Support in nursing—An evolutionary concept analysis

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International Journal of Nursing Studies 44 (2007) 1478–1489 www.elsevier.com/locate/ijnurstu

Support in nursing—An evolutionary concept analysis Peter Stoltza,, Ewa Pilhammar Anderssonb, Ania Willmanc a School of Health and Society, Malmo¨ University, Malmo¨, Sweden Institute of Health Care Sciences, The Sahlgrenska Academy, Go¨teborg University, Sweden c School of Health Science, Blekinge Institute of Technology, Karlskrona, Sweden

b

Received 23 February 2006; received in revised form 20 June 2006; accepted 13 July 2006

Abstract Background: This research into the concept of support was undertaken because of the recurrent use of the concept in nursing research and especially because of the vital importance of support to family carers of older persons. Aim: To inductively develop a definition of support, specifically in the context of family care of frail aged persons. Method: The study followed the evolutionary method of concept analysis. The study was based on data from scientific publications, encyclopaedias and dictionaries. In order to secure a representative sample, highly systematic means of sampling were used. Results: Working with the data underpinning this study, it was possible to put forward a definition of support for family carers who care for a frail aged person at home. The two major dimensions, as described under attributes, were merged into the following definition: ‘‘Support entails the provision of general tangibles such as information, education, economic aid, goods and external services. They are prerequisites for facilitating the family carers’ competence or capacity in care. Moreover it entails necessary qualities such as individualization, adaptability, lastingness, room for verbalizing emotions as well as an idea of reciprocal symmetrical exchange between involved parties. r 2006 Elsevier Ltd. All rights reserved. Keywords: Support; Family carers; Caregivers; Concept analysis

What is already known about the topic?

What this paper adds

 Although much research on support has been done in

 Within family care support appears to have two main



the family care area, the concept remains ambiguous in meaning and difficult to conceptualize. Caring for an older person at home is a situation common to many adults worldwide. Support is recurrently presented as one vital issue for these family carers, but is rarely explicitly defined in studies.

 Corresponding author. Tel.: +46 703 56 98 00;

fax: +46 40 665 81 00. E-mail address: [email protected] (P. Stoltz). 0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.07.014

dimensions: The tangible, concrete and general impersonal dimension which is about increasing family carers’ capacity to care. The intangible, abstract and highly individual dimension is about family carers unburdening their minds to a dedicated other. Nursing scientists may have been careless or unreflecting regarding the multidimensionality of the concept of support when studying family caring of frail aged persons.

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1. Introduction Nursing research and practice rest on a basis of knowledge which may further expand and develop through conceptual inquiry (Asp and Fagerberg, 2005). If conceptualized the concepts can function as tools, illuminating issues and queries in practice as well as in research (Rodgers, 2000). This study was initiated with the intent to explore the concept of support within nursing. The rationale for this was that support, in spite of its everyday and wide use, remains a complex concept. One complicating issue, for example, is that it overreaches several disciplines, including nursing. Other disciplines, close to nursing, that recurrently apply the concept of support are: sociology, epidemiology, psychology, medicine and education. However, the meaning of the concept may vary depending on the discipline. Furthermore, its use does not seem to be declining. On the contrary, the concept of support is currently used repeatedly within nursing, particularly if, as here, put in relation to family carers or family caring. Consequently, for the above reasons, a conceptual inquiry into the concept of support in nursing appears an appropriate thing to do. In nursing, the concept of support has shown to be useful within several areas of the discipline. One of these is the area of family care of older people where interventions labelled support have been tested to balance the poor well-being, depression or coping ability that family carers struggle with when caring for an aged relative at home (cf. Andre´n, 2006; Larson et al., 2005). To resolve these health problems, small short-term interventions are tested and re-tested by researchers in search of evidence of effectiveness. Finding the ‘‘solution’’ or the Support with a capital ‘‘S’’ is highly attractive for several reasons. One of them is that it is now relatively safe to assert the unlikelihood of the formal healthcare system in any country being able to assume total responsibility for providing healthcare to older people (Lyons and Zarit, 1999). This is a global issue with few, if any, exceptions. Besides the issue of evidence of effectiveness, the current status of knowledge concerning support within nursing leaves many more interesting questions unanswered. For example, although there is research into support for family carers (Lui et al., 2005; Rahm Hallberg and Kristensson, 2004; Higginson et al., 2003; Opie et al., 1999), there is an important lack of studies seeking a deeper understanding of the experience of support as it is lived (cf. Stoltz et al., 2006). It is also noteworthy that support in nursing research is seldom clearly defined, and instruments evaluating support vary and can be criticized for appearing arbitrary (cf. Stoltz et al., 2004). These inconsistencies may obfuscate rather than facilitate research into support for family carers. Consequently, there is a need for conceptual clarity and

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increased knowledge in nursing concerning the concept of support. The development of a definition may serve as one point of departure in understanding more about the queries surrounding support in nursing. An appropriate way of developing such a definition is to conduct a concept analysis. If based on systematic and rigorous procedures a concept analysis may help to shed additional light on prior theoretical discussions of the concept and provide a solid base for further research and nursing practice (cf. Rodgers, 2000).

2. Aim The aim of this study was to inductively develop a definition of support in the context of family care of frail aged persons.

3. Method This study follows the evolutionary method of concept analysis as developed by Rodgers (2000). This approach has fundamental differences from, and was developed in response to the criticism of, earlier approaches to concept analysis (cf. Walker and Avant, 1995). Early methods of concept analyses have been critiqued for containing serious flaws as well as misunderstandings as regards the relationship between concept and theory, and for not taking contextual factors into consideration (Paley, 1996). In these early methods, concepts are viewed as static, finite, absolute, crystal clear and the definition of the concept as a natural endpoint (Rodgers, 2000). Early methods proceeding from an essentialist point of view may be questionable from a theory of knowledge perspective if knowledge is instead viewed from temporal, social constructivist and dynamic angles. The evolutionary view appears more contemporary as concepts are considered dynamic and without a final endpoint definition-wise. The evolutionary view is also consistent with the idea of a heuristic cycle of continuously developing results. Concepts are considered to be influenced by time and context, where contexts are discursive, theoretical, cultural, social or disciplinary (Rodgers, 2000). The evolutionary method of concept development specifically underlines concepts as being dynamic and changing over time and context. Also, the evolutionary method acknowledges the existence of vast interrelationships among phenomena and associated concepts. The method emphasizes rigorous and systematic study and the heuristic value of the results and encourages an analysis based on interview data as well as literature (Rodgers, 2000). In order to analyse the concept of ‘‘support’’ and its consistent components in accordance

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with the evolutionary view of concept analysis, this study progressed as follows: After choosing the setting and sample for data collection the searches for data and selection process were initiated. Criteria for inclusion and exclusion of data conformed to the setting and sample. The data was analysed from the following points of departure: ‘‘Support’’ in encyclopaedias and dictionaries, attributes of the concept, antecedents of the concept, consequences and endpoints. Thereafter, a definition was derived and a model case formulated. This was finally followed by a theoretical analysis. 3.1. Searches for data and selection process In this study, literature, particularly the scientific literature, was deemed to be relevant as data for the identification of attributes of the concept of support. The concept of support within the family care context specifically chosen for this study seems to balance between nursing science and sociology. Therefore, data was searched for within the respective databases of these two disciplines. Moreover, this partially satisfies an interdisciplinary dimension as recommended when following the evolutionary approach to concept development. Apart from scientific databases, encyclopaedias and dictionaries were also searched with regard to the concept of support. In the searches for data through encyclopaedias and dictionaries, the possibilities to combine search words were highly limited or even non-existent. Hence, ‘‘support’’ as a title word was considered a sufficient demarcation. The encyclopaedias and dictionaries searched were: The Swedish National Encyclopaedia, Merriam Webster Online, Gale Virtual Reference Library, International Encyclopaedia of the Social and Behavioural Sciences, Oxford Reference Online, The Oxford Dictionary of English, and The Swedish Academy Dictionary. Combined these encyclopaedias and dictionaries rendered a total of 596 hits, which were reviewed. As regards the scientific database searches, the primary search tem ‘‘support’’ was combined with additional search terms used for the purpose of directing the searches towards the context of aged family care. These additional terms were: aged, ‘‘aged 80 and over’’, ‘‘frail elderly’’, ‘‘family care*’’, ‘‘informal care*’’, ‘‘lay care*’’ and caregivers. In order to be eligible for inclusion in this study the scientific literature had to focus on situations where family carers care for a frail aged (465 years of age) person at home. Furthermore, to increase the specificity and relevance of the searches, it was decided that the primary search term should appear in citation title and additional search terms should at least appear in title and/or abstract. Once the scientific literature searches were terminated and the literature was identified, the data from each

scientific database was organized into two separate reference lists using the software EndNote ver. 7.0. One list was created for nursing science (Cinahl, Medline, Psychinfo, The Cochrane Library of Systematic Reviews) and one list for sociology (Sociological Abstracts and Social Science Citation Index). The data were then screened for eligibility at title level and duplicate citations were discarded. At this point 584 citations from the nursing science list and 332 citations from the sociology list remained. Next, the data was sorted by publication date and standard means of probability sampling was employed using SPSS version 12.0. This allowed for a stratified random sample to be drawn from each reference list. Furthermore these processes were attuned to temporal aspects as each list was sorted by publication date. Each stratum represented 20% of the acceptable citations (cf. Rodgers, 2000). After the random selection process 117 citations from the nursing science list and 66 citations from the sociology list remained. Lastly, two of the authors (PS & AW) independently reviewed all abstracts of the randomly selected citations in order to assess which citations should finally be included. Matching citations were immediately retrieved, whilst mismatches were carefully reviewed a second time by PS, who was in charge of the final data selection process. In the end, a total of 18 citations from the nursing science list and 20 citations from the sociology list were finally included rendering the total sum of 38 citations altogether. The data selection process aimed at being inclusive but balancing sensitivity and specificity enough to be manageable (Table 1).

3.2. Criteria for inclusion and exclusion As regards criteria for inclusion, studies should be attuned to the chosen contextual aspects of support for family carers who care for a frail aged person (465 years of age) at home. Consequently reasons for exclusion chiefly pertained to studies focusing on children as cared for persons as opposed to aged persons, or an out-of-home setting such as intensive care units. Studies that did not focus on family carer support, such as studies about life-support/resuscitation or studies about burnout and ethical issues, were also excluded. Likewise excluded were studies based in a sociocultural setting whose comparability or non-comparability with a Scandinavian context was beyond the authors’ ability to assess. Examples of such excluded studies proceeded from a setting in China, Hong-Kong, Jamaica, Malaysia, Singapore, South Africa, Tanzania or Thailand. Studies with no abstract available, incomplete citations or articles in other languages than English or Scandinavian languages were also excluded. All

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Table 1 Overview of the scientific data identification and selection process Data searches in scientific databases CINAHL MedLine PsychINFO The Cochrane Library (Discarded duplicates) Sum Sociological Abstracts Social Science Citation Index (Discarded duplicates) Sum

Total number of hits 482 413 312 37 1217 141 848 989

searches for data were performed during October in 2005.

Acceptable

Random selection

Items finally included

249 230 168 2 ( 65) 584

117

18

80 279 ( 27) 332

66

20

prehensive system of descriptors was reached (Rodgers, 2000).

3.3. Data analysis 4. Analysis and results In encyclopaedias and dictionaries, a total of 596 items were identified through searches, all of which were reviewed. A synthesis of the findings from this review is reported below. As regards the data identified through scientific database searches, a total of 38 citations were finally included, which were retrieved as full-text documents. These scientific data were all subjected to a review aimed at identifying the attributes, antecedents, consequences, related concepts and surrogate terms of the concept (cf. Rodgers, 2000). The emphasis in the evolutionary method is on inductive discovery focused on identification of relevant aspects of the concept. The researcher reviews the literature to identify data relevant to the attributes of the concept and its contextual features (antecedents, consequences, sociocultural and temporal variations), surrogate terms, related concepts and application of the concept. This process was facilitated by the construction of a ‘‘data collection sheet’’. This sheet was photocopied into several separate sheets, one for each scientific data full-text document, where attributes, antecedent, consequence and verbatim passages were noted whilst reviewing. Each item was carefully read to identify the ‘‘general tone’’ of the work and concept use (Rodgers, 2000). The handwritten passages from the review process were transcribed verbatim and sorted into three different tables labelled: attributes, antecedents and consequences. Each category of data were examined separately. Antecedents and consequences were synthesized into a cohesive text, whereas attributes were analysed to identify major themes as presented through the data. Hence, a thematic analysis of the data collected as attributes was employed. This phase entailed an organizing and reorganizing of similarities until a cohesive and com-

4.1. ‘‘Support’’ in encyclopaedias and dictionaries From encyclopaedias and dictionaries it is clear that support is a diverse word which can take on the form of a noun, verb or adjective. Support is widely used within different fields and the general tone as regards the meaning of support can be summarized by the following descriptors as derived from the concise Oxford Dictionary of Current English (Allen, 1990). Support means ‘‘to be carrying all or part of the weight of something’’. It can mean ‘‘to keep someone from falling, sinking or failing or to provide someone with a home and the necessities of life’’. Support can mean ‘‘to enable someone to last out, give strength to, encourage’’. It can mean ‘‘to endure, tolerate, bear out or tend to’’. Support can also mean ‘‘to give help or countenance to, back up, second, to speak in favour of or to be actively interested in’’. Support can be about ‘‘assisting a person by one’s presence’’. It entails the act or an instance of supporting, ‘‘the process of being supported as well as a person or thing that supports’’. The Internet-based ‘‘Oxford Reference Online’’ provided this study with subject areas of support, hence making it possible to identify and divide uses and meanings of support into different fields. The identification of these fields shows that support is diverse and widely used within for instance ‘‘arts and architecture’’ (to serve as a foundation for, the solid substance on which a painting is executed). In ‘‘economics and business’’ (a customer hotline or direct consultation, the purchase of shares or bonds to prevent a drop in prices or fall of exchange). The concept is also used in the ‘‘judicial system’’ (the obligation of a person to

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provide economically for child or former spouse) and ‘‘the military’’ (sustain another force or provide assistance to mission by seaborne/airborne operations) as well as in ‘‘medicine and healthcare’’ (maintenance of the vital functions of a critically ill or comatose person; keeping a body part still for the purpose of healing, tissues contributing to firmness or stability). Support is used in ‘‘computing’’ (programs that assist in the operation of a system without performing the primary function) and ‘‘earth and environmental sciences’’ (the prevention of soil from moving along a hillside or slope, additional feedstuff for wildlife, construction aimed at keeping trees upright). In humankind (vocal or musical technique which produces a tone, specific tutoring for children with special needs, to argue/vote for, to favour actively one that meets opposition, to lend assistance to one who is failing or falling, to publicly defend one unjustly attacked or too weak to advocate her/his own case). In the dictionary of synonyms and antonyms Spooner (1999) makes a distinction between synonyms of support using headings: ‘‘financial support’’ (expenses, funding); ‘‘to support someone in trouble’’ (be faithful to, champion, defend, comfort, encouraged, stick up for, stick with, buoy up); ‘‘support a point of view’’ (accept, adhere to, advocate, agree with, defend, endorse, explain). Also, ‘‘to support oneself’’ means to be leaning or resting, whereas the antonyms of support are to subvert or weaken (Spooner, 1999). The encyclopaedias and dictionaries may be useful to illuminate the diversity and wide range of situations and contexts in which support is used. However, through the encyclopaedias and dictionaries the image of support was more splintered than streamlined, which consequently was of little use here. 4.2. Attributes of the concept At first, the overall impression of the data identified through the scientific database searches reflects the many readings of the term support, which can be represented by the following headings: ‘‘The inconsistent and multiple readings of the term support’’ and ‘‘The great number of prefixes and suffixes to the term support’’. 4.2.1. The inconsistent and multiple readings of the term support One distinguishing feature identified through this attempt to derive a definition of support from the data included in this study was the inconsistent and multiple readings of the term support that researcher’s used in their projects. In other words, what constitutes support and its fundamental nature is either still relatively unexplored or is complex to articulate in a way that is generally acceptable. In one study included here as data,

the authors claimed that varied definitions have gone unnoticed for too long, and these have caused misunderstandings (Thompson et al., 1993). Another instance which adds to the complexity of attempting to define support within this context is that authors occasionally use the term support to describe that which occurs between formal/trained caregivers and the family carers as well as that which occurs between the family carers and the cared-for persons (Cummings, 1996; Lincoln et al., 2003). Moreover, in some cases support is used to describe both the intervention and the outcome in the same trial (Marziali et al., 2005). About one fourth of the scientific studies included here have been explicit with their conception of support in the form of a definition. The level of these definitions has been of varying detail and has either been formulated by the authors themselves or a reference has been used, like for instance House et al. (1988). By way of these definitions authors appear to agree that, although its meaning can vary, ‘‘social support’’ would be the umbrella term of choice (Gottlieb, 1991; Hibbard et al., 1996; Kirschling et al., 1990; Meagher Stewart and Hart, 2002; Schwarz and Roberts, 2000; Shaw, 1997; Thompson et al., 1993). The variety and obfuscation as regards the concept of support are likely to be found at a lower level of abstraction, in other words, at the level of specific constituents, or contents of social support. Social support seems to encompass almost as many dimensions as there are conceivable prefixes and suffixes. Consequently social support can mean nearly anything. 4.2.2. The great number of prefixes and suffixes to the term support One way of illustrating the multiplicity of meanings existing in the family carer support literature is to highlight the great number of prefixes and suffixes used in relation to the term support. These are used in combination with support and often also consequently alter its conceptual meaning. Looking at the included scientific literature collectively, one can see that some of the recurrent prefixes to the term support are: appraisal, available, community service, conjugal, direct, educational, emotional, esteem, family, financial, fiscal, friend, general, indirect, informational, intimacy, instrumental, nursing, perceived, respite, social, workplace (Gottlieb, 1991; Ham, 1999; Hibbard et al., 1996; Jegermalm, 2002; Kirschling et al., 1990; Koopmanschap et al., 2004; Lechner, 1993; Meagher Stewart and Hart, 2002; Molinari et al., 1994; Richmond et al., 1987; Thompson et al., 1993; Todd et al., 2002). Correspondingly, some recurrent suffixes to the term support are: groups, persons, network/s, organization (Edgar et al., 1996; Gilbar, 1997; Gottlieb, 1991). In addition to the overall impression described above, a closer look at the meaning of the concept of support reveals two dialectically interconnected dimensions

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which can also be represented by two headings. They are described below. They represent that, on the one hand, the meaning of the concept of support expresses a dimension that is very tangible, concrete but residing at a general impersonal level. There, support appears as goal-oriented mainly towards increasing the family carers’ caregiving capacities or competence (Heagerty et al., 1988; Koopmanschap et al., 2004). On the other hand support also comes through as something occurring at a more intangible and abstract level with a drive to be attuned to family carers’ needs at an individual and highly personal level. There, support is what happens in meetings between human beings, co-created, as opposed to a service given and received. 4.2.3. The tangible, concrete and general impersonal dimension is about increasing family carers’ capacity to care Within this dimension support can be defined in studies as the total level of assistance or any all services given (Cummings, 1996; Hibbard et al., 1996; Lechner, 1993). The ‘‘pattern’’ of support is more or less directly aimed at the family carer. Support is portrayed as a service that can be given and received, appearing mostly as a formal service defined by tangibles such as visits, telephone calls, home help services, planning care, financial services, day-care services, training (Edgar et al., 1996; Jegermalm, 2002, 2003; Mant et al., 2005; Synak, 1989; Thompson et al., 2005; Tilling et al., 2005). In several cases support for family carers is really about increasing family carers’ caregiving capacity or competence. This is seen as achieved by strategies based on the following underpinnings: respite care (Ham, 1999; Montgomery and Borgatta, 1989), maximizing family carers’ societal/community resource utilization (Barnes et al., 1981; Edgar et al., 1996; Lechner, 1993; Mant et al., 2005; Vickers, 1990; Woods et al., 2003), teaching family carers skills in coping with, managing and making decisions about issues emanating from caregiving (Bass et al., 1998; Cummings, 1996; Hagen et al., 1997; Ham, 1999; Kaye and Applegate, 1993; Magnusson and Hanson, 2004; McFarland and Sanders, 2000; Montgomery and Borgatta, 1989; Vickers, 1990; Woods et al., 2003) or a teaching-learning process based on education and information (Ham, 1999; Heagerty et al., 1988; Magnusson and Hanson, 2004; Mant et al., 2005; McFarland and Sanders, 2000; Molinari et al., 1994; Shaw, 1997; Smyth and Harris, 1993; Todd et al., 2002). Moreover, in some cases support for family carers almost comes through as a by-product in achieving the ‘‘real’’ goal, which is increased emotional and physical health of the cared-for persons (Lincoln et al., 2003). That the stress-coping, or stress-buffering conceptual frameworks prevails in the majority of studies that use the concept of support may be an aspect which is important from an epistemological point of view as it

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affects the kind of knowledge produced. Continued of predominance studies conducted in this way may imbalance the research by mainstreaming it into a norm of action–reaction trials that promote an atomistic reductionistic view of human beings. Studies seldom address this aspect. Of the studies included here as data, only two studies (Jegermalm, 2003; Magnusson and Hanson, 2004) touch upon this aspect. The conceptual frameworks described above may be inconsistent with, or criticized from, a human science angle which promotes a more holistic view of human beings. The rareness of this view can be particularly jarring within nursing science which recurrently underlines holism, or from the perspective of some existing nursing science theories (cf. Parse, 1998). Also, support is recurrently portrayed as unilaterally positive. Only three studies (Demers and Lavoie, 1996; Gottlieb, 1991; Hibbard et al., 1996) discuss or mention negative or adverse effects of support, such as support persons/relations potentially being a source of conflict, or that family carers can feel discouraged from attending support groups where sometimes less autonomous cared-for persons than the ones they care for themselves can be discussed. The studies performed by Molinari et al. (1994) and Tilling et al. (2005) stand out in contrast to the general tone in which support is discussed as they put forward a picture of support as needing to focus less on emotional needs of family carers. Also, in this data material the study by Lincoln et al. (2003) is fairly unique in concluding that all support needed in the community setting had already been provided for by hospital staff pre-discharge, whereas others like Lechner (1993) address community setting problems such as the underused but available services. 4.2.4. The intangible, abstract and highly individual dimension is about family carers unburdening their minds to a dedicated other The intangible, abstract and highly individual dimension of support is accentuated in studies by the use of adjectives such as individualized, adaptable, accessible, responsive, convenient, suitable or tailor-made (Bass et al., 1998; Colantonio et al., 2001; Gottlieb, 1991; Hagen et al., 1997; Lechner, 1993; Magnusson and Hanson, 2004; Marziali et al., 2005; McFarland and Sanders, 2000; Molinari et al., 1994; Richmond et al., 1987). Within this dimension, the necessity to individualize support is highlighted, by, for instance, recommendations such as adaptability depending on family carer characteristics (Tilling et al., 2005) or statements such as that different people learn to cope with life in different ways (Vickers, 1990). Here, the image of support as having to be attuned to family carers’ needs for usefulness is put forward. Hence, support outlines itself as having to be able to fluctuate with and throughout the

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caregiving trajectory (Todd et al., 2002). Studies also underscore the provision of support as a recognition of family carers’ needs and problems and likewise underscore the completion of the continuum from problem identification through helping carers accessing the best care (Heagerty et al., 1988; Koopmanschap et al., 2004; Richmond et al., 1987). Here, in contrast to the previous more tangible dimension, the objective of support emerges as pertaining to the protection or safeguarding of family carers’ relationships. This is key, whether it pertains to family carers’ relations with persons aside from caring, or the seemingly essential symmetrical dimension of reciprocity between the family carer and the cared-for person, because there support is equally good to receive as it is to give (Gottlieb, 1991; Kaye and Applegate, 1993; Marziali et al., 2005; Synak, 1989). However, studies do not only address the interconnecting relations in the triad of family carers, professionals and cared-for persons. A significant accumulation of research exists on support when family carers are assessed in meetings with professionals or peers, individually or in groups. There, support appears to be created, occurring as an important factor when family carers have the opportunity to share emotions, experiences, acquired knowledge and feelings, thus allowing family carers to verbalize, voice and express current ongoings in their life by unburdening their minds to a dedicated other (Barnes et al., 1981; Bass et al., 1998; Demers and Lavoie, 1996; Gilbar, 1997; Hagen et al., 1997; Heagerty et al., 1988; Kaye and Applegate, 1993; Marziali et al., 2005; McFarland and Sanders, 2000; Molinari et al., 1994; Richmond et al., 1987; Shaw, 1997; Vickers, 1990). This dimension can translate into the happenings in the space between human beings or support as a co-created occurrence between humans. 4.3. Antecedents of the concept The description below of antecedents of support represents the collective of all studies included here as scientific data. There is high consistency and agreement between the scientific studies as regards the antecedents of support for family carers. Public investments in support for family carers is a national and international trend, which in summary can be said to be brought about by the extraordinary and significant amount of care family carers provide for months or years at a high cost in time and energy for themselves (Jegermalm, 2003; Thompson et al., 2005). The vast majority of studies included here advantageously describe the family carers’ situation as burdening and disrupting, incorporating fundamental and irreversible life-changes at a multitude of levels. The studies underline that being a family carer leads to strains, stresses, problems and crises at psychological, emotional, social, physical, financial and

practical levels. Family carers struggle with negative emotions such as loneliness, helplessness, hopelessness, loss, vulnerability, fear anxiety, a ‘‘trapped’’ feeling, grief, guilt and shame, all of which potentially lead to depression, deteriorating well-being, poor sleep, poor immune response and an increased mortality rate. Adding to the antecedents and incentive to support is the awareness that family carers may refuse much needed help in spite of all these negative consequences (Gilbar, 1997; Montgomery and Borgatta, 1989). 4.4. Consequences and endpoints Similar to the description of antecedents, the description of consequences also represents the collective of all studies included here as scientific data. As regards the consequences of support, studies are equally much in conformity and agreement as with the antecedents. Many of the words used as descriptors in antecedents are again found as descriptors of consequences but their fundamental interconnection with the intervention itself, if one is attempted, is unclear. The consequences of support as described in the scientific data are described as improvements in one or more of the following areas: adjustment, adaptation, quality of life, acceptance of the situation, understanding, communication, fellowship, sharing, empowerment, control, physical and mental health and social interactions (for e.g., Tilling et al., 2005; Todd et al., 2002; Heagerty et al., 1988). However, consequences are also described in reductions in one or more of the following areas: institutionalization, anxiety, loneliness, isolation, anger, strain and emotional pain. The scales used to measure outcomes of interventions labelled support are recurrently: depression scales, quality of life scales, and general health questionnaires. Some examples of specific scales are: hospital anxiety and depression scale, activities of daily living, use of and satisfaction with services, the modified inventory of socially supportive behaviours, emotional outcomes and reintegration to life (for e.g., Mant et al., 2005; Koopmanschap et al., 2004; Lincoln et al., 2003). 4.5. Derived definition Working with the data underpinning this study, it was possible to put forward a definition of support for family carers who care for a frail aged person at home. The two major dimensions, as described under attributes, were merged into the following definition: Support entails the provision of general tangibles such as information, education, economic aid, goods and external services. These are prerequisites for facilitating the family carers’ competence and/or capacity in care. Moreover, it entails necessary qualities such as individualization, adaptability,

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lastingness, room for verbalizing emotions as well as an idea of reciprocal symmetrical exchange between involved parties. 4.6. Model case The role of the model case is to enhance the degree of clarification by providing an everyday example which includes the attributes of the concept (Rodgers, 1989). Since the attributes of support appear as two separate but dialectically interconnected dimensions (see Fig. 1) two model cases have been chosen in order to enhance the degree of clarification. In accordance with the evolutionary view of concept analysis, the model cases were identified rather than constructed (ibid.). The model cases were identified in interview data originally collected for the purpose of another study conducted in order to understand the meaning of support as narrated by family carers who care for a senior person at home (Stoltz et al., 2006). In reflecting the tangible dimension, where support can be defined as any input given almost as a by-product of a ‘‘real’’ focus on the cared-for person, one interviewee stated: ‘‘ythey come or call [y] so he, it’s probably a very good organization because they have cooperation with each other y it appears to me, and he has, they have come through with means of assistance and almoner and all sorts, so I’ll probably have to say, really, to be able to care for him at home with blood, blood. He has received blood four times a week since he got home and it’s good not to have to go away, because that’s tough, and it was really tough before with all of these doctors, visits and you are no wiser when you leave and very impersonal, because he was admitted twice for blood and I thought that was beneath contempt.’’ This case illuminates that professionals surrounding the family carer have, through means of assistance, provided for the possibility of caring taking place at home. The family carer no longer depends on the hospital. The intangible, abstract and highly individual dimension of family carers unburdening their minds to a

The tangible, concrete and general impersonal dimension is about increasing family carers’ capacity to care

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dedicated other, can be enhanced by another interviewee who stated: ‘‘y and above all that they grabbed hold of me when I left there then and started to cry, then they grabbed hold of me and said ‘don’t you go home now.’ ‘I’m going to go home now,’ I said. ‘No,’ they said, ‘‘you aren’t going home, (name).’ They sat me in a chair, for two and a half hours the staff sat around me, ‘You are not leaving here, why, you are nervous wreck.’ ‘No, I’m not.’ ‘Yes, you are.’ And then they opened my mouth [i.e. meaning that she began to narrate] and then I fell aparty’’. This case illuminates the intangible dimension of support, where professionals acknowledge and detect the family carer’s need to narrate and unburden her mind. 4.7. Surrogate terms and related concepts Related and contrasted words to the concept of support may aid in understanding differences, similarities, outlines or elucidating meanings to give a description which facilitates effective communication of intentions or objectives of support. Related words such as approve, endorse, favour, pull (for), root, embrace, defend, maintain, sustentation may be closer to communicating an agreeable understanding of the concept. Also, the same may be true for contrasted words such as battle, combat, counter, fight, oppose or withstand.

5. Theoretical analysis 5.1. Changes in the concept over time In order to detect any changes in the concept over time the scientific data was sorted by publication date before the randomized sample was drawn. As far as can be told from this study, the meaning and use of the support concept within family care has been fairly coherent over time: complex and unspecified. Perhaps some interventions have been modernized, such as

The in-tangible,abstract and highly individual dimension is about family carers SUPPORT un-troubling their minds to a dedicated other

Fig. 1. A visual display of the two intersecting dimensions that are inevitably and dialectically integrated in the here derived definition of support.

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information via computer and IT, thus adding contemporary aspects to the concept. Otherwise the meaning seems fairly stable and several interventions still take place in groups. Looking at published research, support appears to have been fairly consistent annually in the number of publications since the late 1980s until today, with the possible exception of a slight increase recently. 5.2. Areas of agreement and disagreement across disciplines Cross-disciplinary comparisons may be useful to outline issues for critical reflection, in particular when, as in this instance, a concept in nursing can be considered to have been borrowed from another discipline (cf. Rodgers, 2000). Then there may be legitimate concerns about changes in perspective (Rodgers, 2000). Nursing researchers handle the concept of support in a way that can be interpreted as representing a very low awareness of the complexity of the concept. For example, support has been given a very narrow practical meaning in nursing. Basically it is used as a heading for situations when family carers meet in groups with peers or when different tangible services are provided for them. One may wonder whether the term information might be a more suitable heading for situations where family carers meet with peers once or twice a week. Support should perhaps be reserved for interventions that extend beyond information in their commitments to family carers’ struggles. Moreover, there is a serious lack of studies that discuss potential adverse or negative effects of such supportive interventions. It may well be that a family carer can come out of a support-group meeting, feeling discouraged and worried from having heard narratives about cared-for persons who are worse off than their own charge (Demers and Lavoie, 1996). To summarize, there are almost no studies in nursing that problematize the concept of support. Furthermore, in nursing research support is chiefly used as an answer to and attempt to satisfying needs. In contrast to the nursing literature, sociology literature does not chiefly use the concept of support as an answer to satisfying needs. Instead support is mainly used as a buffer to family carer burden. Studies in sociology also differ from studies in nursing in that there seems to be a slightly higher awareness within sociology regarding the complexity and multidimensionality of the concept. However, sociologists should perhaps follow nursing researchers in reserving the concept of support for interventions that extend beyond information. Here, sociology as well as nursing could employ self-criticism to a greater extent than today, instead of formalizing and implementing information intervention programmes in search of evidence of effectiveness. Furthermore, sociology does not convin-

cingly distinguish the potential difference between social support and social network.

6. Conclusions In accordance with Rodgers (2000), the results of this paper should be considered a starting point as opposed to an ending. The heuristics of the results may now serve as a point of departure for further inquiry. The results here may, for example, have bearing on how future support interventions are designed and evaluated. More specifically, this paper may aid in raising awareness of the complexity of support and the consequent complexity of its evaluation. Moreover, this paper may contribute to an understanding of the meaning of support by elucidating adjacent and necessary qualities such as individualization, adaptability, lastingness, appropriateness and reciprocity. Further nursing research may benefit from critical reflection and increased mindfulness before using the concept of support. Nursing research on family caring should perhaps emphasize the importance of qualities or dimensions such as temporality, sustainability, sensitivity and partnership. Also, nursing research could acknowledge negative outcomes and adverse effects in order to avoid them. Knowledge of adverse effects of support may be especially useful to nurses. This is one main category of health professionals that are expected to provide support for family carers looking after an older person at home. Also, studies that underscore the provision of support as a recognition of family carers’ struggles could likewise underscore the completion of the continuum from problem identification through helping family carers access the best care (Heagerty et al., 1988; Koopmanschap et al., 2004; Richmond et al., 1987). Even though this paper has been completed with limited resources it has several strengths. The use of systematic means of sampling, such as the selections drawn from computerized databases, has increased the likelihood that the analysis of data has been representative (cf. Rodgers, 1989, p. 333). Also, using literature as data has been relevant for the purpose of this study because of its role in institutionalizing concepts within the nursing and sociology disciplines (Rodgers, 2000). The analysis entailed breaking the data apart to identify its constituent components (cf. Sandelowski, 1995). The analysis was successful in the identification and subsequent clarification of relevant aspects of the concept of support. It also elucidated areas of agreement or disagreement across disciplines or contexts. The focus consistently remained on the analysis and identification of useful data and illuminative cases, as opposed to the construction of cases as advocated in other approaches (cf. Chinn and Jacobs, 1983; Walker and Avant, 1995;

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Wilson, 1963). Although it was systematically performed, questions may be raised as regards the representativity of the literature chosen as data for this study. More extensive inclusion of data might have been more successful in illuminating possible contemporary shifts in meaning of the concept in nursing. However, the initial searches were as inclusive as possible, which rendered a large amount of potential data. Due to the strict criteria for inclusion and exclusion these references were rapidly reduced in number. Also, standard means of probability sampling were used in order to arrive at a manageable amount of data without jeopardizing representativity. According to Rodgers (2000), the data included in this study should represent a sufficient percentage of the total data in order to arrive at an acceptable understanding of the concept under study. Furthermore, according to Rodgers (2000), the context within which the concept is to be understood should be taken into consideration. The searches did not identify any previous concept analysis on support within the specific context of family carers who care for a frail aged person at home.

6.1. Implications for education and management Continuing to emphasize and educate healthcare professionals in critical awareness and a critical reflective approach regarding research findings may pave the way for a similar critical approach regarding the manner in which the concept of support is used, interpreted and understood. Lecturers who are responsible for educating healthcare professionals should continue to emphasize critical awareness and, if possible, also underline the intangible dimension of support, which hitherto perhaps has not been as salient. Likewise, managers in the healthcare arena should be critically aware and critically appraise research results as well as guidelines before implementing any changes or programmes to support family carers. Managers should be specifically aware of the endpoints they wish to achieve for family carers as well as contrasting potential adverse effects against potential beneficiary effects of support.

Acknowledgements This study has been facilitated by the School of Health and Society at Malmo¨ University, Sweden. We are also thankful for the excellent service provided by Pablo Tapia and co-workers in the library at Malmo¨ University. The authors also wish to thank Professor Giggi Ude´n for her contribution in the setup of this study.

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