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. Author manuscript; available in PMC: 2020 Nov 3.
Published in final edited form as: Nurs Inq. 2020 May 11;27(4):e12353. doi: 10.1111/nin.12353

A dimensional analysis of inner strength in people ageing with serious illness

Brianna E Morgan 1,2
PMCID: PMC7606643  NIHMSID: NIHMS1611353  PMID: 32394586

Abstract

Nursing models of care show promise in addressing the needs of older adults facing serious illness through supporting inner strength. However, previous conceptual and theoretical models of inner strength are limited. This concept analysis used dimensional analysis methods to explore inner strength in people ageing with serious illness to address limitations by defining a pragmatic, data-driven model. This study analyzed published literature of adults with serious illness that describes inner strength. Thirty articles were selected after review. The result was an explanatory matrix that describes inner strength from the perspective of where have I been, where am I going? within the context of being a person who is living and dies and you have a serious illness. The conditions spotlighting by actors around me and taking stock of others and ideas lead to processes of looking in/looking out and seeing me as I’m seen. The final consequence of this process is meeting me. This updated concept analysis of inner strength improves upon previous models by providing a clinically relevant situation-specific model of inner strength for people with serious illness. Implications for nursing scholarship and practice are described including exploration of person-centered care, relational practice, and health communication.

Keywords: ageing, concept analysis, palliative care, qualitative methods, symbolic interactionism

1 |. INTRODUCTION

Older adults are living longer, in part due to advances in medical science, public health initiatives, and global economic growth. However, the reality of an extended life expectancy for the majority of Americans includes living with multiple chronic conditions as they age (National Institute of Aging, 2016). Further, chronic illnesses make up seven out of the ten leading causes of death, so most will die from one of those conditions (Kochanek, Murphy, Xu, & Arias, 2019). Though nomenclature has changed over time, the terminal phase of chronic illness has more recently been called serious illness (Kelley, 2014). Serious illness impacts life expectancy, function, and overall well-being (Kelley, 2014). Understanding the resources that people use to respond to, process, and move forward with serious illness is key in targeting nursing-directed care for this population.

Inner strength encompasses ‘an internal developmental capacity that supports positive movement through challenging life events’ and has implications for quality of life (Smith, Dingley, & Roux, 2019, p. 38). Older adults living with serious illness may use inner strength as a resource. However, previous conceptual and theoretical models of inner strength are limited in their applicability to people in the terminal phase of a chronic illness. A refined understanding of the nature of inner strength is imperative for informing nursing care that addresses the needs of people who face ageing with serious illness.

2. |. BACKGROUND

2.1 |. Inner strength

Two paradigms conceptualize inner strength in nursing literature—North American and Nordic (Smith et al., 2019). The North American paradigm explores inner strength through a feminist lens by conceptualizing inner strength in women with illness. The Nordic paradigm grounds inner strength in salutogenesis by focusing on healthy ageing in both men and women. While both paradigms reflect the nursing principles of a wellness and person-centered approach, each has limitations when applied to serious illness.

2.1.1 |. North American paradigm

Healthy psychological functioning of women was sparsely represented in the 1970s and 80s. In order to fill this gap and align with the wellness focus of nursing care, scholars highlighted psychological well-being in women and began to conceptualize inner strength through a feminist lens in women with chronic illness (Rose, 1990). Over the subsequent decade, the theory of inner strength (Figure 1), a middle-range theory, was developed with potential implications for nursing practice, suggesting that supporting inner strength would lead to ‘well-being and healing’ (Roux, Dingley, & Bush, 2002, p. 93). Inward reflection, external connection, and finding a ‘new normal’ were key elements to inner strength (Dingley, 1997;Dingley, Roux, & Bush, 2000;Roux & Keyser, 1994). The presence of a challenging, sentinel event was a necessary antecedent though one study suggested that inner strength could also occur throughout the life course (Moloney, 1995;Roux et al., 2002).

FIGURE 1.

FIGURE 1

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Middle-range theory of inner strength (Dingley & Roux, 2014)

The relationship between the person living with illness and healthcare was largely missing from the initial theory of inner strength (Roux et al., 2002). A hermeneutical study added this perspective by exploring the experience of women with multiple sclerosis (Koob, Roux, & Bush, 2002). The authors found that women experienced anguish as a response to perceived judgement by healthcare providers, including nurses (Koob et al., 2002). As a result, the characteristic of anguish was added to the model of inner strength (Dingley & Roux, 2014). Empirical exploration using a questionnaire developed from the theory of inner strength showed inner strength correlated with lower depression and stress (Lewis & Roux, 2011). Further, inner strength explained a large portion of the variance of quality of life, along with time since diagnosis, and depression in a group of North American female cancer survivors (Dingley & Roux, 2014). Though empirical evidence is minimal, there is a hypothesized relationship linking inner strength and its correlates to self-management. This demonstrates the potential for clinical applicability, but, as of yet, there has been no further study.

2.1.2 |. Nordic paradigm

A second group of nurse researchers explored related phenomena to identify the core concepts of inner strength using qualitative meta-synthesis (Lundman et al., 2010). Their initial qualitative and foundational theoretical work was situated from the perspective of salutogenesis, which focuses on gains related to healthy ageing and wellness in contrast to losses from disease and decline (Lundman et al., 2010;Nygren, Norberg, & Lundman, 2007). The authors completed a literature search of overlapping concepts correlated with inner strength—resilience, sense of coherence, hardiness, purpose in life, and self-transcendence (Lundman et al., 2010). Connectedness, creativity, firmness, and flexibility emerged as core concepts of inner strength (Lundman et al., 2010). While similar concepts to connectedness, creativity, and flexibility were reflected in the theory of inner strength, firmness was unique to this work and corroborated by early qualitative work (Lundman et al., 2010;Nygren et al., 2007).

Similar to the North American paradigm, the Nordic paradigm also generated a quantitative survey based on the researchers’ meta-synthesis (Lundman et al., 2011). Inner strength was higher in Nordic women than men and decreased with increasing age (Viglund, Jonsén, Lundman, Strandberg, & Nygren, 2013). There was no difference across cultural groups (Viglund et al., 2013). Further testing showed that inner strength may mediate the relationship between illness and self-rated health as higher inner strength was associated with better self-rated health, while having an illness was associated with poorer self-rated health and lower inner strength (Viglund, Jonsén, Strandberg, Lundman, & Nygren, 2014). Finally, the Nordic paradigm explored their theoretical model in people who age with illness (Viglund, Jonsén, Lundman, Nygren, & Strandberg, 2017). Older adults with high levels of inner strength were targeted for qualitative interviews. Results confirmed the constructs of connectedness, flexibility, and creativity and highlighted themes of focusing on the positive and belief in a higher power (Viglund et al., 2017).

3 |. SIGNIFICANCE AND PLAN

There are significant theoretical, sampling, methodologic, and pragmatic limitations to the foundational work in inner strength that deserve attention. This study proposes to address these limitations through a concept analysis of existing literature using dimensional analysis methods. Dimensional analysis is a data-driven qualitative analysis that uses open, axial, and theoretical coding along with dimensionalizing and an explanatory matrix to create a situation-specific theory (Schatzman, 1991).

The existing paradigms of inner strength have theoretical bases in feminism and salutogenesis that limit their applicability to ageing with serious illness. The North American paradigm’s roots in feminism exclude the experience of inner strength in men and focuses on the early stages of chronic illness (Roux et al., 2002). The Nordic model’s roots in salutogenesis favor a focus on healthy ageing by excluding those with illness (Lundman et al., 2010). Although more recent work explores inner strength in people with chronic illness, the research group only selects individuals who demonstrate high levels of inner strength (Viglund et al., 2017). Preferentially exploring the experience of successful ageing inherently focuses on outcomes rather than processes. Therefore, it eschews the experience of those people who may be in the process of coming to inner strength.

Population sampling also influences the presentation of inner strength in the literature. Early studies in the North American paradigm primarily focused on white middle-aged women, though later studies have included greater racial and sociodemographic diversity. The Nordic group, while including more gender diversity, has only explored inner strength in a Nordic population with little racial, cultural, and socioeconomic diversity. Finally, many participants were studied after the completion of a challenging circumstance, for example, during survivorship or after a hospitalization, rather than during the longitudinal illness experience itself (Dingley & Roux, 2014). Positive movement is often only attributed to those who have improved (Charmaz, 1983). Targeting people with serious illness, which by definition is progressive and terminal, will offer unique insight into this specific phase of illness.

Both paradigms also have methodological limitations. The Walker and Avant concept analysis used in the North American paradigm outlines a step-by-step process of analysis, which makes it attractive to process-oriented researchers. However, the method is rigid and lacks analytic tools to abstract the concept from contextual bounds. Additionally, the use of case examples in this method inserts the researchers’ bias and assumptions. The methodology in the Nordic paradigms explores inner strength within socially constructed paradigms, which may influence its interpretation. A data-driven approach lessens influence from bias and social construction.

Though many have suggested clinical implications of the two paradigms, neither has yet to be applied in the clinical setting, which leaves much of this theoretical work untested in the clinical context. The theory of inner strength is a middle-range theory, which may not be readily adaptable to specific clinical scenarios. While the Nordic paradigm suggests core constructs in their meta-synthesis, no clear theoretical model is depicted. In order to bring the principles of inner strength to the clinical setting, a more clinically relevant, data-driven, pragmatic theory is necessary.

This concept analysis aims to address the limitations of previous theoretical and conceptual work by exploring the nature of inner strength in people ageing with serious illness using dimensional analysis. It better meets the needs of a diverse and ageing population, the majority of whom age with illness, by focusing on people currently living with serious illness, regardless of their race, ethnicity, or gender. This work focuses on serious, life-limiting illness, rather than all chronic illness given that most of the population will die from a chronic illness and this phase of illness is under-represented. This work also considers ageing as a life course phenomenon and therefore includes all adults across the lifespan rather than solely people who are considered ‘old’ (Elder, 1998).

Dimensional analysis is a data-driven method aimed at abstracting complex concepts from their social bounds and reconstructing a pragmatic framework best suited to describe the concept (Schatzman, 1991). Applying dimensional analysis to the extant literature capitalizes on the available descriptions of inner strength and its related concepts without being constrained by social bounds. The explanatory matrix, the product of dimensional analysis, serves as the basis for situation-specific theory. Situation-specific theory, as opposed to middle-range theory, has direct clinical applicability in a specific population and offers greater opportunity to inform clinical care (Im, 2005).

4 |. METHODS

4.1 |. Dimensional analysis

Dimensional analysis (DA), like grounded theory, is rooted in a naturalist paradigm that assumes constructed ‘indeterminate realities and plural perspectives’ (Schatzman, 1991, p. 306). DA has explicit theoretical grounding in symbolic interactionism, which asserts that knowledge and meaning are created through social interaction (Kools, McCarthy, Durham, & Robrecht, 1996). Specifically, the basis for social interaction lies in the three premises of symbolic interactionism: (a) A person acts toward objects based on the meaning such objects have for that person, (b) the meaning an object has for a person is derived from social interactions with others, and (c) the meaning of an object is handled in and modified through an interpretive process (Blumer, 2005). In this method, constructed meaning is physical, social, and abstract (Blumer, 2005).

Analytic techniques in DA, grounded by its theoretical underpinnings, synthesize various data sources such as interviews and written work in order to generate situation-specific theory. Although this is a novel approach, dimensional analysis methods have been applied within a concept analysis framework to explore concepts as they are presented in the extant literature (Evered, 2020;Udlis, 2011). Two key tools served as the basis for analysis in DA—dimensionalizing and the explanatory matrix (Schatzman, 1991). Dimensionalizing breaks down a complex problem to its most basic ‘parts, attributes, interconnections, context, processes, and implications’ in order to reconstruct it with a new and clearer understanding (Schatzman, 1991, p. 309). The individual researcher drives reconstruction based on analytic requirement, experience, knowledge, and contextual understanding. Dimensionalizing occurs in a simultaneous or circular pattern with open, axial, and theoretical coding to determine ‘what all is involved’ in the phenomenon of interest (Schatzman, 1991).

The product of DA is an explanatory matrix. The matrix organizes salient conceptual components from theoretical and axial codes into a theoretical structure that serves as a situation-specific theory (Kools et al., 1996). The components include perspective, context, conditions, processes, and consequences. The perspective holds the greatest explanatory power and underlies all the components within the matrix. The context outlines the bounds of the matrix to describe what or who is included. Conditions facilitate, block, or shape the processes and consequences. Processes are the intended or unintended actions or interactions that occur in response to the conditions. Finally, consequences are the outcomes of the processes (Kools et al., 1996). The explanatory matrix serves as both an analytic tool and the outcome of this method (Schatzman, 1991). The matrix defines key components of a phenomenon and encourages the researcher to rotate components within the matrix to explore alternate meanings and explanations (Schatzman, 1991). The final explanatory matrix is the most fruitful configuration of components that best tells the story of the phenomenon (Schatzman, 1991).

4.2 |. Literature sampling

A literature search was conducted in collaboration with a library scientist. Search terms focused on pinpointing literature that describes inner strength from the perspective of the person with serious illness (see Supplementary Information 1). Serious illness search terms were an amalgam of search terms from previous work exploring a serious illness population and included diagnosis, prognosis, and health service-specific search terms (Bernacki & Block, 2014;Staszewska, Zaki, & Lee, 2017). The foundational work from both the North American and Nordic paradigms and related literature were used to guide search terms for inner strength (Dingley et al., 2000;Lundman et al., 2010). Databases included MEDLINE, EMBASE, CINAHL, and PsycINFO in order to explore the research question from a comprehensive view of health, which includes the perspective of biomedicine, nursing and allied health, and psychology and related fields. Search tools such as MeSH terms, truncation, and Boolean operators were used to expand or narrow searches as appropriate for each database. No date limitations were used as this concept is not time bound.

The author reviewed resulting abstracts using inclusion and exclusion criteria for article type, life stage, serious illness, and inner strength (Figure 2). This analysis focuses on the adult life stage only as issues of independence and dependence, which may influence inner strength, are socially constructed differently for children than adults (Harrison & Stuifbergen, 2005). Additionally, this analysis focuses on inner strength with serious illness as a person experiences ageing. Serious illness inclusion criteria were based on the definition described in the literature and generally accepted in the field of palliative care (Kelley, 2014). Literature included focused on the perspective of the person currently living with serious illness in order to stay true to a personally defined lens of inner strength. This study conceptualized strength broadly, as this is the main concept of interest. Gray literature, conference abstracts, dissertations, books, book reviews, and obituaries were outside of the scope of this study.

FIGURE 2.

FIGURE 2

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Inclusion/Exclusion criteria

The search resulted in 1,212 abstracts after de-duplication (Figure 3). The author reviewed all abstracts according to inclusion and exclusion criteria. Of those, 1,027 were excluded after abstract review. Full articles were retrieved for 185 sources as determination for inclusion could not be made using the abstract alone. All remaining articles were reviewed, applying the criteria. In total, 1,182 were excluded due to not meeting inclusion criteria for article type (21), language (3), life stage (95), serious illness (755), or inner strength (308). The resulting 30 articles used for analysis represented men and women aged 20 to 99 from 14 countries on four continents (North America, Europe, Asia, and Australia) (see Supplementary Information 2).

FIGURE 3.

FIGURE 3

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PRISMA flowchart of search strategy

4.3. |. Data analysis

The 30 articles produced in the literature review served as the data for analysis and were uploaded and analyzed in QSR International’s NVivo 12 software for open coding (QSR International Pty Ltd., 2018). Articles were randomly ordered to prevent undue influence from sequential articles by the same author. Open coding identified the smallest possible meaning units to break concepts from context (Kools et al., 1996). In order to closely address the research question at hand, codes were preferentially chosen from the perspective of the person with serious illness. Axial codes emerged as groups became clear and eventually reached a critical mass of dimensions that had some explanatory power (Kools et al., 1996). Both open coding and axial coding continued iteratively as new patterns emerged and others required further exploration (Kools et al., 1996). Dimensionalization, constant comparison, reflexivity, theoretical sensitivity, and memoing were used throughout in order to contextualize the researcher’s lens and biases and come to analytic insights (Kools et al., 1996;Rae & Green, 2016;Walker & Avant, 2011). Theoretical sampling was used to explore new concepts and clarify emerging ideas until theoretical saturation was reached (Kools et al., 1996). Finally, theoretical codes were developed and further analyzed using the components of the explanatory matrix (Kools et al., 1996). Rotating theoretical codes to different components of the explanatory matrix uncovered new meaning and explanation of the most salient dimensions. Through this process, the author determined a final matrix that best describes the phenomenon of inner strength through perspective, context, conditions, processes, and consequences.

5 |. THE EXPLANATORY MATRIX

The resulting explanatory matrix (Figure 4) outlines a situation-specific theory of inner strength. The perspective of where have I been, where am I going? grounds the entire matrix. Inner strength exists within the context of the tension between being a person who is living and dies and you have a serious illness. The conditions of spotlighting by actors around me and taking stock of others and ideas are specified by the processes of looking in/looking out and seeing me as I’m seen. The consequence of this process is meeting me. Articles cited in results are data referents.

FIGURE 4.

FIGURE 4

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Explanatory matrix

5.1 |. Perspective

The perspective of where have I been, where am I going? encompasses a person’s life as it has been lived as well as the future that they feel is ahead of them, as if positioned on a timeline looking back and forward. A person with serious illness describes looking back at ‘a whole life’ ‘over time’ influenced by experiences they or others have had (Franklin, Ternestedt, & Nordenfelt, 2006;Haug, DeMarinis, Danbolt, & Kvigne, 2016). They also describe who they are with respect to race, religion, culture, or roles in family, work, and society (Chao, Chen, & Yen, 2002;Henry et al., 2010;Sherman, 2001;Walker et al., 2017).

Individuals with serious illness describe a forward-looking perspective as they are ‘thinking of the future’ (Franklin et al., 2006). This may be influenced by their understanding of their illness. Some people describe ‘uncertainty’ in their future, while others describe ‘expectations’ for what is ahead (Franklin et al., 2006;Sherman, 2001). The future perspective is less clearly described than the process of looking back. Overall, a person’s perspective of where they have been and where they are going serves as the foundation on which a person experiences illness, others, and identity.

5.2. |. Contexts

5.2.1 |. Being a person who is living and dies

This context describes the aspects of being a human who is currently living and dies. Living is presented as a gerund to demonstrate that people state ‘I’m still alive’, even as they acknowledge that they are dying (Asgeirsdottir et al., 2013;Sherman, 2001). Dies is in present tense as people represent a spectrum of perceived closeness to death that may be correlated with actual closeness to death. Some people feel that they are currently ‘dying’, while others acknowledge that they will die in the future (Haug et al., 2016;Sherman, 2001). Some refer to death directly, while others refer to it in the abstract—’when I am gone’ (Asgeirsdottir et al., 2013;Franklin et al., 2006;Sherman, 2001). Regardless, death is present in this context of being human. Also inherent in this context is the spectrum of health and illness, described as ‘well’, ‘health’, ‘sick’, and ‘ill’ (Asgeirsdottir et al., 2013;Fromme & Billings, 2003).

5.2.2 |. You have a serious illness

This context comprises the medicalized aspect of having an illness (e.g., ‘diagnosis’ and ‘disease’) (Haug et al., 2016). You have a serious illness includes defining the illness through severity, where the person is along the timeline of illness, the symptoms of the illness, and its past and future treatments. Second person is used because of the external designation of illness onto a person. Inherent in this context is being a patient within the healthcare context, whereas being a person who is living and dies can exist outside of the healthcare context.

There is a tension in ownership between being a person who is living and dies and you have a serious illness represented as a spectrum. Some find that the medical aspects of illness are designated and owned by healthcare, such as ‘receiving the diagnosis’, while others take on diagnoses as part of their identity and humanness, such as ‘I am so sick’ (Haug et al., 2016;Sherman, 2001). Where a person sits along this spectrum is likely to influence the conditions, processes, and consequences.

5.3 |. Conditions

5.3.1 |. Spotlighting by actors around me

Spotlighting is the action of someone highlighting various aspects of a life with illness. Spotlighting includes two key components—the actor who directs the spotlight and the object of the spotlight. Also essential within these two components is the meaning that the actor and the object of the spotlight have for the person living with serious illness. The meaning for the person is what drives or inhibits a person’s process of engaging with inner strength. Meaning may be influenced by the relationship of the person to the actor and the nature of the object of the spotlight.

The actors who control the spotlight can be the person with serious illness themselves or the people and institutions around the person. Specific individuals and groups include ‘family’, ‘caregivers’, the ‘healthcare team’, and religious actors, such as ‘God’ and ‘church’ (Asgeirsdottir et al., 2013;Franklin et al., 2006;Fromme & Billings, 2003;Haug et al., 2016;Sherman, 2001). The nature of the relationship between the person with serious illness and the actor is not clearly defined in this study unless that actor is also part of the looking in/looking out and seeing me as I am seen process.

The presence and impact of losses as well as the past and future of illness are highlighted as objects of spotlighting. The ‘impact of the illness’ ‘with all its losses’ is highlighted more often than positive impacts of illness (Franklin et al., 2006). For example, physical losses are described, such as ‘bodily losses’ and ‘deterioration’ (Franklin et al., 2006;Sherman, 2001). How those losses impact the boundaries of a person’s ability, such as ‘dependency’, ‘inability’, or ‘limitations’, is often highlighted (Franklin et al., 2006;Fromme & Billings, 2003;Henry et al., 2010). Finally, the past and future of illness is described using both medicalized language, such as the ‘clinical course’, ‘prognosis’, or ‘side effects’, and person-centered language, such as ‘patient priorities’ and ‘personal story’ (Fromme & Billings, 2003;Haug et al., 2016;Rand et al., 2012;Walker et al., 2017). The future of an illness is described through its ‘vulnerability’, ‘challenges’, ‘uncertainty’, ‘change’, and ‘inescapability’ (Franklin et al., 2006;Fromme & Billings, 2003;Grumann & Spiegel, 2003;Sherman, 2001). These objects differ depending on the perspective, context, and the actor, though this is not thoroughly explored in this study. Finally, there is likely a correlation between actors and what is highlighted in the spotlight. For example, healthcare providers are likely more apt to mention prognosis, but this was not well defined by this method.

5.3.2 |. Taking stock of others and ideas

In addition to spotlighting, a necessary condition for the processes and consequences to occur is taking stock of those outside of oneself and of abstract ideas around illness. This step prepares the person for the action-oriented processes of looking in/looking out and seeing me as I am seen. Taking stock of those outside of oneself includes identifying those people and institutions with which one interacts. These people may also be the actors holding the spotlight. A person’s environment influences these groups. For example, those living in long-term care or hospitals are more likely to take stock of healthcare providers in addition to identified family (Franklin et al., 2006;Timmermann, Uhrenfeldt, Hoybye, & Birkelund, 2015).

There are also many abstract concepts and ideas around illness that people take stock of to determine what is important to them. These include ‘death’, ‘life after death’, ‘faith’, ‘spirituality’, ‘hope’, ‘purpose’, and ‘value’ (Asgeirsdottir et al., 2013;Franklin et al., 2006;Fromme & Billings, 2003;Grumann & Spiegel, 2003;Haug et al., 2016;Sherman, 2001). How people think about death and spirituality are major themes within this dimension. Ideas about death include a range of emotions, such as a fear, acceptance, and welcoming. Spirituality is present for people in a variety of ways, whether within a religious institution or through communion with nature or art. While these concepts are universal, not all ideas emerge in this process for all people.

5.4 |. Processes

5.4.1 |. Looking in/looking out

Looking in/looking out are internal and external processes that ultimately impact how a person perceives themselves. The process of looking in is an inward exploration of the self, including a review of the values and ideas identified in taking stock, the nature of one’s relationship to oneself, and the meaning that relationship provides for where the person is now. The process of looking out is an exploration of the meaning provided by the people, groups, and institutions outside of oneself identified in taking stock. Internal comparisons, such as ‘I used to’ and ‘but now I’, and external comparisons, such as ‘in relation to other people’ and ‘changed my whole family’, demonstrate that movement occurs during this process (Chao et al., 2002;Franklin et al., 2006;Sherman, 2001). These comparisons are done in the perspective of where I have been/where am I going? and facilitated or blocked by the ability of the person to take stock and the nature of spotlighting. The nature of internal and external relationships varies between ‘supportive’ and ‘caring’ to ‘judgmental’ and ‘distressing’ (Franklin et al., 2006;Rand et al., 2012;Walker et al., 2017). The meaning of these relationships to the person also varies between ‘important’ and ‘essential’ to ‘alienating’ and ‘isolating’ (Franklin et al., 2006;Fromme & Billings, 2003;Sherman, 2001). This process leads a person from taking stock to a new understanding of the meaning internal and external entities have for them.

5.4.2 |. Seeing me as I am seen

Being seen by others strongly influences one’s internal view of oneself and view of those around them. It is represented as a fulcrum tipping the looking in/looking out process. For example, just ‘being seen as the persons they are’ provides meaning for individuals and influences their view of themselves (Franklin et al., 2006). Further, this meaning influences their relationship with those outside of them—’my doctors and nurses have shown me’ something about myself (Sherman, 2001). Some people want to be seen as changed from their former selves, such as a former substance abuser who felt that he is now ‘seen as the good guy because I volunteer to help others’ (Sherman, 2001). Others want to be seen in their cherished roles ‘as a provider for their family’ or as ‘a doctor again’ (Fromme & Billings, 2003;Walker et al., 2017). Seeing me as I am seen demonstrates the influence others have on the internal process of exploring meaning for the person living with serious illness. As with looking in/looking out, seeing me as I am seen includes defining the nature of the relationship (e.g., ‘accepting’) and understanding the meaning for the person (e.g., ‘strengthened their identity’) (Asgeirsdottir et al., 2013;Franklin et al., 2006).

5.5 |. Consequences

5.5.1 |. Meeting me

The final step in this process is a new discovery of oneself called meeting me. While some people find or gain inner strength, others find a me that does not possess the type of inner strength described in previous theoretical models. Strength here is conceptualized as finding a me that is the result of the process of inward and outward reflection and is consistent with who the person sees themselves to be. The me that a person may meet can be varied and could include the new me, the reconfigured me, the maintained me, the strengthened me, the living with me, and the unchanged me. Versions of me are fluid and dynamic. One person may vacillate between versions throughout time or occupy multiple versions at once. There is no rank order to these outcomes and therefore no optimal outcome that individuals are meant to attain.

The new me includes ‘new identities’, ‘perspectives’, and ‘connections’ gained from the processes and exploration of self, others, and meaning (Haug et al., 2016;Sherman, 2001). The reconfigured me includes ‘changes’, ‘re-prioritization’, ‘reconciliation’, and ‘reframing’ of identity and relationships that perhaps the person had had prior, but are now different in some way (Chao et al., 2002;Franklin et al., 2006;Haug et al., 2016;Sherman, 2001). The maintained me describes people who maintain their identity and relationships despite the challenges of illness (Franklin et al., 2006;Sherman, 2001). This often comes as a struggle (Franklin et al., 2006). The strengthened me demonstrates a person who maintains themselves, but emerges from the process ‘enhanced’, living ‘more fully’, or ‘strengthened’ in their identities and relationships (Asgeirsdottir et al., 2013;Franklin et al., 2006;Henry et al., 2010;Walker et al., 2017). The living with me describes a person who has ‘come to terms with illness’ and is ‘living with’ and ‘facing’ illness and all that comes with it (Asgeirsdottir et al., 2013;Grumann & Spiegel, 2003;Haug et al., 2016;Sherman, 2001). Finally, unlike the maintained me, the unchanged me chooses to remain unchanged rather than struggling to maintain who they are.

6 |. DISCUSSION

This dimensional analysis reconceptualizes a pragmatic situation-specific theory of inner strength for people ageing with serious illness that builds upon prior understanding. The perspective of where have I been, where am I going offers conceptual grounding in individual experiences and expectations emphasizing the person as the central actor in the illness experience. Through spotlighting, taking stock of others and ideas, looking in/looking out, and seeing me as I am seen, this model corroborates the relational aspect of inner strength between a person and their surroundings previously demonstrated in the theory of inner strength, while expanding the role of the healthcare provider (Roux et al., 2002). This model adds clinically relevant elements to prior work by updating the conditions of inner strength to spotlighting by actors around me and adding the context of the tension between being a human who is living and dies and you have a serious illness. Finally, the outcome of meeting me allows for greater inclusivity and flexibility.

The perspective where have I been, where am I going asserts that inner strength is rooted in the point view of the person living with serious illness. A person’s perception of their story, past and future, and where they are positioned along a perceived timeline has the most explanatory power in this process. Just as suffering with terminal cancer is shaped by a person’s past, present, and future, so too is their strength (Gregory, 1994). This is likely reflective of designing methods that used the person’s voice as the central informant. While the person’s perspective is implicit in the philosophical underpinnings of the theory of inner strength, in this model it is the lodestar for the entire process. This is consistent with the shift toward the person living with serious illness as the expert in their experience that is essential for person-centered care (Kogan, Wilber, & Mosqueda, 2016;Thorne, 1998).

Throughout its history, the phenomenon of inner strength has been characterized as relational. Rose (1990) recognized the complex reciprocal inward relationship with oneself through the theme of interrelatedness. Dingley et al. (2000) and Roux et al., 2002 expanded upon this theme to include the relationship between the person and their surroundings through the attribute of connectedness. Through its grounding in symbolic interactionism, this concept analysis capitalizes on the inward and outward relational nature of inner strength throughout much of the explanatory matrix in spotlighting, taking stock of others and ideas, looking in/looking out, and seeing me as I am seen. Further, it expands the relational nature of the healthcare provider beyond the theme of anguish and considers the way healthcare providers might act to facilitate or enhance the process of inner strength (Dingley & Roux, 2014;Koob et al., 2002).

The condition of spotlighting is a novel dimension of this study that differs from previous conceptual work. Spotlighting highlights aspects of illness, ageing, or life and allows space for the person with serious illness to assign meaning. Previous work highlighted the presence of a challenging life event as the precipitating factor to engage in the process of finding inner strength (Dingley et al., 2000;Roux et al., 2002). Spotlighting, while inclusive of challenging events, does not presuppose the meaning that something is challenging to the individual. Further, previous work has shown the deleterious impact that spotlighting can have on an individual, including restriction, isolation, discrediting definition of self, and becoming a burden (Charmaz, 1983). This adds potential positive growth that could result from spotlighting, without denying the challenging aspects. This is consistent with a movement toward understanding the dialectic nature of chronic illness as both challenging and strengthening and centers on meaning throughout (Paterson, Thorne, Crawford, & Tarko, 1999).

The context of the tension between being human and being viewed through a medical lens in this model speaks to medicalization of illness and death. Medicalization shifts normal developmental markers, such as birth and death, into the realm of medical concern (Mohammed, Peter, Gastaldo, & Howell, 2020). When knowledge of medicine is privileged, an imbalance in power between patient and provider is created (Mohammed et al., 2020). However, for some, medicalized language and knowledge can be internalized into a person’s identity leading to greater ownership of their illness (Mohammed et al., 2020). The reciprocal nature of medicalization is well represented in this model in way that has not been previously conceptualized.

The spectrum of outcomes of meeting me offers a more inclusive way of describing inner strength. In the North American and Nordic models, inner strength is one outcome to be fostered or attained. This model moves away from an outcome model and toward a process model that considers inner strength as an ongoing process with the potential to impact other outcomes, such as quality of life or self-management (Dingley & Roux, 2014). The consequences of meeting me are not defined by rank, suggesting that one consequence is more favorable than the other. It allows flexibility for multiple, overlapping outcomes that are person-dependent rather than aspirational. The dynamic and fluid nature of meeting me demonstrates that inner strength is an ever-evolving process that changes over time. Finally, this model allows for people with serious life-limiting illnesses who do not have the benefit of hindsight to consider inner strength as a resource.

6.1 |. Limitations

In order to target adults living with serious illness, some limitations to this concept analysis emerged. The language of serious illness has changed over the decades, with various terms indicating the terminality and impact of illness. This study is unique in that it combines diagnosis, prognosis, and health service-specific search terms for serious illness, where previous studies typically use one strategy (Bernacki & Block, 2014;Staszewska et al., 2017). However, despite the broad search strategy, the resultant data sources were primarily people with oncologic diagnoses. This may have biased the results of the model. Further work using case examples of alternative diagnosis groups is warranted to test the validity of this model in different groups.

This study focused on adults who are socially considered independent to offer a situation-specific theory that is clinically relevant. Life experience, life course, and dependency emerged as important factors in this model. Expanding this model to include children and young adults or those with altered levels of dependence going into adulthood, such as people with lifelong disabilities, could be considered in order to apply this theory to other areas. However, this was not within the scope of this study. Additionally, people with cognitive impairment and limited insight, while not excluded, may not be fully integrated into this study as no articles that described people with cognitive impairment were identified. Additional theoretical sampling would be valuable in confirming that this population would indeed fit within this model.

6.2 |. Implications

There is clear consensus that older adults living with multimorbidity affecting their longevity need innovative care that is specifically directed to their needs (Naylor, Hodgson, & Demiris, 2018). This updated concept analysis of inner strength informs person-centered care, relational practice, and communication practice of nursing (Doane & Varcoe, 2007;Hartrick, 1997;Kogan et al., 2016). Through this lens, there are many implications for nursing scholarship and practice.

The perspective of where I have been, where am I going and the contexts of being human and having a serious illness offer theoretical grounding for a person-centered approach and opportunity for further exploration (Kogan et al., 2016). Empirical research aimed at testing the influence of the person’s perspective of their past and future in guiding inner strength will further inform the model. Additionally, exploration of the influence that medicalization of illness and death have on the relationship between being a person and having a serious illness deserves further clarification through empirical testing to understand how this spectrum influences the conditions, processes, and consequences. Importantly, future research should include the perspective of people living with serious illnesses beyond cancer, such as cognitive impairment to test whether these assumptions hold true for all people with serious illness.

Further clarification of the relational nature of inner strength will help determine how health systems can interact with individuals to support their inner strength rather than putting the onus on the individual. First, deeper exploration of the influence that external and internal factors have on the process of building inner strength offers opportunity to expand understanding of this concept. More specifically, empirical testing of the seesaw-like effect seeing me as I am seen may have on the process of looking in/looking out warrants investigation. Additionally, understanding how the nature of relationships might affect meaning to the person with serious illness will offer additional clarification in this model. Clinical models of relational practice that emphasize the intuitive humanistic nature of nurses may be specifically valuable for people ageing with serious illness (Doane & Varcoe, 2007;Hartrick, 1997).

Spotlighting is a novel characteristic that elucidates potential areas for future study that were not realized in previous conceptualizations of inner strength. Key for nursing research is the suggestion that nurses play a role in spotlighting, where previous theoretical models did not offer a clear mechanism for the role of nursing beyond anguish (Dingley & Roux, 2014;Koob et al., 2002). Attitudes and agendas are expressed during healthcare communication, which may block or facilitate inner strength (Thorne, 2006). Exploring how attitudes are conveyed via spotlighting during these conversations may further inform communication paradigms that influence nursing practice (Paladino et al., 2020).

Overall, this concept analysis reconceptualizes inner strength using dimensional analysis in order to better meet the needs of a population ageing with serious illness. Inner strength is an inward and outward process of meeting me—an authentic version of oneself—in the context of shifting health. Inner strength is rooted in the experience and meaning of the person living with serious illness. Inner strength is inherently relational and influenced by an individual’s environment, including nurses. Finally, the outcome of inner strength is dynamic and overlapping without a set endpoint. Key implications influence person-centered care, relational practice, and communication for nurses to improve care for people ageing with serious illness.

Supplementary Material

supplement 1
supplement 3
supplement 2

ACKNOWLEDGEMENT

The author would like to acknowledge and thank Dr. Sarah Kagan, Dr. Mary Naylor, and Dr. Barbara Riegel for their thoughtful mentorship, critique, and guidance in this work. The author also thanks Dr. Jane Evered, Dr. Elise Tarbi, and Dr. Clare Whitney for their support in peer-rehearsals and co-dimensionalizing.

Funding information

This work was supported by the National Institute of Nursing Research, the Ruth L. Kirschstein National Research Service Award training program in Individualized Care for At Risk Older Adults (T32NR009356).

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