong et al. 2010, Jenaro et al. 2010).

Constructed cases

Constructed cases illuminate the concept by describing the

concept’s presence in a model case, the absence of a concept

in a contrary case and the differences between the concept

and a closely associated concept in a related case (Walker &

Avant 2010).

Model case

JM, BSN, CCRN has practiced for 10 years in the intensive

care unit (ICU) of an acute care hospital that also has a Level

1 trauma centre. She excitedly tells her colleague that she had

the most wonderful day because she knew that Mr T’s tidal

volume and fluids needed to be increased before his blood

gases, blood pressure and urine output continued to deteri-

orate. Her colleagues and her manager congratulate her on

seeing what they did not see. Dr J. congratulated her on her

‘good call’ and asked how she knew. She helped Mr T’s wife

find ways to ensure her husband had some uninterrupted rest.

She was able to help a younger nursing colleague who was

Table 1 Emergence of work engagement definitions, attributes and measurement.

Kahn (1990)

Maslach and Leiter

(1997)

Schaufeli et al.

(2002)

Harter et al.

(2002a)

Vinje and Mittlemark

(2008)

Definition ‘Harnessing of

organizational

members’ selves to

work roles’ (p. 694)

Opposite end of

burnout continuum

‘Positive, fulfilling

work-related state of

mind’ (p. 465)

‘Searching for,

experiencing, and holding

on to the meaningful work

that enables one to live

one’s values’ (p. 200)

Defining

attributes

Use of ‘preferred self’

(skill, talent) in

performing tasks,

presence, and

connection to others

in fulfilling role

Energy (vs. exhaustion)

Involvement

(vs. cynicism)

Efficacy (instead of

reduced efficacy)

Vigour – high energy

levels with willingness

to persist in investing

in work even during

difficult times

Dedication – enthusiasm

and identification with

work

Absorption – deep

engrossment in work

Extended engagement

model adds personal

efficacy

Emotionally

connected

to each other;

cognitively

vigilant

Calling – a path to

meaningfulness

Zest – experience

meaningfulness

Vitality – hold onto

meaningfulness

Measurement Grounded theory that

was later ‘scored’

Maslach Burnout

Inventory (MBI-GS)

(Maslach & Jackson

1981)

Utrecht Work

Engagement

Scale (UWES)

Q-12 Phenomenology

JAN: CONCEPT ANALYSIS Engagement

� 2011 Blackwell Publishing Ltd 1417

Table 2 Antecedents of work engagement.

Job demands Job resources

Personality

characteristics

Organizational

actions

Organizational

life

Job demands are ‘physical,

social or organizational

efforts of the job that

require sustained physical

and/or mental efforts’

(Demerouti et al. 2001,

p. 501) that lead to energy

depletion and exhaustion

(Schaufeli & Bakker

2004)

Job resources are

motivational. ‘physical,

social, or organizational

aspects of the job that may:

(1) function in achieving

work goals; (2) reduce job

demands and the

associated physiological

and psychological costs;

(3) stimulate personal

growth and development’

(Demerouti et al. 2001,

p. 501)

Kim et al. (2009) study

(n = 187 Subway workers

and managers in 51 stores)

of the Big 5 personality

characteristics

[neuroticism (negative

affect), extroversion,

agreeableness,

conscientiousness and

openness to new

experiences] found that

conscientiousness

positively predicted work

engagement and

neuroticism inversely

predicted engagement

Clarity of

expectations

and basic materials

and resources are

provided

Feelings of

contribution

to the organization

Belonging to

something

beyond oneself

Workload, control over

work

Reward and recognition

(ongoing weekly

feedback)

Sense of community

(collegial social

support)

Fairness as opposed to a

lack of transparency

and promotions not

handled equitably

(Freeney and Tiernan

2009)

Bacon and Mark (2009)

study (n = 146 hospitals,

2720 patients, 3718

nurses in 286 nursing

units) found that hospitals

with >5% increase in

admission and higher

complexity were

negatively related to

work engagement

Kim et al. (2009) study

(187 Subway managers

and workers) found that

skill variety and

management position were

predictive of engagement

Buoyancy (daily resilience)

is a personal belief that

one can effectively manage

problems (Parker &

Martin 2009)

(PsyCap) composite of

self-efficacy, optimism,

hope, and resilience as

greatest contributor to

organizational

commitment (Luthans

et al. 2007) (n = 167

management college

students; n = 115

engineers and technicians

of Fortune 500 company

and n = 144 insurance

company employees)

Opportunities for

growth and

development

(Harter et al.

2002b)

Recognition,

person-job fit and

energy that comes

from being valued

in a climate that

supports employee

interests/passions.

(Kerfoot 2007)

Higher levels of support

staff and of work

engagement of nurses

were related to higher

patient satisfaction

ratings

Schaufeli and Bakker

(2004) motivational job

resources are collegial

social support,

performance feedback

and coaching

Job resources leads to

work engagement which

leads to personal initiative

that leads to work-unit

innovation that leads to

personal initiative that

leads to engagement, and

predicts future resources

(Hakanen et al. 2008a)

Job control is the job

resource that leads to

work engagement

(Mauno et al. 2007)

Personal resources of

self -efficacy

Optimism

Organizationally based

self-esteem

(Xanthopoulou

et al. 2009)

Trust (willingness to

accept vulnerability and

positive expectations) in

top management,

supervisors and co-worker

engagement has a

spiralling effect in that one

leads to more of the other.

Trust is based on belief

that trustee is competent

(knowledgeable &

capable), reliable, open

(free flow of information),

and concerned (will not

behave opportunistically

and will act in trustor’s

best interest) (Chugtai &

Buckley 2008)

L. Antoinette Bargagliotti

1418 � 2011 Blackwell Publishing Ltd

Table 3 Empirical findings about work engagement.

Investigator Sample Methods Findings

Level of

evidence *

Harter et al.

(2002a)

Meta-analysis of 42

studies (n = 36

companies, 7936

business units, 198,

514 employees

Gallup Workplace Audit r = 0Æ77 between overall satisfaction and employee engagement; 70% higher

success rate of business units above

median on work engagement than those

with below the median rates of work

engagement; 103% higher rate of success

when work engagement above/below

median was compared across companies

Level 1

Spence-Laschsinger

et al. (2006)

N = 322 nurses in

Ontario, Canada

acute care hospitals

Maslach Burnout Inventory

(MBI-GS)

Areas of Work Life (AWF)

Nurses reported greatest degrees of match

in community, value congruence and

rewards and mismatch in workload,

fairness and control. 53% reported

severe burnout; Greater control was

predictive of less onerous workloads,

greater rewards, better collegial

relationships and greater sense of

organizational fairness

Level III-3

Andreassen et al.

(2007)

N = 235 Norwegian

bank employees

Workaholism Scale

(Norwegian version)

UWES (Schaufeli &

Baker 2003) Cooper

Stress Index MBI-GS

Subjective Health

Complaints Inventory

Years worked at bank and enjoyment of

work explained 29% of the variance in

Work Engagement (R2 = 0Æ29 in 2 step model)

Level III-3

Brake et al. (2007) N = 497 Dutch

dentists

Ultrecht Work Engagement

Scale (UWES)

Maslach Burnout

Inventory –General

Survey (MBI-GS)

High levels of work engagement that

persisted across age groups; Burnout

dimensions of emotional exhaustion and

depersonalization were negatively

correlated to work engagement

Level III-3

Mauno et al. (2007) (NT1 = 735; NT2 = 623)

2 year longitudinal

study

random sample of

Finnish healthcare

workers at three

hospitals in one

healthcare district

Survey

UWES

Job Insecurity Scale

Quantitative Workload

Inventory (QWI)

Job control (time and

method) Organizational

Based Self Esteem

(OBSE) Management

quality (4 items) from the

Organizational Culture

Inventory-50

High levels of vigour and dedication were

stable over time and most predicted by

job resources (control and OBSE)

Level III-3

Hakanen et al.

(2008a)

3 year cross-lagged

study (n = 2,555

Finnish dentists)

Dentists’ Experienced Job

Resources Scale (DEJRS)

3 job demands (workload,

work content, and

physical work

environment)

Family/partner Support

Scale Home Demands

UWES; MBI

Burnout, Work Engagement, Depression,

and Organizational Commitment were

stable at Time 1 (T1) and Time 2 (T2)

3 years later

Home demands/home resources did not

affect well-being factors

Job resources at T1 effected work

engagement at T2. Burnout at T1 predicted depression at T2; Lack of job

resources at T1 predicted burnout at T2

Level III-3

JAN: CONCEPT ANALYSIS Engagement

� 2011 Blackwell Publishing Ltd 1419

Table 3 (Continued).

Investigator Sample Methods Findings

Level of

evidence *

Mackoff and Triolo

(2008a)

N = 30 outstanding

nurse managers

Nurse Manager

Engagement

Questionnaire

Interview

Signature behaviours of mission drive,

generativity and/or, identification,

boundary clarity, reflection,

self-regulation, attunement, change agility,

affirmative framework were associated

with work engagement

Level III-3

Mackoff and Triolo

(2008b)

N = 30 outstanding

nurse managers

Nurse Manager

Engagement

Questionnaire

Interview

Organizational cultures of learning, regard

meaning, generativity and excellence were

associated with work engagement

Level III-3

Rothman (2008) N = 677 South African

police officers;

Stratified random

sample

Minnesota Job Satisfaction

Questionnaire

MBI-GS

UWES

Police Stress Inventory

Cynicism was related to exhaustion

(r = 0Æ59), dedication related to vigour (r = 0Æ78), lack of support was related to stressfulness of job demands

(r = 0Æ72), intrinsic job satisfaction related to extrinsic job satisfaction

(r = 0Æ61), vigour and dedication led to work engagement which is related

to work-related well-being. In a

4-factor model, job satisfaction

(r = 0Æ45) and work engagement (r = 0Æ43) were related to work-related well-being while burnout (r = �0Æ91) and occupational stress (r = �0Æ35) were not

Level III-3

Vinje and

Mittlemark (2008)

N = 11 Norwegian

community health

nurses identified as

exemplary

Qualitative analysis of

interviews

(phenomenological

interview to gather data

and hermeneutic interview

to interpret data)

Meaningfulness

Calling

Zest for work

Vitality

Level IV

Freeney and

Tiernan (2009)

N = 20 Irish nurses in

general and psychiatric

units of an acute care

hospital

Focus groups Barriers to work engagement-

Organizational life (workload, lack of

control, reward, fairness, lack of sense of

community and values conflict between

caring and hospital focus on finance

Engagement was related to intrinsic reward

of seeing patients recover, social support

from colleagues, and energy

Level IV

Simpson (2009b) N = 167

medical-surgical

RNs in 6 hospitals

UWES-9

Turnover Cognitions

Scale (TCS)

Index of Work Satisfactions

(IWS-R)

Job Search Behavior Index

(JSBI)

The combination of professional status,

interaction, and thinking of quitting

explained 46% of the variance

(P < 0Æ001) in work engagement; professional status and interaction

moderated the relationship between

thinking of quitting and work

engagement

Level III-3

L. Antoinette Bargagliotti

1420 � 2011 Blackwell Publishing Ltd

unsure about her clinical judgment, double-check her assess-

ment. She is thrilled that her task force’s work on handoffs

will be tested as a standard procedure for the hospital. She

loves nursing.

This is a model case because of the energy and enthusiasm

(vigour) JM displays in her work. Her dedication to nursing

work is exemplified by her careful attention to the condition

of her patient, her meaningful involvement of the family in

providing care, her consensual validation of a younger

nursing colleague and her work on ‘hand-offs’ to improve

nursing practice. She is absorbed in the practice of nursing.

Contrary case

TN, BSN became a nurse because her parents thought

nursing was a good profession for her. She has practiced for

2 years in a surgical unit. The unit is well staffed, she believes

her salary and benefits are excellent and she enjoys her

younger colleagues. She works nights so that she does not

have to see families or physicians and can minimally interact

with patients. She is planning to practice for only six more

months until she is married. Her job enables her to have the

time to plan and pay for her wedding.

This is a contrary case because none of the attributes of

work engagement, dedication, absorption, or vigour are

present.

Related case

AB, BSN declines the offer of another position because she

does not want to leave her current job in the ICU. She has

practiced in this unit for 5 years and knows the practice

patterns of physician and nurse colleagues. Her salary and

benefits are excellent, the hospital is close to her home and

her work schedule enables her to have the time she wants to

devote to her family. Her supervisor is not engaged in the

patient care issues of the unit because he has no background

in critical care. Nursing is a job for most of her colleagues

and she misses having colleagues who want to discuss

intriguing cases. She is dedicated to providing the best

possible care for patients but avoids asking questions that

could lead to change because that would cause problems.

Subsequently, her work is not as interesting or absorbing as

it once was.

This is a related case because it describes embeddedness, a

closely related but different concept (Walker & Avant 2010).

In this case, dedication (although limited) is the only attribute

of work engagement that is present. The excellent salary and

benefits, schedule, geographical convenience and familiarity

that anchor A.B. to this job describe embeddedness. Absorp-

tion would create questions leading to change that would

cause problems in this work setting. Enthusiasm would be

misunderstood as being too involved.

Table 3 (Continued).

Investigator Sample Methods Findings

Level of

evidence *

Jenaro et al. (2010) N = 8 nurse managers

256 RNs and 148

certified nursing

assistants (CNAs)

Modified Survey on Job

Satisfaction

(Cantera 2003)

General Health

Questionnaire (GHQ-28)

(Lobo et al. 1986)

WES (Spanish version)

13Æ3% of nurses (including CNAs) scored high on all 3 measures of work engagement.

Satisfaction with position, less social

dysfunction and less stress with patient care

explained 42% of the variance and 34Æ6% (P < 0Æ001) of the variance in vigour

Level III-3

Wong et al. (2010) N = 280 acute care

registered nurses in

Ontario, Canada

Authentic Leadership

Questionnaire (ALS)

(Avolio & Gardner 2005)

UWES-short form, Personal

identification with the

Leader (Kark et al. 2003),

Helping and Voice

Behaviors Scale (VanDyne

& LePine 1998),

International Survey of

Hospital Staffing and

Organization of Patient

Care Outcomes (Aiken

et al. 2001)

Authentic leadership directly affected trust

(b = 43, P < 0Æ001). Trust affected work engagement (b = 0Æ19, P < 0Æ001), Social identification (identification with the work

group) affected work engagement (b = 0Æ41, P < 0Æ001)

Level III-3

*National Health and Medical Research Council – Australian Government levels of evidence used.

JAN: CONCEPT ANALYSIS Engagement

� 2011 Blackwell Publishing Ltd 1421

Antecedents

Antecedents are those factors that precede the occurrence of

the concept (Walker & Avant 2010). Kahn (1990) likened

engaging in work to entering into a contract. There is

meaningfulness (a valued benefit), safety (protective guaran-

tees) and availability (resources to fulfil the contract). These

may appear to be Kahn’s defining attributes of what he

described as personal engagement (in work). However, since

Kahn’s ‘conditions’ are conditional to personal engagement

in work, they are antecedent to work engagement. As noted

in Table 2, employee personality characteristics (personal

resources) and organizational actions (job resources) have

been explored as possible antecedents of work engagement

because work engagement has been conceptualized in a job

demands/resources framework.

What must be present in the nurse’s work environment for

dedication, vigour and absorption to occur? When the

findings from work engagement studies are sifted through

the evidence about the practice environment of nurses

(Institute of Medicine 2003, Joint Commission for Accred-

itation of Healthcare Organizations 2005, Lake 2007,

Zangaro & Soeken 2007, Cummings et al. 2010), trust and

autonomy emerge as the two antecedents to the work

engagement of professional nurses.

Autonomy

Autonomy is a threshold issue for professional nursing practice

(Institute of Medicine 2003, Joint Commission for Accredita-

tion of Healthcare Organizations 2005, Chen & Johantgen

2010). The International Council of Nurses described auton-

omy as an intrinsic motivator for nurses (Manion 2009),

Fagermoen (1997) found it to be an embedded value in the

practice of Norwegian nurses (n = 6 interviews; n = 767

survey respondents), and Australian nurses ranked it as most

important in their job (Finn 2001). Zangaro and Soeken’s

(2007) meta-analysis of 31 job satisfaction studies (n = 14,567

nurses in US, Israel, England, Australia, Scotland, Canada,

Hong Kong, Sweden, Netherlands) found autonomy to have

the second highest positive effect size (ES = 0Æ30, P < 0Æ01)

with the most positive correlation (r = 0Æ39) occurring among

acute care hospital nurses.

Predictably, every grand theory of nursing is predicated on

nurses making decisions. Autonomy to make appropriate

patient care decisions is a prerequisite to having Kahn’s

(1990) availability (ability to do the job, fulfil the contract).

In the case of nurses, the contract is a social contract to give

safe and effective care. As noted by the Institute of Medicine’s

(2003, 2010) reports, the nurse’s personal availability (skill

set to do the job) has too often been stymied by organiza-

tional or systemic constraints.

From a business perspective, Drucker (1993) asserted that

autonomy and recognition of expertise are essential to

‘knowledge workers’ (p. 6) who use their specialized knowl-

edge to achieve work goals. He described teachers as the first

knowledge work professionals to emerge at the beginning of

the 20th century and nurses as the second (Drucker 2002).

The pernicious effects of diminished nursing autonomy can

be found in the results of a 2009 Gallup poll of US national

opinion leaders (n = 1500) across government, business, and

health care [Robert Wood Johnson (RWJF) 2010]. They

ranked nurses second to physicians as the most trusted source

of healthcare information in the US and next to last (patients

being last) in their influence over US healthcare reform over

the next 5–10 years (Robert Wood Johnson Foundation

2010).

Pink (2009) described autonomy as self-direction that leads

to work engagement. Autonomy requires having choice over

the ‘4-T’s’ of task, time, technique and team (Pink 2009,

p. 94). As Pink (2009) observed, management is an invented,

rather than a naturally occurring phenomenon. Management

is based on the notion that people act when prodded to do so

and stray from a circumscribed path without direction to stay

on task. Conceptually and pragmatically, prodding and

directing squelch work engagement. From a business

perspective, the outcomes of autonomy can be found in

post-it notes, a 3M product that was developed by a scientist

in his 15% ‘doodling time’; in the successes of Atlassian, a

$35 million Australian company that grew by 168% last

year, that now devotes 20% of its engineering time to

projects that are of the engineers design and choice; and in

G-mail that was developed in Google’s ‘20% free time’ as are

half of Google’s annual innovations (Pink 2009).

Trust

Trust, the second antecedent of work engagement in nursing,

is salient for nurses because integrity is legally demanded and

central to the ethical comportment of nurses. Subsequently,

trust is a fundamental expectation that nurses have of their

practice setting. However, Altuntas and Baykal’s (2010)

study of Turkish acute care hospital nurses (n = 482) found

that nurses minimally trusted the hospital while highly

trusting their managers and colleagues. Since trust in the

institution moderately correlated (r = 52, P = 0Æ000) with

the civic virtue (concern and active involvement in the life of

the organization) of these nurses, Altuntas and Baykal’s

(2010) findings suggest why institutional trust is also impor-

tant to the organization.

L. Antoinette Bargagliotti

1422 � 2011 Blackwell Publishing Ltd

Jameton (1984) underscored the salience of trustworthy

practice environments to nurses when he asserted that nurses

experience moral distress ‘when one knows the right thing to

do, but institutional constraints make it nearly impossible to

pursue the right course of action’ (p. 6). When nurses practice

in healthcare systems where the mission to give safe, effective

care is subverted for financial gain, nurses find themselves as

the only trustworthy actors in an untrustworthy environ-

ment. The IOM (2003) study found a wide spread loss of

trust among American nurses in hospital organizations

because nurses believed that efficiency initiatives had over-

shadowed patient safety. Canadian nurses (random sample

n = 388) reported that their highest intensity of moral distress

was working with unsafe RN levels (Pauley et al. 2009). At

the heart of contemporary nurses’ concerns is that financially

driven healthcare shreds the nursing safety net and erodes the

enduring social contract that nursing has with its public.

Australian nurses described the substitution of RNs in the UK

with healthcare technicians as a crisis that placed patients at

risk (Shields & Watson 2008). This central concern of nurses

is echoed by 60% of the American public who ‘do not trust

hospitals to do the right thing for patients’ (King & Moran

2006, p. 3) and who believe hospitals ‘place economics ahead

of patient care’ (p. 5). Freeney and Tiernan’s (2009)

qualitative study of Irish nurses found that the values conflict

between patient care and organizational financial constraints

was a barrier to work engagement.

For the purposes of this concept analysis, trust is the

willingness to be vulnerable to another because the other is

‘competent, reliable, open and concerned’ (Mishra 1996,

p. 265). In Mishra’s (1996) definition of trust, the willingness

to trust or be vulnerable to another is conditional upon the

other acting in competent, reliable, open and concerned

ways. Work engagement requires creating a culture of trust at

all organizational levels (Chugtai & Buckley 2008, Macey

et al. 2009).

Trustworthy organizations act reliably when they make

decisions that support the stated mission. They act compe-

tently to improve the organization, are open in their processes

and demonstrate concern by acting in the best interest of

employees and following-through on promises (Gardner et al.

2005, Denham 2006, Chugtai & Buckley 2008, Wong &

Cummings 2009). Trustworthy managers are competent and

act reliably when they give good advice and guidance. They

act fairly and impartially to all employees, are available to all,

are open to the uninhibited flow of ideas and act in the best

interests of employees (Chugtai & Buckley 2008). Wong

et al.’s (2010) study of Canadian nurses (n = 280) found that

trust in the manager directly affected work engagement.

Wong et al.’s (2010) finding that social identification

(identification with the work group) had the greatest effect

on the work engagement of nurses underscores the vital

importance of trusting collegial relationships.

In trusting collegial relationships, colleagues are compe-

tent. Vital information can be openly shared because it will

not be misused in harmful ways. Colleagues demonstrate

concern for each other by working together through difficult

times (Chugtai & Buckley 2008, Freeney & Tiernan 2009).

Collegial supportive relationships among nurses that value

individual contributions is one of the prescribed characteris-

tics of professional nurses in the American Association of

Critical Care Nurses (AACN) Synergy Model (Hardin 2009)

of nursing practice at the bedside.

All these dimensions of trust (organizational, managerial

and collegial) are reflected in four of the five factors in

Olson’s (2010) Hospital Ethical Climate Survey (HECS):

‘peers willingness to listen to concern about patients’ care, ....

managerial support, shared sense of mission, and trust’

(p. 345). Trust is an antecedent of work engagement for

nurses because it frees intellectual capital to be directed

towards work, rather than towards protecting self from the

effects of poor decisions by others.

Consequences

There are organizational and personal consequences of the

work engagement of nurses. A Gallup study of outcomes in

more than 200 hospitals found that the work engagement of

Registered Nurses was the primary predictor (P < 0Æ05) of

mortality variance among hospitals and patient complication

rates (Blizzard 2005b).

Increased levels of personal initiative (PI) that extend

beyond the formal requirements of work have been found to

be an outcome of work engagement. In a study of 2555

Finnish dentists, PI predicted perceptions of work-unit

innovativeness suggesting the contagiousness of work engage-

ment (Hakanen et al. 2008a). Personal initiative differs from

absorption, an attribute of work engagement, because

personal initiative means taking an innovative or new action

or approach. Absorption refers to being immersed in a

subject, in this case, nursing practice.

In the Gallup meta-analysis of 955,905 respondents in the

US and 23 other nations, work engagement accounted for

78% of the variance in profitability across 17,339 business

units (Harter et al. 2009). Those business units with higher

levels of work engagement had a 94% higher success rate in

their own organization and a 145% higher success rate across

organizations (Harter et al. 2009). Harter et al. (2009) found

that work engagement/disengagement ratios of 9Æ57:1 are

found in the most successful companies in comparison to the

JAN: CONCEPT ANALYSIS Engagement

� 2011 Blackwell Publishing Ltd 1423

ratio of 1Æ83:1 that occurs in average companies. Gallup

estimated that a consequence of disengagement is a produc-

tivity loss in the US alone of $300 billion annually.

Empirical referents

Empirical referents are the processes that can be used to

measure the concept (Walker & Avant 2010). All the mea-

sures of work engagement are self-reported survey instru-

ments. The Ultrecht Work Engagement Survey (UWES)

(Schaufeli & Bakker 2003) has a 17-item long form, a 9-item

short form available in 22 languages and a student form

available in three languages that measures vigour, dedication

and absorption.

The Q12, originally referred to as the Gallup Workplace

Audit (GWA), is a 12-item instrument (Harter et al. 2002b)

that measures dedication, absorption, vigour and collegial

and managerial support, autonomy and essential resources

(Harter et al. 2002b).

Discussion

A limitation of this concept analysis is that the empirical

work was not limited to studies of nurses, who may have

differing levels of professional commitment than do other

professionals or occupational groups. History is also an

important limitation of this analysis as the climate for nursing

practice is in flux as economic conditions change.

The use of concept analysis as a methodology, specifically

Walker and Avant’s (2010) model, is a limitation of the study

(Morse 1995, Paley 1996, Penrod & Hupcey 2005, Duncan

et al. 2007, Beckwith et al. 2008, Risjord 2009). However, as

Simpson (2009a) noted, it is the lack of conceptual clarity

about work engagement that has resulted in multiple lines of

inquiry with mixed results.

Understanding work engagement in nurses, the largest

health professional group in all nations, is critically impor-

tant. Underscoring the pragmatic urgency of this issue are the

error rates in care reported by sicker adults who had received

health care in the past 2 years: Australia (n = 702, error

rate = 27%); Canada (n = 752, error rate 30%); New

Zealand (n = 704, error rate = 25%); the UK (n = 1770,

error rate = 22%); the US (n = 1527, error rate = 34%); and

Germany (n = 1503, error rate = 23%) (Schoen et al. 2005).

The IOM (2003) reported that the work environment of US

nurses was ‘a threat to patient safety’ with ‘threats [that] are

found in all four of the basic components of all organizations-

organizational management practices, workforce deployment

practices, work design, and organizational culture’ (Execu-

tive Summary, p.3).

When the definition of work engagement is combined with

its antecedents and consequences, a formal definition of work

engagement emerges. In nursing, work engagement is the

dedicated, absorbing, vigorous nursing practice that emerges

from settings of autonomy and trust and results in safer, cost

effective patient outcomes. From this definition, work

engagement can be developed as an explanatory middle

range theory that conceptually captures the concerns that

nurses have about their work environment. The assumptions

that underlie work engagement, the linkages between the

antecedents of autonomy and trust and the relationship of the

antecedents of trust and autonomy to the closely related

concepts of transformational and authentic leadership styles

are some of the remaining areas to be developed in a middle

range theory.

A middle range theory of work engagement could explain

the dedication, absorption and vigour of nurses that are

What is already known about this topic

• Work engagement is the important question for all professionals.

• Nurses’ levels of work engagement are lower than those for other hospital groups.

• The enduring shortage of nurses, growing political pressures to stem healthcare costs, and medical error

rates create a climate that underscores the importance of

work engagement.

What this paper adds

• The attributes of work engagement are vigour, dedication and absorption.

• Trust (organizationally, managerially and collegially) and autonomy are the antecedents that have

explanatory power for work engagement in adverse

situations.

• The outcomes of work engagement are higher levels of personal initiative, decreased hospital mortality rates

and higher financial profitability for organizations.

Implications for practice and/or policy

• The work engagement of nurses is enhanced in trustworthy practice settings that value the autonomy of

nurses.

• The antecedents for work engagement are relational ways of behaving and being, rather than resources that

can be transacted.

• Safe patient care requires the engagement of nurses in their practice.

L. Antoinette Bargagliotti

1424 � 2011 Blackwell Publishing Ltd

strategically important to the profession and to the patients

who seek nursing care. The antecedents of work engagement,

trust and autonomy, are amenable to change and highly

congruent with intrinsically held professional nursing values.

Conclusions

Creating practice environments that fully engage nurses in

their practice is a central issue for the nursing profession, a

safety issue for patients, and an important economic issue for

all the nations. Since the antecedents of work engagement are

relational rather than transactional, they have no financial

costs. These antecedents shed important light on the direction

that healthcare organizations, nurse managers and nurses can

take to create a work environment that supports the work

engagement of nurses.

This concept analysis provides a clearer direction for future

research in the work engagement of nurses and a theoretical

underpinning for the myriad studies of the work environment

and MagnetTM forces.

Conflicts of interest

No conflict of interest has been declared by the author.

Funding

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

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JAN: CONCEPT ANALYSIS Engagement

� 2011 Blackwell Publishing Ltd 1427

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of

evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance

and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original

research reports and methodological and theoretical papers.

For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan

Reasons to publish your work in JAN:

• High-impact forum: the world’s most cited nursing journal and with an Impact Factor of 1Æ540 – ranked 9th of 85 in the 2010 Thomson Reuters Journal Citation Report (Social Science – Nursing). JAN has been in the top ten every year for a decade.

• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries worldwide (including over 3,500 in developing countries with free or low cost access).

• Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan. • Positive publishing experience: rapid double-blind peer review with constructive feedback. • Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication. • Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley

Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).

L. Antoinette Bargagliotti

1428 � 2011 Blackwell Publishing Ltd

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