Concept Analysis of Caring Thinking in Iranian Nurses: A Hybrid Model

Introduction: The concept of caring thinking has been utilized in nursing, and although it has been de ﬁ ned and evaluated using a variety of methods, yet it remains an abstract concept in nursing practice. This paper presents a concept analysis to de ﬁ ne and clarify the concept of caring thinking to provide a deeper understanding of how caring thinking can be incorporated into nursing. Therefore, the present study is carried out for the purpose of dening and clarifying its concept in the nursing profession. Methods: This study used a hybrid model of concept analysis comprising three phases, namely a theoretical phase, eld work phase, and a nal analysis phase. To nd relevant literature, electronic search of valid databases was utilized using keywords related to the concept of caring thinking. Field work data were collected over a 10-month time period from 2017 to 2018. In the eld work phase, in-depth interviews were performed with 10 nurses and academic nurse. The conventional content analysis was used in two theoretical and eld work phases, and the results were combined in the nal analysis phase. Results: The 4 main themes extracted included “Correct thinking”, “Responsibility”, “Professional commitment”, and “Ethical thinking” and the nal denition of the concept was presented. Conclusion: The results of this study showed that clarifying the concept of Caring thinking leads to better understanding and common perception of this concept and helps nurses to exhibit caring thinking and provide quality care. Caring thinking arranges the systematic approach to and practice of behaviors. Actually, caring thinking is form of thinking contributing to correct thinking. Therefore, the results of this study have implications for nursing practice, nursing education, and nursing research.


Introduction
Nursing fosters humans through care and forms a unique relationship between patient and nurse ( 1 ).
Conceptual care is complex and multi-dimensional ( 2 ) and the main aspect and nursing support point ( 3 ).
Caring is complementary to the conversation and agent forms people with different perspectives alongside each other. Care is the transformation of emotions into choices, decisions and judgments. In other words, a form of emotion turning into choices, decisions and judgments. Caring originates in the heart and human values. That is, caring is grounded in the behavior or thinking of a person, being used depending on individual values ( 4 ). Care means paying attention to the views and interests of others and treating others in the way you would like to be treated yourself. This is a principle of care thinking ( 5 ).
In Lippmann's view, there are three types of thinking: Critical Thinking, Creative Thinking, and Caring Thinking ( 6 ). In his view, care thinking weight philosophically is higher than that of creative and critical thinking and shadows critical and creative thinking ( 7 ).
Caring thinking modi es the divergence of creative thinking and promotes its cognitive dimension. Critical thinking is also cognitive, and its emotional dimension is then complemented with care thinking ( 8 ). Actually Caring thinking is the care of the ow and the process of thinking ( 9 ). In fact, caring thinking is a form of care that has been converted into practice ( 10 ). With caring thinking, enthusiasm, stimulation of emotional excitement increases and deep sensation emanates ( 11 ). A person with caring thinking tends to think in a way that the best and most useful results are achieved. Through caring thinking, behaviors can be formed and achieved systematically. Caring thinking can be provided by a person with a constructive value system ( 12 ).
Integrating care thinking in nursing practices with the motto of paying attention to view points and interests, treating patients the way would you would like to be treated, and attracting the participation of patients in health care decisions can achieve the goals of healing patients, improved quality of care, increasing patients' inheritance, increase in patient safety and their self-e cacy, the estimation of the patient's more realistic expectations of what might happen. Then, all of this leads to better health outcomes. In this regard nurses play an important role. Promoting level of nursing knowledge in this context can lead to improved quality of care ( 13 ). There is no study on caring thinking notion analysis in Iran, and all such research has been carried out in other societies whose concepts vary greatly from that of Iran.
The social and native environments within which the concept arises are important for its study as it nds its real meaning in the social context, and this meaning typically varies from one culture to another ( 14 ).
To analyze the caring thinking concept in Iran context, the hybrid model was further selected as the most proper method on the basis of all involved people experiences, particularly nurses; this is since this concept analysis model enables actual participant experience to be included in the de nition of the concept ( 15 ). The hybrid model, on the other side, combines empirical observation with theoretical analysis; this is useful as no empirical de nitions are on this notion in Iran. An emphasis on the necessary facets of the caring thinking de nition is enabled by this. It may be operational by detailed concept analysis and its dimension's clari cation. Then, steps can be taken to promote the quality of care and nursing education via the concept implementation in nursing education. This research exploring the caring thinking de nition on the basis of the hybrid model was performed in this respect.

Methods
The investigators applied the hybrid model presented by Schwartz Barcott and Kim to analyze the caring thinking concept. The model consists of 3 phases of theoretical, eldwork, and analytical ( 16 ). The method focuses on the development of the concept, being performed over phenomenon qualitative investigations in its arisen location. The experimental and theoretical methods are put together to introduce a novel approach, and the nal concept development is achieved by inducing and comparing so that, in the end, a kind of decrease is made ( 16 ).
For the theoretical phase, in total, 125 resources (43 full text, 82 Persian / English abstracts and books) were considered regarding and exclusion criteria (unrelated concerns) mad the inclusion criteria (literature in Persian or English with relevant keywords in the title, abstract, or keywords), besides evaluating the quality of the resource. In this phase, the textual content analysis was applied to extract and analyze the data. Further, each literature text was studied thoroughly, and any words, phrases, and sentences implying caring thinking's de nition and dimensions were determined.

Fieldwork phase
From July 2017 to November 2018, eld data were gathered from ten participants (Table 1). They were selected purposefully. The major methods of collecting the data were interview and observation of nonverbal behaviors, and eld notes took during the interviews. Up until data fullness, in-depth, semistructured, individual, face-to-face interviews were conducted with the participants continually; if necessary, further interviews were done. All additional interviews were recorded. The maximum variety concerning age, gender, education level, marital status, clinical experience, employment status, besides sector and sort of institute, were taken into account in the participants' selection. The interview location and time were chosen based on the participants' desire. At this phase, the interview controlling questions were as below: _How has caring thinking been de ned? _What is caring thinking in nursing? _What factors effect on education for caring thinking?
_What is the nature of caring thinking?
_How Caring thinking is measured in nursing?
The duration of the interviews was in the range of 30 to 50 min. The participants selected the location of the interviews. As quickly as possible, the interviews were carried out. The MAXQDA software, Version10, was applied to manage and organize the data. The Lincoln and Guba criteria, such as conformability, credibility, transferability, and dependability, were applied to assure the qualitative data reliability ( 17 ). With ten participants, 14 interviews were done. The conventional content analysis was applied based on the method proposed by Graneheim and Lundman to analyze data ( 18 ).
To attain the overall comprehension and themes, transcribed interviews on a variety of occasions were read word by word, line by line, and paragraph by paragraph. The unit meanings and primary codes were then taken out. Similar codes were categorized next as subclasses. Classes were formed by the subclasses all together. There was an effort in order to make homogeneity within the classes but the highest heterogeneity between the classes. The themes were also formed by classes. Final analytical phase The data gained from the literature review in the theoretical phase were compared with the codes and classes gained from the phase of eldwork in the nal analytical phase; as a nal point, the shared characteristics of the caring Thinking concept were determined, and the concept was de ned.

Ethical approval
Ethics Committee of Tehran University of Medical Sciences approved this research. All the respondents were noti ed of the purpose of the study, and each provided written informed consent.

Results
The theoretical phase results In this study, from various resources and databases, the de nitions, dimensions, and characteristics of caring thinking, besides care thinking, and nursing are collected in the theoretical phase.

Caring Thinking
Cognitive and emotional thinking combination is caring thinking when it comes to important matters. Phrases such as "thinking with your heart" or thinking with your personal values are used in ordinary language. Caring thinking enables an individual to build a thorough value system forming comprehensive and sympathetic judgments. Caring thinking expressions are as many judgments as creative or critical thinking expressions. What allows an individual to select what he/she considers signi cant in a speci c context is caring thinking (aesthetic, ethical, or scienti c); it decides what a person concentrates on. The moral and aesthetic perceptions of people are determined by caring thinking in many ways. To think thoughtfully, indeed, means to think e ciently, ethically, normatively, appreciatively, and to actively take part in society with a concern for the common good ( 19

Dimension of Caring Thinking
There are two ways to dimension caring thinking. Caring, as earlier mentioned, involves a subject and an object. The person is the subject, and the item focused on by caring is the object. As regards its subject, it includes several phases, like obeying the commands, self-awareness, own values, and ethical rules. It tends to itself, others, nature, and principles regarding its object ( 4,20

Caring Thinking and Nursing
Caring thinking is a kind of formula that brings creative and critical thinking together. Among the formulas, this is a third form or a higher level. Feeling transformation into decision, choice, and judgment is caring. That is to say, it is the forms that turn feelings into decisions, choices, and judgments ( 4 ).
Thinking is devoid of a values component without caring. Thinking is liable to approach its subject matters indifferently, apathetically, and uncaringly if it does not contain valuing or valuation; i.e., it could be diffident even about inquiry itself ( 20 ).
Indeed, Caring is the essence of nursing ( 21 ). Furthermore, enhancing nurses' ability to improve patient care outcomes is one of the needed goals for education in nursing. Learners need to transfer learned knowledge to actual practice to achieve this goal. Knowledge of thinking paradigms concerning speci c subject content is needed to achieve e cient transfer ( 22 ), and Caring transformation into practice results in caring thinking ( 4 ). Thus, over caring thinking, behaviors can be made systematical; the most appropriate manner for this systematical behavior is pragmatism. Human is inclined to think in a way to get bene t from thinking. This is the reason why caring thinking is considered as a type for organizing people thinking practice ( 23 ).
Caring thinking is associated typically with the same taxonomy's e cient domain, although the critical and creative thinking tackles the Bloom Taxonomy's cognitive domain. Bloom considers emotional effects and affects in the evaluation and synthesis process but within cognitive processes ( 24 ).
The ethical inquiry role in the processes bears caring thinking's major features, like turning rules, values, and thoughts into action. Caring thinking direct association with virtue and ethics is shown by its convergence. Moral education, based on Burns and Rathbone (2010), includes two modules: virtue and caring theory education ( 25 ). Caring thinking was de ned by Noddings (1988) as the moral requirement of ethical education, considering caring as the core of the educational approach and its drive. Accordingly, four fundamental activities were suggested by him as modeling, dialogue, practice, and con rmation ( 26 ).
Educators can facilitate knowledge transfer by using caring thinking and developing instructional designs that incorporate subject content and cognitive processes associated with the subject content use. It is, however, di cult to develop such instructional designs ( 27 ). In this situation, nurses and clients can understand and experience the true concept of care, provide quality care and feel worthwhile.

Results of the eldwork phase
Two hundred thirty primary codes, 18 subclasses, 10 classes, and 4 themes were gained in the phase of eldwork (Table 2). Here is an expression of a nurse in this regard: "Actually, caring thinking takes care of the ow of thought. For nurses to make timely decisions and measure all aspects of a client's conditions, it requires the aggregation of critical thinking, ethical thinking, creative thinking and affective thinking. Altogether they create caring thinking." Theme 2: Ethically thinking Documentation of the ethics and valuation in nursing care was focused on in the phase of the eldwork.
To care is to concentrate on what we esteem, to appreciate its worth, to value its value. An ethical inquiry role in the procedures bears the caring thinking's major features like turning rules, values, and thoughts into action.
An academic nurse in this regard stated:" Each of us has our own values and beliefs, and in the care we provide, these internal values, our laws and our thoughts are re ected in our behavior. When nurses respect the values of patients, it means to work ethically. Protecting the privacy of the patient by the nurse, respecting the patient's rights and their beliefs to provide necessary needs and nursing care is an example of ethical thinking that is a signi cant feature of caring thinking."

Theme 3: Responsibility
The responsibility of nurses was the problem that was mentioned frequently by the participants or attained by observational eld notes. This theme revealed that responsibility is essential to be in action at any event possible if it is determined as the possible result's acceptance in advance.
One of the participants expressed it in this regard: "The responsible nurse, after providing care, evaluates the quality of care from the patient to assess the recovery and the impact of care. One of the patients has said that some are doing their job and they are going to follow their work, but there are some who, after completing their work, will come back to you and ask questions, to see if the problem has been resolved or not."

Theme 4: professional commitment
This theme indicated that participants emphasize that professional commitment is how people think about their profession and the motivation to work in that profession, and nurses who have a higher commitment are more accountable.
A nurse expressed: "A professional commitment means adherence to the goal of nursing (care). Care is the basis of our work. Therefore, we must know everything that makes us care and think correctly."

Results of Final analytical phase
The data found in the literature review in the theoretical phase were compared with the codes and classes gained from the phase of eldwork in the nal analytical phase; as a nal point, the caring thinking concept's shared characteristics were recognized, and the concept was de ned.
In the third phase of the concept analysis, with a combination of theoretical phase results and insights achieved in the eldwork phase, the nal de nition of the concept was presented:" Caring Thinking is the side of giftedness that emerges from the person's heart, thinking with your heart and personal values. It enables people to build a sound value system to make comprehensive and compassionate judgments. Whilst emotional over excitability (or intensity) and deep sensitivity are at the center of Caring Thinking. Caring thinking, on the other side, is considered a type of thinking to organizes our thinking practice, contributing to correct thinking."

Discussion
Caring thinking is de ned as a third type of thinking added to critical and creative thinking (two types of thinking come to the fore) ( 20 ). The center of caring thinking is emotional over deep and intensity sensitivity ( 7 ). Caring thinking has four characteristics of affective, valuation, active, and normative linked together ( 20 ). Also, caring thinking is dimensioned in two ways: a subject and an object. The person is the subject, and the item directed by caring is the object ( 4 ).
Careless thinking refers to thinking without hesitation or consideration, and fear of values and law ( 28 ). Therefore, we can say that a kind of thinking that contributes to the right thinking is caring thinking and arranges the practice of behaviors.
The eldwork results revealed that caring thinking in the Iranian healthcare system and medical education is an unfamiliar concept. The majority of healthcare providers, nurses, in particular, do not have any idea about the precise meaning of caring thinking. Therefore, in order to increase the knowledge and improve the perspective and attitude of nurses and students, a caring thinking course should be considered in the university curriculum. To train academic nurses about empowering nurses, nursing schools and hospitals also have to offer a plan. In Iran, due to insu cient academic nurses' attention to nursing students and bringing them up, increasing nursing students' admissions, the large number of patients, excessive workload and shortage of nurses in hospitals, the nurses lose their motivation to become involved in quality of care.
To satisfy the varying roles within the healthcare career, nurses who select this job need to keep a level of competence and skill. Assuring that the professional is guided by strong and autonomous, analytical, and reflective theorists is the responsibility of nursing educators ( 29 ). In an early academic path, professors could draw upon plans to enable their students to use qualities associated with developing the skills of caring thinking. Encouraging and educating skills of caring thinking skills in nursery students can assure the nursing future supported as experienced nurses start retiring. Previous studies have highlighted this point repeatedly ( 20, 7, 4, 12, and 21 ).

The study limitations
One limitation of the survey was inaccessibility to the full-text of some of the required papers. Another limitation of the study is the fact that in the eldwork stage, the environment is limited to Iran. C is a complicated concept, and to provide a comprehensive de nition of it, it is essential to be investigated from nurses' points of view in different contexts and cultures.

Conclusion
This study revealed that the clari cation of the caring thinking concept resulted in its better comprehension and mutual perception, helping nurses to have caring thinking and offer quality care. A systematic approach is established by caring thinking in behavior practice. Caring thinking is, indeed, a system of thinking that contributes to right thinking. This study's results, therefore, include some implications for nursing practice, research, and education.