A systematic literature search was conducted in the fields of nursing sciences, medicine and psychology. Purposeful sampling was carried out covering a period from 2003-2013. The data bases Cinahl, Medline, Embase, and PsycInfo were used with the assistance of a librarian who developed search strategies adapted to each database. The term care was searched in combination with following key words: Care AND Concept Analysis AND limitations which included timeline, Review OR Systematic Review OR Metasynthesis OR Meta-analysis OR Narrative review. The search resulted in 414 citations. The title and abstract of all 414 citations were printed and two reviewers (MK and JO) independently reviewed each title and abstract for eligibility. During this process, 219 citations were excluded due to the titles not being relevant, were in duplicate form, and/or written in a language which was not English. The 123 citations which were found relevant were retrieved for detailed evaluation. The titles and/or abstracts of these 123 articles were read again by the two reviewers independently. Inclusions criteria included having either the word care/caring in the title or in the abstract, were written in English, and were a form of concept analysis, a systematic review, meta analysis or metasynthesis. Duplicate citations were again excluded. This process resulted in 35 articles which were fully retrieved. After detailed reading, a further 6 articles were deleted as they did not discuss care or caring per se, did not apply an explicit method of concept analysis or the findings did not reflect the perspectives of staff, care recipients, or family members. Upon the second reading of the 29 articles, a further 4 were excluded because they did not discuss care or caring per se or explain their literature review methodology. All decisions to exclude articles were based on consensus between the reviewers. The final sample included 25 articles. No further references were attempted located by hand searching, manual scanning lists of relevant articles or gray literature (see Figure 1).

During data collection and analysis, each article was read attentively to identify the general idea of the work and the meaning of the caring concept as described by the authors. The analysis was carried out according to the thematic analysis procedure as described by Miles and Huberman [13] . A mixed classification grid which included attributes, antecedents, nursing actions and outcomes were developed. The data categorized under the category nursing actions is the focus of this paper. First, the data findings were loosely categorized at broad, topical levels according to Swanson’s caring processes. Then clusters of phenomenon were categorized using a constant comparative method. For each of the categories, data was read thoroughly and assigned descriptive words. An attempt was made to preserve the rich details of the findings as descriptions at the cluster levels. The second author (JO) read through the classification schemes, raised questions and suggested alterations. Both authors discussed the classification of findings until agreement was reached. A log book allowed the authors to trace more easily the various steps followed during these processes, thereby supporting the reliability of the study. Team work during data collection and analysis allowed to take into account the subjectivity of the researchers, thus improving the credibility of the study [14] .

Knowing focuses on centering on the other which includes having a humanistic view of the person [15] - [18] . It also seeks to gain insight to and understanding of another’s situation with a process of interpretation, sensitivity, inference, empathy, intuition, intellectual cognition and imagination [19] . Other characteristics include actively attempting to understand and identify the other’s meanings, cognitive appraisals, concerns and interpretations of their situation and their perception of their relationships with the caregiver [20] - [22] . The literature also described being physically and mindfully present [20] , displaying attentiveness, engagement, and being deeply involved and going beyond routine [20] [22] [23] .

Knowing also emphasizes a nurturing way of relating to a valued other [1] [15] [22] where key factors include treating patients as unique persons [16] [24] with an attitude of respect [1] [20] [22] [25] [26] and being non-judgmental [20] and respectful of the other’s wishes [17] .

Knowing includes an informed understanding of the other. Main characteristics embody having detailed knowledge of the other’s experience and needs [15] [27] , using experience―based information [19] with good knowledge of clinical practice and well developed assessment skills [20] [27] [28] in data gathering, clinical reporting and documentation [19] and excellent verbal and non-verbal communication [15] [18] - [21] [25] [27] with emphasis on open dialogue.

Integral to knowing is the necessity of conducting a comprehensive individual assessment which is holistic. The health professional assesses existing physical psycho spiritual [20] and existential needs [24] with consideration of patients perceptions, beliefs, values and wishes [16] [17] [23] and appreciation of family traditions [29] . Knowing is considered context specific and entails an ongoing and crisis orientated assessment [20] which is culturally sensitive with acceptance for variability [18] [20] The process of knowing includes showing respect for individual differences by assessing demographic data, age, gender, marital status, education, social influences from cultural backgrounds, health care experiences, length of stay, environmental resources such as payment expectations, government and other agencies [22] .

The process of being with includes an intimate caregiving relationship characterized by expert nursing practice, interpersonal sensitivity and intimate relationships [20] . Interpersonal sensitivity is regarded as intuitive, empathetic insight into another’s suffering and an imaginative process where caregivers symbolically and metaphorically place themselves into a patient’s shoes to gain a multidimensional understanding of a patient’s thoughts and feelings [23] . Being with also consists of being creative and daring and being firm and doing things that the patient does not like [20] .

Being with is based on connecting, bonding and attachment [16] . Some literature describes intimate relationship as the perpetual existence of a bond and covenant which embodies caring benevolence [29] . Other characteristics of being with include mutual trust [30] availability [20] reciprocal linking [19] [20] [29] and constancy, endurance and adaptability within a stable relationship [20] [29] . Other key factors in being with are being protective [15] and displaying cautiousness in avoiding harm and danger [15] [20] . In being emotionally present, the health professional is emotionally open to the other’s feelings and attempts to calms fears [20] [22] is comfortable in sharing thoughts and feelings, also with family [20] . However, the health professional can experience strong emotional feelings such as joy, highly cherishing and love [15] as well as anger, weariness, and irritation [20] . Conversely, hurried and mechanical caring [20] versus caring with a warm, reassuring manner and complete engagement [23] can be considered an anti thesis to being emotionally present.

Being with also includes authentic presencing [24] with key aspects including showing interest, concern and engagement [1] [23] , being compassionate and empathetic [16] [19] [22] , sympathetic [19] [23] honest and sincere [15] and sensitive [18] . Authentic presencing is also described as a way of being [15] .

Being with also embraces emotional adaptability. Key factors include becoming deeply involved without becoming overly emotional, destructive, controlling and self centered [20] . Other defining qualities include expressing surface and deep emotions during encounters either in deep acts or surface acts. Emotional adaptability consists of awareness of self and other where the professionals use themselves therapeutically [23] . One can protect oneself in a positive manner, have spiritual/philosophical beliefs, can manage personal vulnerability and have the ability to tolerate uncertainty [1] . Emotional adaptability is also reflected in the nurses’ consciousness and work persona and includes work experience [19] . Awareness of the impact of personal qualities such as age, nurses past and impact of social norms and societal culture on self [16] [19] [30] is also reflective of emotional adaptability. Being with is also characterized by decentering which include characteristics such as the ability to maintain a degree of objectivity in therapeutic relationships where one attempts to understand and put aside or inhibit own impulses making a conscious effort to differentiate one’s view from the view of another [19] . It also takes into consideration one’s attitudes towards the other and positioning within relationships [19] [31] .

Conversely, emotional adaptability can be threatened by emotional demand, interaction frequency, and work complexity which can result in high stress experiences [19] . Reduced emotional adaptability can also contribute to depersonalization, reduced output and endurance, diminished performance, loss of empathy, poor judgment and compassion fatigue [32] . Health professionals experiencing emotional demand, use emotional labor strategies such as standing back, hardening, professional face, going with the flow, negotiation and accommodation, and containing and avoidance of too much liking or disliking [23] (see Figure 2).

Doing for is also multifactorial with a focus on professional competence [15] [20] [30] . Characteristics of professional competence include education and training [25] clinical knowledge [15] [22] professional and personal qualities and ongoing adjustment [15] [16] [30] learning [15] collective skills [19] skill mix [16] and self confidence [15] [20] [30] . Indicators of professional competency include detecting, preventing, listening, anticipating, educating, advocating, monitoring and practicing surveillance which can produce both positive and negative outcomes [15] . Providing reassurance, support, comfort, acceptance, legitimacy, confidence, promoting healing, reducing injury and suffering and providing for physical and emotional needs are also characteristics of professional competency [23] .

Professional competence also includes adequate knowledge in providing care [15] [25] and involves professional attitude, professional presentation and caring capacities [22] . Providing care is task or procedure planned, occurs in and is influenced by context, is directed by process, skilled, safe, experiential, coordinated, individualizes, collaborates and is evidence based [15] . Competence is also shown in the development and execution of expert therapeutic physical psycho spiritual nursing interventions [28] and providing individualized, holistic care

that maximizes growth and development [17] [24] [30] . Professional competence also includes professional/technical skills [15] , regarding procedures, tests and administering medications [22] , demonstrating thorough effective management of all symptoms assessed [17] , minimizing toxicity [24] and in the provision and/or management of pain relief [22] . Conversely, lack of clinical experience, education, patient assessment skills and educational training contribute to professional incompetence [28] .

Comforting helping actions are also a corner stone of professional competency [15] which include concern for patient’s privacy, prompt in response, listening and giving time to speak [22] using touch [18] [20] , imagery and prayer [18] with eye contact and verbal reassurance [20] .

Doing for is also anticipatory in that the professional initiates care early with interdisciplinary team work [24] . It also consists of advance planning with discussion on preferred place of death and includes extended family, with community and pastoral support [18] . It also has a multidisciplinary approach, educates and trains team members on effective communication techniques, clarifies roles and responsibilities, refers patients, mobilizes instrumental tangibles and emotional support from family, peers, community members and the health care team [17] [25] [31] and encourages colleagues to express their concerns [20] .

Doing for is grounded in preserving the dignity of the other. Conversely, patients lose their value and dignity as human beings due to nursing abuse. Patients can suffer from uncaring encounters described as unintentional events, also including intentional harm. Cultural and structural elements in the encounter can also be uncaring resulting in carelessness with delays in treatment and inappropriate management of acutely well patients [28] [33] , leading to enmeshment and exploitation [1] .

In enabling, there exists a need for self-care [25] , which is impacted by the patient’s intrinsic motivation, competence and self determination [22] . It focuses on regarding patients as partners, in a collaborative symmetrical relationship with interactive assessment of patient’s knowledge and self management skills [25] . It also involves mutual commitment of both professional and other to engage in the healing process and the sharing of common goals [29] .

Enabling also consists of how professionals manage complex care which requires ongoing personal adjustments, navigating a plan of care, concurrently managing interactions within the health system, providing education and supportive interventions with the purpose of increasing patient’s skills and confidence in managing health problems [25] . Conversely, lack of recognition of patient deterioration, failure to appreciate clinical urgency, incomplete and missing patient documentation and/or difficult documentation which are difficult to read can decrease quality care [28] .

A cornerstone of enablement is providing effective/developmentally appropriate communication with patients and family. This involves providing communication regularly, clearly, accurately, honestly and empathetically in regards to family dynamics, cultural and religious beliefs and previous experience with loss, also considering the nature of the illness [26] . Communication also embodies providing information and educating [20] , such as explanation about the other’s care, medications, tests, and overall condition [22] , providing written materials, phone calls, emails, internet use, independent learning with software and telehealth systems monitoring, coaching and counseling [25] as well as providing information which isn’t welcome [20] .

Willingness to share power and responsibility is also a characteristic of enabling [20] [26] [34] . Both parties must be able to accept the power relation and recognize each others’ expertise, with acceptance of mutual dependency [26] . Enabling also consists of empowerment partnership and mutuality with family. Mutuality is care which is open and characterized by wanting to be of help and accepting help from each other with dignity [26] . Partnership between patients/professionals emphasizes shared responsibility, information, care taking, having access to information about the family and recognizes the family member as an important source of information. It incorporates defining role and responsibilities in collaboration, allowing family members to choose their degree of involvement, and support of family emotions with sensitivity to individualized needs. Partnerships also concentrate on family strengths with accepting individuality and diversity and enables choice and decision making. It includes respectful coalition between health care team, patient and family [16] [22] [24] [25] honoring family choices [21] and uses patient’s wishes to guide activity [16] .

Enabling emphasizes ongoing validation of caring processes which are evidenced based [20] . Ongoing validation requires that caring outcomes should be measured and defined [15] although the literature underlines the need for the development and testing of quality of life instruments in order to establish appropriate outcomes measures [17] and questionnaires assessing patient suffering [33] . Barriers to enabling include lack of clear description of measureable behaviors and patient outcomes [15] [16] [23] and the need to evaluate existing instruments to verify accurately whether they reflect caring attributes [25] .

Maintaining belief is grounded in recognition of a person as a spiritual being with a belief in God, a supernatural being, a life force, with a dynamic quest for a transcendent relationship [18] . Maintaining belief is based on a humanistic view of the person [18] , respects individual differences and treats patients as a unique person [16] [22] and considers the whole patient [15] - [18] [24] . Maintaining belief also accepts other people as they are [15] and understands the need for the maintenance of a harmonious balance between body―mind-spirit [29] . Maintaining belief is grounded in giving hope, love, and compassion and it helps with the quest to discover meaning in life, with self, other-God, with regard to issues of suffering [15] [18] and taking cues from the person’s religious and spiritual orientation [18] (see Figure 2).

It has been stated that the goal of nursing theory is to contribute to the wealth and knowledge required for clinical practice in a variety of settings [41] . Recent studies have shown that Swanson’s theory can inform practice and lead to near practice approaches as well as investigable factors that influence outcomes that are desired in nursing practice. Numerous hospitals and health care facilities have since adopted Swanson’s theory of care as a guide to their own nursing services. Although her theory was originally conceived within a perinatal field, it has been successfully applied across a wide spectrum of nursing care during the past two decades including palliative care, mental disorders, dementia, parental support groups, home care, and critical care among numerous others, demonstrating a parsimonious theory that claims a broad diversity of application within the context of nursing practice.

The biases introduced in this study include the inability to include all of the relevant literature and unpublished material. Certain citations may have been missed during the search stage due to the search words and combinations applied. However, the search strategy adapted for different databases was developed by a librarian. Other terms used with the key words in our search method such a qualitative studies, phenomenology, grounded theory and ethnography could have produced a broader base of relevant literature. Another limitation is that all the articles were written in English, and written by nurses from Western post―industrialized countries and base their findings on the perspective of the nurse. Very few articles were found that were based on the patient perspective which has been supported by others [42] . Further, the searchers’ subjectivity remains a bias to thematic analysis although team work decreased this limitation and increased credibility of the work [14] . The identification and naming of codes, themes, sub-themes were discussed by two independent researchers throughout all the phases of the analyses. Although language is critically fundamental to the evolution of all disciplines and within any discipline, the selected terminology used in classifying themes and sub themes in this study represents selected terminology denoting specific nursing knowledge. Another bias concerns whether the themes and sub-themes accurately reflect the meanings evident in the data set as a whole. Interpretations of the data may have been enhanced by inviting people with different expertise to discuss the interpretation of the findings. Using Software programs for preparing and instructing the data may have also improved the different categories of description, however, the use of such software packages has also been debated. Finally, our systematic literature review covers the period from 2003-2013. This is a short contemporary view. However, the authors believe that concepts per se are dynamic, impacted by changing sociocultural influences and represent a probable truth at this certain point in time ( [43] , p. 404).