ABSTRACT
Aim
Conducting a concept analysis of caring partnerships can enhance understanding and communication among professionals and aid in perceiving and measuring the concept. Therefore, this study aimed to elucidate the concept of a caring partnership in nursing based on Newman's health as expanding consciousness theory.
Design
Concept analysis.
Review Methods
The eight‐step approach of Walker and Avant's concept analysis was employed to explore the caring partnership concept, including its definitions, defining characteristics, antecedents, consequences and empirical referents through a comprehensive literature search.
Results
The identified defining attributes—presence, mutual trust and connectedness—describe a caring partnership as a meaningful connection between a nurse and a client. A caring partnership serves as a nursing intervention wherein a nurse assists a client in navigating difficult situations to find meaning, fostering an expansion of consciousness for both.
Conclusions
Recognising these attributes enhances nurses' understanding of caring partnerships, offering a rationale for their application in research and clinical practice. This study provides theoretical evidence for research on caring partnerships as well as the implementation of the concept in clinical practice.
Implications for the Profession
This study is novel in that it provides theoretical evidence for research on caring partnerships as well as the implementation of the concept in clinical practice by defining it based on Newman's health as expanding consciousness theory.
Impact
Subsequent studies should develop instruments for measuring caring partnerships and education programs that enhance caring partnerships, considering the attributes and definitions of the concepts derived in this study.
Reporting Method
We have adhered to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines.
Patient or Public Contribution
No patient or public contribution.
Keywords: caring partnership, concept analysis, nurse‐client relationship, nursing care, nursing intervention
1. Introduction
Caring is fundamental to the nursing profession. Since its inception, nursing has been committed to the care of wounded and injured individuals, which is considered the ultimate mission for nurses (Newman 2008). Nursing theorists explain that care is the essence and starting point of nursing (Watson 1999), as well as an intrinsic characteristic and expression of humanity (Boykin and Schoenhofer 2001). Newman (1994) emphasized the importance of care in nursing, arguing that performing professional responsibilities habitually without care does not constitute true nursing. As care is more health‐centred than treatment‐centred, interaction within individual relationships is a critical care factor (Watson 1999). Therefore, nurses must discover what is meaningful and important to a particular individual rather than focusing only on the scientific guidelines for care (Watson 1999). Care is provided through a blend of activity and relational elements. Care is a series of activities to help others, reflecting an interpersonal attitude imbued with concern and devotion towards others, as well as engagement in scientific and systematic processes (Lee 1996). Improving the activity component of care can potentially reduce the nursing workload and pioneer new service areas, possibly leveraging artificial intelligence (AI) and robotics with advances in scientific technology in this era of the Fourth Industrial Revolution. Moreover, the patient‐centred relational elements of care, which cannot be replaced by scientific technology, should be further emphasized (Aungsuroch and Gunawan 2019; Tak 2018).
Newman used the term ‘caring partnership’ to represent the relationship between nurses and clients in the context of delivering care (Newman 2008). The term ‘caring partnership’ began to be widely used in research emphasising the partnership between nurses and clients, particularly by Endo et al. (2000). While Newman did not explicitly define a caring partnership, she viewed the nurse‐client relationship as central to care and described it as a partnership (Newman 2008). She explained that a caring partnership should precede nursing care and that it is the basis of nursing practice. In the nurse‐client relationship, a partnership involves working together towards common goals, empowering each other and sharing the power to influence results based on adequate information that contributes to the plan, enabling clients to fully participate in the plan (Tunnard and Ryan 1991). Nursing interventions derive from a relational paradigm where the professional forms a partnership with the client in turmoil; through this process, both the professional and client manifest a higher level of consciousness (Newman 1994). The role of the client is not assumed to be passive, where they merely receive care from a competent nurse; instead, this relationship emphasizes mutual dependence and reciprocity (Riley 2017).
The term ‘caring partnership’ has been used interchangeably with several other terms to describe the nurse‐client relationship, including ‘caring relationship’ (Granados Gámez 2009), ‘therapeutic alliance’ (Zugai et al. 2015) and ‘therapeutic relationship’ (Coelho et al. 2021). Although these terms share similar meanings, a distinctive feature of a caring partnership is that nurses and clients are not merely viewed as care providers and care recipients, respectively. Instead, collaboration to attain common goals and mutual growth is emphasized. From this perspective, a caring partnership signifies a relationship that enables a higher level of care.
Accordingly, based on the Health as Expanding Consciousness theory, studies conducted in various countries with diverse subjects have demonstrated that recognising community patterns can serve as a catalyst for change. This occurs through patterning life within shared difficulties, evolving the nurse‐client relationship and following the process of Newman's praxis (Smith 2011). However, the concept of a caring partnership lacks a clear definition and discussions on its conceptual properties and practical applications remain limited. Previous studies based on Newman's Health as Expanding Consciousness theory have referred to this concept using various terms, including ‘Newman's praxis relationship’ (Rosa 2016), ‘nursing relationship’ (Picard 2000), ‘meaningful relationship’ (Rosa 2006), ‘nursing partnership’ (Endo 1998; Litchfield 1997; Neill 2002; Pharris 2002). However, the use of similar yet not identical terms to express related concepts can lead to confusion in communication. This lack of clarity may hinder the recognition of the concept and its application as an intervention in nursing practice.
Concept analysis is a process of clarifying a concept by identifying its attributes, simplifying it into basic factors to resolve ambiguity within theoretical concepts and providing a clear operational definition. This lays a foundation for expanding and advancing the body of nursing knowledge by strengthening the structure of the theory, clarifying vague concepts and aiding future users to employ them consistently (Walker and Avant 2021). Therefore, conducting a concept analysis of caring partnerships will enhance understanding and communication among colleagues interested in this concept and facilitate the discovery of means to perceive and measure the concept.
Despite the increasing use of the term ‘caring partnership’ in nursing literature, its conceptual boundaries, defining attributes and practical applications remain unclear. Furthermore, the interchangeable use of related terms contributes to conceptual ambiguity, limiting its application in clinical practice and research. Therefore, the aim of this study is to clarify the concept of caring partnership using Walker and Avant's concept analysis method and to establish a clear operational definition based on Newman's Health as Expanding Consciousness theory.
2. Methods
This study followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. The PRISMA flow diagram is presented in Figure 1, and the PRISMA checklist is provided as supporting information (File S1).
FIGURE 1.
Literature extraction flow diagram.
2.1. Study Design and Data Sources
The eight‐step concept analysis procedure proposed by Walker and Avant (2021) was utilized to define the concept of caring partnership and identify its meaning and attributes. The eight steps were as follows: (1) selecting the concept of interest; (2) establishing the purpose or objective of the analysis; (3) identifying the scope of the concept using all available means; (4) determining the attributes of the concept; (5) presenting a model case of the concept; (6) presenting similar, related, contrary, invented and illegitimate cases; (7) identifying the antecedents and consequences of the concept; and (8) defining empirical referents.
To enhance methodological transparency, each step of Walker and Avant's (2021) concept analysis was applied systematically as follows. In step 1 (selecting the concept), ‘caring partnership’ was chosen based on its frequent but inconsistent use in nursing literature. In step 2 (determining the purpose), the aim was to clarify the concept and establish an operational definition grounded in Newman's Health as Expanding Consciousness theory. In step 3 (identifying all uses of the concept), a comprehensive literature review was conducted across multiple databases, including nursing and interdisciplinary sources, to explore definitions and uses of the concept. In step 4 (determining defining attributes), the included articles were analysed using an inductive content analysis approach. Recurrent patterns and key phrases related to nurse–client relationships were extracted, compared and grouped. Through iterative discussion, three core attributes—presence, mutual trust and connectedness—were identified. In step 5 (constructing a model case), a representative clinical scenario including all identified attributes was developed based on the researchers' clinical experience and literature findings. In step 6 (constructing additional cases), borderline, related and contrary cases were created to distinguish the concept from similar or incomplete forms of relationships. In step 7 (identifying antecedents and consequences), contextual conditions preceding the concept and outcomes resulting from it were derived from the literature and validated through discussion among the researchers. In step 8 (defining empirical referents), observable indicators and existing measurement tools related to similar concepts were reviewed to suggest potential empirical referents of caring partnership.
2.1.1. Inclusion and Exclusion Criteria
We included the studies that (1) focused on the concept of caring partnership and discussed its definitions, defining characteristics and components; (2) were published between 1963 and 2023; (3) were peer‐reviewed; and (4) were written in English or Korean. Accordingly, we excluded articles lacking definitions and defining characteristics of caring partnerships.
2.1.2. Searching Strategy
Walker and Avant (2021) suggest using all possible sources of information related to the concept when analysing the concept. Thus, a literature search was conducted to define the concept of a caring partnership and extract its decisive attributes. The search encompassed databases such as PubMed, CINAHL, Embase, PsychInfo and Research Information Service (RISS), operated by the Korea Education and Research Information Service (KERIS). Keywords used included ‘caring partnership’, ‘caring relationship’, ‘therapeutic partnership’, ‘therapeutic relationship’, ‘therapeutic collaboration’, ‘therapeutic alliance’, ‘care partnership’, ‘partnership in care’ or ‘presence’ and ‘Newman’ or ‘health as expanding consciousness’. The search period (1963–2023) was selected to capture the historical development of the concept of caring partnership alongside the evolution of nursing theories, particularly following the emergence of relational and humanistic paradigms in nursing. This broad timeframe allowed for the inclusion of both foundational theoretical works and contemporary empirical studies.
2.1.3. Selection Process
A total of 501 articles (215 from PubMed, 56 from CINAHL, 38 from PsychInfo, 172 from Embase and 20 from RISS) were identified. After removing duplicates, titles and abstracts were screened to assess relevance to the concept of caring partnership. Articles that did not explicitly address the concept or lacked conceptual definitions were excluded. Full‐text screening was then conducted for the remaining articles to determine eligibility based on the inclusion criteria. Additional relevant studies grounded in Newman's Health as Expanding Consciousness theory were identified through manual searching and reference tracking, resulting in six additional articles. Ultimately, 13 articles were included in the final analysis (Figure 1, Table 1).
TABLE 1.
Concept of caring partnership in literature.
| Author (year) | Subject | Purpose | Antecedents | Attributes | Consequences | |
|---|---|---|---|---|---|---|
| 1 | Endo et al. (2000) | 10 Japanese families with a wife‐mother hospitalized for cancer | Elaborating pattern recognition as a nursing intervention for families with patients diagnosed with cancer | Client(s):
|
|
Client(s):
Nurse(s):
|
| 2 | Pharris (2002) | 12 adolescent males convicted of murder | Engaging in mutual process of pattern recognition with adolescent males convicted of murder | Client(s):
|
|
Client(s):
|
| 3 | Picard and Mariolis (2002) | Baccalaureate nursing students, clients and faculty | Mirroring nursing praxis with nursing students | Nurse(s):
|
|
Nurse(s):
|
| 4 | Neill (2002) | 3 Australian women with multiple sclerosis and rheumatoid arthritis | Describing life patterns of three women |
Client(s):
Nurse(s):
|
|
Client(s):
Nurse(s):
|
| 5 | Gong (2004) | 9 victims of sexual violence | Exploring health experiences of victims of sexual violence reflected in Newman's health as expanding consciousness theory |
Client(s):
Nurse(s):
|
|
Client(s):
Nurse(s):
|
| 6 | Endo et al. (2005) | 9 practicing nurses in cancer centre | Addressing process of practicing nurses' transformations in a caring, pattern‐recognising relationship with clients |
Client(s):
Nurse(s):
|
|
Client(s):
Nurse(s):
|
| 7 | Sim (2005). | 7 low‐income elderly persons living alone | Confirming health experience patterns of low‐income elderly living alone | Client(s):
|
|
Client(s):
Nurse(s):
|
| 8 | Rosa (2006) | 10 men and 8 women, primarily of retirement age, with chronic skin wounds (CSW) | Understanding persons living with CSW, focused on healing and recovery | Client(s):
|
|
Client(s):
Nurse(s):
|
| 9 | Flanagan (2009) | 31 patients and 4 nurses in pre‐surgery clinics | Evaluating pre‐surgery nursing practice model derived from nursing theory |
Client(s):
Nurse(s):
|
|
Client(s):
Nurse(s):
|
| 10 | Kweon and Lee (2009) | 6 depressive adolescents | Exploring health experience of adolescents with depression | Client(s):
|
|
Client(s):
Nurse(s):
|
| 11 | Fujiwara and Endo (2017) | A patient with cancer and her family amid a difficult health situation | Practicing caring partnership with a client who could not share their desires and find their future direction in a gear change period and documenting the process of their relational changes within this process |
Client(s):
Nurse(s):
|
|
Client(s):
|
| 12 | Mitsugi (2019) | A client facing a chaotic experience at the end of life and a nurse | Exploring patterning process between a client facing chaotic experience and a nurse |
Client(s):
Nurse(s):
|
|
Client(s):
Nurse(s):
|
| 13 | Imaizumi et al. (2021) | 3 patients in cancer treatment phase | Demonstrating helpfulness and possibility of ‘caring partnership’ with patients in the treatment phase based on Newman's health as expanding consciousness theory |
Client(s):
Nurse(s):
|
|
Client(s):
Nurse(s):
|
2.1.4. Validation Process
To ensure the credibility and rigour of the analysis, two researchers independently reviewed and analysed all selected articles. Each researcher identified attributes, antecedents and consequences separately, followed by a comparison of results. In cases of disagreement, the researchers engaged in repeated discussions to reach consensus. When necessary, the original texts were re‐examined to ensure that interpretations were grounded in the data. This iterative validation process enhanced the trustworthiness of the findings.
Following this process, we selected the concept of ‘caring partnership,’ established the purpose of this concept analysis and identified its attributes based on information from various sources. To achieve this, we examined all content related to caring partnership in the 13 selected articles and identified common attributes among them. In addition, content deemed important, even if not commonly found, was included. The analysis incorporated not only direct expressions from the subjects in each selected study but also each researcher's interpretations and findings.
Two researchers identified the attributes, antecedents and outcomes of caring partnership through a process of content analysis and discussion. This iterative process was repeated until consensus was reached. Subsequently, we developed model, borderline, related and contrary cases. These case scenarios were constructed based on the researchers' clinical and academic backgrounds. To understand the context in which caring partnership emerges, we identified the antecedent factors that precede the concept as well as the factors that result from it. Finally, we defined the empirical referents for the attributes that constitute the concept of caring partnership identified in this study.
2.1.5. Data Extraction
Data extraction was conducted using a structured approach. Key information from each selected article—including definitions, attributes, antecedents, consequences and contextual descriptions—was extracted and organized into a comparison matrix. The researchers independently reviewed and coded the data, followed by discussions to resolve discrepancies and refine categories. This process ensured consistency and rigor in identifying the defining attributes of the concept.
2.1.6. Reflexivity
This concept analysis involves interpretive processes that may be influenced by the researchers' clinical and academic backgrounds. The researchers have experience in nursing practice and are familiar with relational and humanistic nursing theories, including Newman's Health as Expanding Consciousness. To minimize potential bias, the researchers engaged in continuous reflection throughout the analysis process, critically examining their assumptions and interpretations. Regular discussions were conducted to ensure that the findings remained grounded in the literature rather than personal perspectives.
2.2. Ethical Considerations
This study was a concept analysis based on previously published literature and did not involve human participants or identifiable data. Therefore, ethical approval was not required.
3. Results
3.1. Concept Selection
Caring partnership (Moore 2004) was selected for concept analysis. As an abstract concept, caring partnership is challenging to define and implement in practice due to its philosophical and ontological nature.
3.2. Purpose of Concept Analysis
The purpose of this concept analysis is to identify the attributes of ‘caring partnership’ and provide a clear conceptual definition based on Newman's Health as Expanding Consciousness theory. This analysis aims to enhance conceptual awareness in nursing practice and facilitate its effective application.
3.3. Identification of the Scope of the Concept
3.3.1. General Meaning of ‘Caring Partnership’
By definition, caring signifies displaying kindness and concern for others. The English word ‘care’ encompasses meanings such as ‘providing what someone needs for their health, nurturing, looking after, giving attention, and feeling of worry’ (Oxford Dictionary). Partnership refers to a relationship between two people or organisations or the state of having such a relationship. Initially introduced in the 1700s, the term began to be used in law and industrial development in the 1800s to indicate ‘co‐ownership.’ Over time, it expanded to include attributes such as dedication, coordination, trust, quality of communication, participation and conflict resolution skills, extending into various fields, including economics, politics, education, social sectors and healthcare settings.
In healthcare, partnerships are applied in contexts such as health policy and law, healthcare systems and relationships between long‐term care facility staff and caregivers, as well as between parents of paediatric patients and nurses (Jeong 2020). A ‘caring partnership’ specifically refers to a partnership that displays kindness and concern for others, particularly prevalent in companies and organisations providing community‐based home care services. It emphasizes reflecting individual needs when caring for older adults, children and individuals requiring care due to illness.
3.3.2. Use of ‘Caring Partnership’ in the Literature
3.3.2.1. Use of the Concept in Other Disciplines
In the field of education, Noddings (2012) used the term ‘caring relation,’ emphasising care focused on human emotions and relationships in education. In primary medicine, a caring partnership is described as a union between patients and physicians based on mutual trust to achieve set goals. It becomes crucial during the transition from a market‐centred healthcare industry to the acceptance of health as a social benefit. Physicians should be prepared to establish a caring partnership with patients by treating them with sincerity and respect. Ethical principles—beneficence, non‐maleficence, justice and respect for persons—serve as the foundation for a caring partnership (Balint 2005; Shapiro et al. 2003).
3.3.2.2. Use of the Concept in Nursing
In nursing, care is a key concept that characterizes nursing practice. It involves a series of activities aimed at helping others, requiring attention, dedication, interpersonal relations and a scientific and systematic process. Care must be preceded by an awareness of others' need for help, coupled with the moral and cognitive motivation to assist them. The outcomes of care include healing, satisfaction and growth for both the caregiver and the recipient (Lee 1996). Care is a unique relational construct distinct from concepts such as exchange, communication and role relationships, involving both the caregiver and the recipient. Nurses transform care into nursing care by embodying intentional care in their relationships with clients (Kim 2010).
A caring relationship, similar to a caring partnership, is defined as a helping relationship involving interactions between a nurse and a client. It is foundational to nursing and aims to meet the healthcare needs of individuals under treatment. Considered a nursing intervention, a caring relationship requires specific training, as with other nursing skills. The nurse–patient relationship, a typical form of a caring relationship, involves interaction, communication, respect for ethical values, acceptance and empathy to encourage self‐reflection and behavioural change. Its main components include communication, active listening and respect (Allande‐Cussó et al. 2022). Thus, a caring relationship is one that supports the client, distinguishing nursing from other professions.
Traditionally representing the nurse‐client relationship, the caring relationship—defined as the nurse providing care and the client receiving care—evolved with the promotion of democratic thinking in healthcare relationships and endeavours to respect basic human rights, transforming into a nurse‐client partnership (Gallant et al. 2002). A nurse‐client partnership is a respected and negotiated method of collaboration within an honest and reliable relationship based on empathy, support and mutualism, which enables choice, participation and equity (Bidmead and Cowley 2005). Compared to a caring relationship, a caring partnership places greater emphasis on mutual cooperation towards a common goal and mutual growth between nurses and clients.
The term ‘caring partnership’ has been primarily used in studies based on Newman's theory. It has also been used to describe palliative care nursing (Morgan 2001), relationships among families or healthcare staff caring for patients with illnesses (Maas et al. 1994; Ryan and McKenna 2013) and relationships between two hospitals that share expertise (Moore 2004). Morgan (2001) stated that an effective caring partnership among nurses, patients and caregivers encompasses harmony in working towards common goals and that nurses should encourage patients and caregivers to become active participants in making important decisions affecting future treatments. Furthermore, Morgan highlighted the importance of the nurse's ability to foster a spirit of collaboration in the development of a caring partnership, requiring high‐level interpersonal skills and self‐awareness to transform authoritarian and oppressive behaviours into collaborative support. Based on the health as expanding consciousness theory, nursing involves being fully present with the client without judgement, goals or intervention strategies, forming a caring partnership by simply being with them as opposed to doing something for them (Pharris 2002). Nurses focus on forming relationships and being with clients rather than measuring effective actions for change. In a caring partnership, nurses and clients explore and share understandings, supporting transformative power (Newman 2008). Thus, rather than attempting to treat the client from a medical diagnostic perspective, it provides the opportunity for the client to know themselves better, find meaning in their current situation and life and gain insights about the future (Gong 2004).
Nursing is not about changing the client's existing patterns; rather, it involves recognising the client's patterns based on information representing the whole picture and relating to the client's patterns as they are. The nurse‐client energy fields interpenetrate amid the building of such relationships, allowing the client to become aware of their patterns and find meaning (Endo 1998). Litchfield (1999) viewed the caring partnership as one of the processes of praxis in nursing, interacting with pattern recognition, dialogue and health as dialectic (Figure 2). A caring partnership can facilitate the client's connectedness with the environment, with the potential for healing and growth within various health experiences (Yeo 2019). Nurses can directly witness healing in their clients' bodies depending on their vitality, sensation for themselves and personal relationships, and they may also note transformations that occur within themselves (Pharris 2002; Newman 2008).
FIGURE 2.
A process of praxis in nursing (Litchfield 1999).
In essence, a caring partnership in nursing is fostered as the nurse and client interact with a common goal and interest. This interaction encompasses presence, mutual trust and connectedness. It enhances the client's ability to act for themselves, while the nurse can experience healing, satisfaction and growth, as with their clients. Therefore, the caring partnership is distinct from other similar concepts—it affects bidirectional transformations.
3.4. Decisive Attributes of the Concept
The following decisive attributes of caring partnerships were presented by all selected studies. The first is ‘presence’. This involves entering the client's life with respect for human beings. It is a conscious act where the body, mind and soul are fully present to the client and represents a type of non‐sensory understanding of the other's existence. The second attribute is ‘mutual trust’. This is the belief shared between the nurse and client that they will be honest and truthful and will not cause harm to each other, and the trust in the infinite potential, intuition and transformative power of the individual, regardless of what happens in the present moment. The third attribute is ‘connectedness’. This attribute represents a relationship connected by energy that resonates simultaneously and bidirectionally in the present moment. As it entails an acceptive, supportive, respectful, considerate and empathetic interaction, the client's genuineness may be revealed from one moment to another.
3.5. Model Case and Secondary Cases of the Concept (Borderline Case, Related Case, Contrary Case)
A model case includes all the decisive attributes of the concept. Based on the three decisive attributes of caring partnerships identified in this study, we developed the following model case:
A 55‐year‐old Mr. Z was diagnosed with congestive heart failure in his early 40s and has been repeatedly hospitalized and discharged. He has been receiving medication for depression at an outpatient psychiatric clinic owing to a recent suicidal ideation. This time, as heart failure worsened again, severe dyspnoea occurred and he was admitted to the hospital. While Mr. Z was anxious and scared due to dyspnoea, he thought it would be better to just die. Nurse A, who was the primary nurse for Mr. Z, understands the importance of a caring partnership. With a unitary perspective, Nurse A approached Mr. Z with a warm smile, introduced herself and sat beside his bed, explaining the ordered tests while making eye contact. She encouraged Mr. Z to express his health concerns and personal fears and worries. Nurse A actively listened to Mr. Z and his caregiver, empathized with his situation and was present with him. While connected to various tubes and monitoring devices, Mr. Z dozed off for a moment and suddenly tried to get out of bed, so Nurse A went to his bedside. Seeing Nurse A, Mr. Z sat down again and shed tears. Nurse A accepted his state and supported him so that he could lean on her. Mr. Z experienced dyspnoea and hyperventilation, the typical symptoms of pulmonary edema and Nurse A informed Mr. Z that she would give him the prescribed medications for these symptoms. She helped him into a posture that could ease his dyspnoea and help him relax. She made a plan to perform position change, aspiration, back massage and vital sign measurements at once and explained this to Mr. Z to obtain consent. This was to reduce stimuli for him to sleep well through the night. As Mr. Z's urine output decreased and oxygen saturation dropped, Nurse A promptly notified the physician to provide appropriate treatment, administered the medications and stayed with him until his condition improved. Nurse A developed a nursing plan with Mr. Z and explained the test results and physical changes in a way he could understand. During their conversation, Mr. Z started talking about something that he had not told anyone else, saying that he believed it was okay to tell her about it. Mr. Z spoke about his worsening relationship with his mother due to repeated hospitalisations as his symptoms cycled through improvement and worsening. He also had postponed his wedding to his fiancé due to the onset of his illness, which now has been called off. He said that every time he experiences dyspnoea, he gets reminded of the traumatic memories where his stepfather used to strangle him when he was a child. He explained that his stepfather pushed him hard to the wall and strangled him for playing pranks on his younger stepbrother and that his stepfather's violent abuse continued without his mother knowing. As he told his story, Mr. Z cried and Nurse A held him quietly. After some time, Mr. Z apologized for revealing his secrets abruptly. Nurse A told him it was an honour because it meant that he trusted her. Moreover, she told Mr. Z that she would help him look for a trustworthy counsellor if he wished to seek counselling. As Mr. Z's condition stabilized and improved, Nurse A discussed the necessary education after discharge with Mr. Z and his caregiver. The education included not only complication prevention and self‐care for congestive heart failure but also depression management. At discharge, Mr. Z said that he would tell his mother about his stepfather when he returned home after discharge and expressed gratitude for Nurse A's kindness, detailed explanations, encouragement during tough times and help in improving his relationship with his mother. Nurse A experienced a process in which she truly got to know her patient rather than merely focusing on medical diagnosis or problem‐solving. She realized the impact of her work on patients' lives and their families and gained confidence in her work. The experience of being with the patient led Nurse A to see herself in a new light and realize her transformation.
3.6. Secondary Cases of the Concept (Borderline Case, Related Case, Contrary Case)
Reviewing different cases is another process of internal dialogue. Examining cases similar or contrary to the concept of interest facilitates making better judgements about the most fitting attributes or characteristics. Reviewing various types of cases that have been proven useful in the past allows for an assessment of what the attributes of the concept of interest explain and do not explain (Walker and Avant 2021).
3.6.1. Borderline Case
A borderline case includes most, but not all, attributes of the concept. While it may contain most or all attributes, the duration or intensity of occurrence might differ fundamentally (Walker and Avant 2021).
A 55‐year‐old Mr. Z was diagnosed with congestive heart failure in his early 40s and has been repeatedly hospitalized and discharged. He has been receiving medication for depression at an outpatient psychiatric clinic owing to a recent suicidal ideation. This time, as heart failure worsened again, severe dyspnoea occurred and he was admitted to the hospital. While Mr. Z was anxious and scared owing to dyspnoea, he thought it would be better to just die. Nurse B, the primary nurse for Mr. Z, introduced herself with a warm smile, sat beside his bed and explained the nursing plan while making eye contact. She encouraged Mr. Z to express his health concerns and personal fears through questions and actively listened to Mr. Z and his caregiver, empathising with him and being present. While connected to various tubes and monitoring devices, Mr. Z dozed off for a moment and suddenly tried to get out of bed, so Nurse B went to his bedside. Seeing Nurse B, Mr. Z sat down again and shed tears. Nurse B accepted his emotions and helped him to stabilize safely. Mr. Z demonstrated dyspnoea and hyperventilation, the typical symptoms of pulmonary edema and Nurse B informed Mr. Z that she would give him the prescribed medications for these symptoms. She helped him into a posture that could ease his dyspnoea and help him relax. She made a plan to perform position change, aspiration, back massage and vital sign measurements at once and explained this to Mr. Z to obtain consent. This was to reduce stimuli for him to sleep well through the night. As Mr. Z's urine output decreased and oxygen saturation dropped, Nurse B promptly notified the physician to provide appropriate treatment, administered medications and stayed with him until his condition improved. Nurse B developed a nursing plan with Mr. Z and explained the test results and physical changes in a way he could understand during each of her shifts. As Mr. Z's condition stabilized and improved, Nurse B encouraged self‐care and educated Mr. Z to prevent potential complications while encouraging the caregiver to participate in the treatment as well. During discharge, Mr. Z expressed gratitude for Nurse B's kindness, detailed explanations about the progress and encouragement during tough times and Nurse B felt rewarded.
3.6.2. Related Case
A related case is regarding the concept of interest but does not include all attributes of the concept. It is similar to the concept of analysis and somewhat linked to it. Although it is considerably similar to the concept of analysis, it gives other ideas when reviewed closely; it clarifies what the attributes of the concept of analysis explain and do not explain (Walker and Avant 2021).
A 55‐year‐old Mr. Z was diagnosed with congestive heart failure in his early 40s and has been repeatedly hospitalized and discharged. He has been receiving medication for depression at an outpatient psychiatric clinic owing to a recent suicidal ideation. This time, as heart failure worsened again, severe dyspnoea occurred and he was admitted to the hospital. While Mr. Z was anxious and scared owing to dyspnoea, he thought it would be better to just die. Nurse C, the primary nurse for Mr. Z, introduced herself and explained the work plan. She tried to listen carefully to Mr. Z and his caregiver and resolve their discomfort. While connected to various tubes and monitoring devices, Mr. Z dozed off for a moment and suddenly tried to get out of bed, so Nurse C went to his bedside. Seeing Nurse C, Mr. Z sat down again and shed tears. Nurse C helped him to stabilize safely. Mr. Z demonstrated dyspnoea and hyperventilation, the typical symptoms of pulmonary edema and Nurse C informed Mr. Z that she would give him the prescribed medications for these symptoms. She helped him into a posture that could ease his dyspnoea and help him relax. She then performed position change, aspiration, back massage and vital sign measurements at once to reduce stimuli for him to sleep well through the night. As Mr. Z's urine output decreased and oxygen saturation dropped, Nurse C promptly notified the physician to provide appropriate treatment, administered the medications and monitored him until his condition improved. Nurse C explained the test results and physical changes to Mr. Z during each of her shifts. As Mr. Z's condition stabilized and improved, Nurse C encouraged self‐care and educated Mr. Z to prevent potential complications. During discharge, Mr. Z expressed concern that he might be hospitalized again even though his condition has improved.
3.6.3. Contrary Case
A contrary case is one not related to the concept. Identifying what a concept is does not help in understanding how the concept under analysis differs from the contrary case (Walker and Avant 2021).
A 55‐year‐old Mr. Z was diagnosed with congestive heart failure in his early 40s and has been repeatedly hospitalized and discharged. He has been receiving medication for depression at an outpatient psychiatric clinic owing to recent suicidal ideation. This time, as heart failure worsened again, severe dyspnoea occurred and he was admitted to the hospital. While Mr. Z was anxious and scared due to dyspnoea, he thought it would be better to just die. Nurse D, the primary nurse for Mr. Z, checked to confirm that the tubes and monitoring devices were well connected and checked Mr. Z's status through those monitors. When Mr. Z dozed off for a moment and suddenly tried to get out of bed, Nurse D went to his bedside and laid him down again. She told Mr. Z not to sit up again and organized the lines. She paid attention to the patient's physical needs, such as performing position changes, aspiration, back massage and vital sign measurements, as well as administering medications at the scheduled times. Nurse D did not spend time talking with the patient. The patient exhibited anxiety and fear of the symptoms and hospital environment, but the nurse simply informed the patient that the treatment was going as planned and that he would get better in time. Instead of interacting with the client, Nurse D was focused on completing the task. The family complained to the nurse, but Nurse D dismissed their complaints, saying that she was doing everything she could to address the patient's physical needs.
3.7. Antecedents and Consequences of the Concept
The antecedents of a caring partnership refer to the setting in which care occurs. These are contexts where clients and nurses meet, not only in healthcare facilities but also at patients' homes and throughout the community. Clients lacking connectedness often experience suffering, chaos, distress or predicament at a point in life with no clear path. To foster caring partnerships, nurses should have a good grasp of health by expanding consciousness theory, adopting a unitary perspective and engaging in self‐reflection. As a consequence of a caring partnership, clients can recognize their potential, improve severed relationships and find new rules in life. This is referred to as a transformation. Experiencing the power of transformation boosts nurses' confidence in practice (Table 2).
TABLE 2.
Antecedents, attributes and consequences of caring partnership.
| Antecedents | Attributes | Consequences |
|---|---|---|
|
Setting
Client(s)
Nurse(s)
|
Caring partnership
|
Client(s)
Nurse(s)
|
3.8. Definition of Empirical Referents
Empirical referents are categories or distinctions of actual phenomena that indicate the presence or occurrence of a concept. Often, attributes and empirical referents are the same (Walker and Avant 2021). There have been no prior studies using empirical tools to assess the existence or effectiveness of a caring partnership between nurses and clients. There are tools measuring interactions, care behaviours and therapeutic relationships between nurses and patients, as well as partnerships between nurses and caregivers of paediatric patients (Choi and Bang 2013; Coelho et al. 2021; Cossette et al. 2006; Wu et al. 2006). However, these tools only measure a similar concept to caring partnerships and do not encompass all attributes of caring partnerships. The empirical referents of caring partnership derived from these tools measuring similar concepts are presented in Table 3.
TABLE 3.
Empirical referents of caring partnership.
| Attribute | Empirical referents | Source |
|---|---|---|
| Presence | Understanding and accepting the patient, regardless of their verbalisations | TRAS |
| Understanding the patient's feelings | TRAS | |
| Being empathetic or identifying with the patient | CBI‐24 | |
| Spending time with the patient | CBI‐24 | |
| Mutual trust | Acting in such a way to gain the patient's trust | TRAS |
| Treating the patient as an individual | CBI‐24 | |
| Allowing the patient to express feelings about their disease and treatment | CBI‐24 | |
| Considering patients as complete individuals, showing interest beyond their health problem | CNPI | |
| Basic trust in each other | PNPPS | |
| Connectedness | Attentively listening to the patient | CBI‐24 |
| Helping the patient grow | CBI‐24 | |
| Being patient or tireless with the patient | CBI‐24 | |
| Helping the patient look for a certain equilibrium/balance in their lives | CNPI | |
| Helping the patient recognize means to resolve their problems efficiently | CNPI |
Source: TRAS (Therapeutic Relationship Assessment Scale‐Nurse), CBI‐24 (Caring Behaviours Inventory‐24 items), CNPI (Caring Nurse–Patient Interaction—short scale), PNPPS (Paediatric Nurse Parent Partnership Scale).
In this study, a caring partnership was defined based on a concept analysis as the meaningful connection formed between a nurse and client through mutual trust and complete presence with each other. It involves nurses helping clients in challenging situations to discover meaning and is a nursing intervention that facilitates expanded consciousness for the client and nurse. This operational definition provides a clear basis for future measurement, empirical testing and application of the concept in both research and clinical nursing practice.
3.9. Conceptual Framework
Based on the identified antecedents, attributes and consequences, a conceptual framework of caring partnership was developed (Figure 3). The framework illustrates caring partnership as a dynamic process that emerges from specific contextual conditions and leads to transformative outcomes for both the client and the nurse. Antecedents such as client distress, a nurse's unitary perspective and self‐reflection create the conditions for the development of a caring partnership. Within this context, the interaction between nurse and client is characterized by presence, mutual trust and connectedness. These attributes collectively form the core of the caring partnership. As a result of this process, clients are able to find meaning in their experiences, restore relationships and undergo personal transformation. Simultaneously, nurses experience professional growth, increased confidence and transformation. This framework highlights the bidirectional and transformative nature of the caring partnership.
FIGURE 3.
A conceptual framework caring partnership.
4. Discussion
We conceptualized a caring partnership based on Newman's theory using concept analysis and identified three attributes: presence, mutual trust and connectedness. Below, we primarily discuss these three attributes of a caring partnership.
The first attribute is ‘presence’. Presence means entering the life of a client with respect for human beings. It is a conscious act where the body, mind and soul are fully engaged and represents a non‐sensory understanding of the existence of the other. In the nurse‐client relationship, presence means being fully open to whatever happens, being attentive to care and uniting with the client to facilitate transformation (Newman 2008). In the study by Endo et al. (2005), nurses could see things they had not seen before and better understand their clients by being present without the obligation to do something to alleviate their suffering. Presence allows nurses to fully focus their attention on the client, listen to meaningful stories and create an enriching environment for the clients, aiding them in recognising their patterns through insights (Fujiwara and Endo 2017; Mitsugi 2019; Picard and Mariolis 2002). For clients, simply having someone by their side and being watched over in a crisis where previous coping mechanisms are ineffective can be of significant comfort and the experience of being fully understood, empathized with and accepted can itself be a transformative power (Gong 2004; Kweon and Lee 2009).
The second attribute is ‘mutual trust’. Having mutual trust means consistently believing in an individual's infinite potential, intuition and transformation, regardless of what happens in the present moment. Nurses must trust that the client knows what they should do and empower them to continue doing that (Gong 2004; Rosa 2006). Endo et al. (2005) reported that nurses developed a new understanding of the roles and responsibilities of nursing as they realized their typical patterns of care, excessive passion and unilateral help when they do not believe in the client's potential. In a study by Imaizumi et al. (2021), nurses believed that anyone can utilize their inner strengths to find new ways of life when faced with hardship and this belief allowed them to continue fostering caring partnerships with clients facing difficulties. Clients can develop trust in nurses who observe their difficulties and willingly partake in resolving the challenges with them (Kweon and Lee 2009). As trust develops, clients can discuss their actions that they had not shared with other people before (Pharris 2002).
The third attribute is ‘connectedness’. This refers to a relationship that provides energy for new perspectives or directions, is simultaneous and bidirectional and resonates in the present moment. This relationship can be visualized as ripples created by throwing two pebbles into water (Newman 1994). Nurses use intuition and sensitivity to decide what to talk about and what questions to ask the client, striving to maintain a non‐judgmental, supportive and genuine relationship in their interactions. This involves trying to understand the feelings of the clients when they speak and making an effort to listen to what they cannot express (Endo et al. 2000; Gong 2004). Rather than focusing solely on the disease narrative, nurses pay attention to transcendence and change as a transition to their entire life story (Neill 2002). Nurses act as facilitators in providing clients with a sense of self‐esteem and value so that they experience and recognize the value of meaning and aspects. Clients recognize that they are respected as their nurse acknowledges them, attentively listens and continuously pays attention to them, through which they gain confidence in their existence and actions (Endo et al. 2000; Flanagan 2009; Kweon and Lee 2009; Sim 2005).
The caring partnership has a different theoretical foundation from the transpersonal Caritas relationship in Watson's caring science theory, yet it shares conceptual similarities in the essential elements of caring relationships. Watson stated that transpersonal Caritas relationships occur when a caregiver connects with someone and seeks to embrace their spirit through genuine and complete caring, being fully present and conveying concern for the inner life of the other person and the personal meaning they attribute to situations, experiences and moments in their lives (Delgado‐Galeano et al. 2023).
Both Newman and Watson emphasize relationship‐centred care, approaching client care through the unitary transformative paradigm in nursing (Newman 2008; Perkins 2021). Being present with the client in the caring partnership, recognising the client's patterns as they are and establishing a meaningful relationship align with Watson's concept of transpersonal caring and the fourth Caritas process: developing helping–trusting–caring relationships (Kathleen and Watson 2018; Perkins 2021). In addition, enabling patients to recognize patterns and find meaning through open, conversational interactions in the caring partnership aligns with Watson's concept of the caring moment (Alligood 2014).
However, the caring partnership and the transpersonal Caritas relationship differ in their approach and focus. Watson emphasizes forming a transpersonal caring relationship in which patients and nurses are deeply connected. This relationship is based on love and empathy, with nurses seen not merely as care providers but as beings who promote human and spiritual healing (Delgado‐Galeano et al. 2023). In contrast, Newman highlights the companion relationship between nurses and patients, where nurses create a supportive environment that enables patients to recognize their patterns and find meaning in their experiences (Imaizumi et al. 2021).
Applying the caring partnership in practice while integrating Watson's concept of the transpersonal Caritas relationship may lead to more comprehensive nursing care. In the future, comparative studies should explore how both theories address measuring the quality of caring relationships, their impact on clinical outcomes and well‐being and their potential to transform nursing education paradigms. Such analysis would clarify conceptual similarities and differences while advancing the identity of nursing as a humanistic and relational science.
A structured comparison between Newman's caring partnership and Watson's transpersonal caring relationship is presented in Table 4 to further clarify their conceptual similarities and differences. While both theories emphasize relational and humanistic approaches to care, the concept of caring partnership provides additional insights by explicitly framing the nurse–client relationship as a mutual and evolving partnership rather than a primarily nurse‐led caring interaction. Unlike Watson's framework, which focuses on the nurse's role in delivering transpersonal caring, the caring partnership emphasizes reciprocal engagement and shared transformation. This perspective highlights the client as an active co‐participant in meaning‐making, thereby extending existing relational theories by emphasising a dynamic and explicitly bidirectional process of transformation. Caring partnership differs from related concepts such as therapeutic relationships or caring relationships in that it explicitly emphasizes mutuality, co‐creation of meaning and transformation for both the nurse and the client. Rather than a unidirectional caring process, it represents a dynamic and reciprocal interaction grounded in a unitary perspective.
TABLE 4.
Comparison between Newman's caring partnership and Watson's transpersonal caring relationship.
| Aspect | Newman (caring partnership) | Watson (transpersonal caring) |
|---|---|---|
| Theoretical foundation | Health as expanding consciousness | Human caring science |
| Nature of relationship | Partnership (mutual, reciprocal) | Transpersonal (spiritual connection) |
| Role of nurse | Facilitator of pattern recognition | Provider of caring presence and healing |
| Role of client | Active participant, co‐creator of meaning | Recipient‐participant in caring moment |
| Key process | Pattern recognition, dialogue, transformation | Caritas processes, caring moment |
| Focus | Meaning‐making and transformation | Human dignity, love and healing |
| Outcome | Mutual transformation | Healing and harmony |
Rosa (2006) stated that the nurse‐client relationship is a mutually motivative process of building a partnership, understanding a particular situation, recognising response, choice and action and enhancing connectedness. Nurses provide support, reflection, care and teaching and verify healing during this process. Clients bring about their knowledge accumulated through their current situations (living with an illness) and their lifelong experiences. A caring partnership leads to the client's interactive and repetitive movements, where they discover their new self as facilitated by the nurse's intentional focus, knowledge and expertise, which leads to an appreciation of meaning and change. Newman (2008) stated that the focus of the nurse‐client relationship should be on the connection between the two. As we tend to view nurses and clients as separate entities, there is a tendency to observe the relationship from the outside. Nonetheless, Newman posits that it is necessary to view it from within and recognize the shared consciousness that arises. When the nurse is fully and faithfully with the client, this meeting forms a new dynamic pattern of integration. The nurse can leave when the client gains insight while together; even in the nurse's physical absence, the client can enter the centre of the resonance process. Thus, their transformative pattern continues even when they are apart.
4.1. Limitations and Strengths
Although this study employed a systematic literature search across multiple disciplines over the past 60 years, it is possible that some relevant studies on caring partnership were not included. In addition, despite following Walker and Avant's (2021) systematic approach, the identification of attributes and definitions relied on qualitative interpretation, which may have been influenced by the researchers' perspectives. Nevertheless, this study has several strengths. It provides a theoretically grounded and operationally defined concept of caring partnership based on Newman's Health as Expanding Consciousness theory. Unlike previous studies that have used the term interchangeably with related concepts, this study clearly differentiates caring partnership by identifying its defining attributes—presence, mutual trust and connectedness—and emphasising its bidirectional and transformative nature. Furthermore, this study offers a foundation for future research and practice by clarifying the concept and suggesting directions for the development of measurement instruments and educational interventions to enhance caring partnerships in clinical settings.
5. Conclusion
Through concept analysis using Newman's theoretical perspective, we found that a caring partnership is primarily defined as building a meaningful connection between nurses and clients through mutual trust and being fully present. In this relationship, the nurse helps the client find meaning in difficult situations and facilitates expanded consciousness in both the client and the nurse. This interaction encompasses presence, mutual trust and connectedness, enhancing the client's ability to act independently while allowing the nurse to experience healing, satisfaction and growth alongside their clients. Therefore, the caring partnership is distinct from other similar concepts in that it fosters bidirectional transformations.
6. Implications for Nursing Practice and Research
To exhibit evidence‐based nursing practice, it is essential to explain the phenomena in measurable or communicable ways. We conducted this study to examine the meaning and attributes of caring partnerships based on the health as expanding consciousness theory. In our concept analysis, a caring partnership was defined as building a meaningful connection between nurses and clients with mutual trust, being fully present and a nursing intervention that facilitates expanded consciousness in the client and nurse. This study is novel in that it provides theoretical evidence for research on caring partnerships as well as the implementation of the concept in clinical practice by defining it based on Newman's health as expanding consciousness theory. Subsequent studies should develop instruments for measuring caring partnerships and education programs that enhance caring partnerships, considering the attributes and definitions of the concepts derived in this study.
Author Contributions
Study conception and design: H.K., S.K. and S.J.J.; Data collection: H.K. and S.K.; Data analysis and interpretation: H.K., S.K. and S.J.J.; Drafting of the article: H.K., S.K. and S.J.J.; Critical revision of the article: H.K., S.K. and S.J.J.
Funding
This research was supported by the New Faculty Startup Fund from Seoul National University and the BK21 Four Project (Center for World‐Leading Human‐Care Nurse Leaders for the Future), funded by the Ministry of Education and the National Research Foundation of Korea.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
File S1: PRISMA 2020 checklist.
Acknowledgements
Artificial intelligence use statement: AI‐assisted tool (ChatGPT) was used for language editing purposes only. All content was reviewed and verified by the authors.
Data Availability Statement
The data presented in this study are available on request from the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
File S1: PRISMA 2020 checklist.
Data Availability Statement
The data presented in this study are available on request from the corresponding author.