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Longing: A Concept Analysis Shelley-Rae Pehler, PhD, RN, Stephanie Sjostrom, and Michelle Markwardt Shelley-Rae Pehler, PhD, RN, is an Associate Professor in the Department of Nursing, University of Wisconsin-Eau Claire, Eau Claire, Wisconsin, Stephanie Sjostrom is a Baccalaureate Nursing Student at the Department of Nursing, University of Wisconsin-Eau Claire, Eau Claire, Wisconsin, and Michelle Markwardt is a Baccalaureate Nursing Student at the Department of Nursing, University of Wisconsin-Eau Claire, Eau Claire, Wisconsin.
Search terms: Concept analysis, longing, nursing diagnosis development Author contact: [email protected], with a copy to the Editor: [email protected] Funding: Funding for this project came from the University of Wisconsin-Eau Claire Blugold Commitment-Funded Faculty/Student Research Collaboration.
PURPOSE: This paper uses Rodgers’ evolutionary view of concept analysis to define the human response of longing. The purpose is to develop a definition of longing as the first step in diagnosis development. DATA SOURCE: A literature review was conducted by searching the Cumulative Index to Nursing and Allied Health Literature, American Theological Library Association Religion, JSTOR Philosophy, JSTOR Religion, PsycINFO, and PubMed databases to yield an across-discipline sample of articles. DATA SYNTHESIS: Three researchers identified the attributes, antecedents, consequences, situational context, and surrogate terms of longing. CONCLUSIONS: An operational definition was developed. IMPLICATIONS FOR NURSING PRACTICE: Longing is clearly a human response to loss, crossing illness and situations in which nurses encounter patients in multiple settings. This supports the need to further develop longing into a nursing diagnosis.
The art of what nurses do is often invisible. Documentation in nursing is more often about patient physiological measures and procedures done with or for the patient. Yet it is the very essence of nursing to try to assess the patient’s response to a diagnosis or life circumstance from a holistic lens. Longing is one type of human response that has been identified in patients. Most often associated with chronic or terminal illnesses, where patients have longed for the life they had before the illness (Arnaud, 1959; Morrison & Burgman, 2009; Ohlen & Holm, 2006; Pehler & Craft-Rosenberg, 2009; Ready, 2010), additional studies are finding longing in areas of life not necessarily associated directly with illness. Longing is found in people who are homeless (Baumann, 1996; Farkas & Yorker, 1993) or in instances of child abuse (Baldwin, 2003; Holm, Berg, & Severinsson, 2009)—areas that are still within the domain of nursing care. To be able to identify and treat longing in patients, nursing must have a clear definition of the concept (Herdman, 2012). When the assessment of a patient’s response identifies a need, the use of standardized nursing languages, such as NANDA-I (Herdman, 2012), provides an avenue to share that need with other healthcare providers. Nursing diagnoses are “clinical judgments of actual or potential health problems/life processes that lead to the selection of nursing interventions to help patients achieve outcomes” (Herdman, 2012, p. 515). As tools of communication, nursing diagnoses share with other healthcare providers the clinical judgments that guide the patient’s plan of care. As a foundational tool, the concepts from which nursing diagnoses are developed must come from a clear © 2014 NANDA International International Journal of Nursing Knowledge Volume 25, No. 3, October 2014
set of criteria so that nurses can easily identify this phenomenon. As one of the first steps in developing a nursing diagnosis, a concept analysis is crucial to clarify how a concept is being used in nursing. Longing is a concept that has not been clearly identified or defined in nursing despite articles and research studies that have begun to explore longing in patients. This research study, using Rodgers’ evolutionary view of concept analysis (Rodgers, 2000), was the first step to develop a nursing diagnosis by suggesting a conceptual definition of longing. Method Rodgers’ evolutionary view of concept analysis (Rodgers, 2000) was used to guide this study. This nursingbased analysis tool is a method used to further develop nursing concepts based on how the concept is used in the literature. In addition to finding the attributes that define the concept, Rodgers’ method uses a rigorous analysis through inductive inquiry to learn the nature of the concept, and the sociocultural, disciplinary, and interdisciplinary contexts. The primary activities used in this concept analysis methodology are outlined in Table 1. Literature Search/Sample A literature search was conducted in the spring of 2011 using the databases of the Cumulative Index to Nursing and 133
Longing: A Concept Analysis
S.-R. Pehler et al.
Table 1. Activities in Rodgers’ Evolutionary View of Concept Analysis 1 2 3
4 5 6
Identify the concept of interest and associated expression Identify and select setting and sample for data collection Collect data, identifying the attributes, contextual basis including the interdisciplinary, sociocultural, and temporal (antecedent and consequential occurrences) Analyze data according to the above characteristics Identify an exemplar Identify implications, hypotheses, and implications for further development of the concept
Rodgers (2000).
Table 2. Literature Search Results Discipline of first author
Number of articles
Nursing Psychology Physician Clergy Sociology Occupational therapy Public health
44 10 6 4 1 1 1
Allied Health Literature (CINAHL), American Theological Library Association (ATLA) Religion, JSTOR Philosophy, JSTOR Religion, PsycINFO, and PubMed. Based on a prior research study where longing was a key theme of spirituality in illness (Pehler & Craft-Rosenberg, 2009), the search terms longing and illness were used. The initial search yielded 1,105 resources. Sources were exported to EndNote (Thomson Reuters, Carlsbad, CA, USA), where duplicates, books, book reviews, and articles not written in English were removed. Of the 127 articles remaining, an additional 60 were eliminated because the search yielded the term belonging (and no longing) as the concept in the article, or the content of the article was from the author’s perspective rather than from a patient’s perspective. The final sample yielded 67 articles, which were used in the analysis, and were from the disciplines of (based on first author) medicine, occupational therapy, nursing, psychology, public health and health services, religion, and sociology (Table 2). Data Analysis Three researchers reviewed the articles, identifying the attributes, antecedents, consequences, situational context, and surrogate terms of longing in the data analysis. Once any of the items were identified and agreed upon by at least two members of the research team, the findings were further reviewed to identify the themes. Articles from each database (e.g., CINAHL, PubMed, and ATLA) were analyzed 134
separately, then combined to identify consensus across disciplines. Although not a requirement of Rodgers’ evolutionary view of concept analysis, saturation was achieved as no new attributes were identified after approximately 95% of the articles were reviewed. Attributes of Longing The variety of contexts in which the term longing was revealed in the literature not only emphasized and supported the need to more clearly define the term longing, but also provided an opportunity to explore the breadth of how longing has been used. Beyond describing the human response when a person has a physical illness, longing was also used to describe the experience of lovesickness (Tallis, 2005) and homesickness (Thurber, 1999; Thurber, Sigman, Weisz, & Schmidt, 1999). There were distinct similarities in the attributes and consequences of those articles compared with articles where the context of longing occurred within physical and mental illnesses. In the broadest sense, all of the articles discussed longing within the context of loss. Losses are experienced not only with a physical or mental health concern, but also loss of country (as in immigrants who needed to move to a new country) (Svenberg, Mattsson, & Skott, 2009), the feelings of loss that children experience when away at a summer camp (Thurber, 1999), and the loss of a love relationship (Tallis, 2005). It is because of those commonalities that the articles were kept in the final sample, adding to the breadth of contexts in which longing was found in the literature. From the articles reviewed, seven major attributes were found. Disconnection was the attribute that was the most prevalent and present in four of the seven disciplines (Table 3). The attribute of hope was found second in frequency and appeared in the literature from three of the disciplines. Although initially thought of as an outlier (Rodgers, 2000), final analysis confirmed hope as an attribute, not only due to its frequency and presence across three disciplines, but also due to the theoretical insights into the nature of longing. Disconnection. The theme of disconnection was the most frequently found attribute. Authors described a profound disconnection of what used to be and the longing to get back to what was. This disconnection was described in a physical sense, as when an illness takes away a person’s physical abilities. Authors described this as sense of living in-between (Bruce, Schreiber, Petrovskaya, & Boston, 2011; Ohlen & Holm, 2006). The person was living in-between what he or she now could functionally do, yet longed for his or her former physical self and abilities. There was also a feeling of disconnection when Bruce et al. (2011) compared the suffering of people with lifethreatening cancer and their family caregivers. The participants’ experience of groundlessness occurred as the disease shook the patient and family caregivers to their
S.-R. Pehler et al.
Longing: A Concept Analysis
Table 3. Attributes of Longing Attribute in order of frequency, with descriptions of how used in the literature Disconnection—separation, isolation, interruption of life, had something but now do not have (e.g., relationship, health, home country, self—who they were/are), missing (missed activities, missed time together, missing home) Hope—looking forward, not backward in time and space, looking for a new normal Existential questioning—seeking meaning and purpose to life Abandoned—feeling of isolation, deserted, not a part of, left out Despair—feeling of total unacceptability, powerless over situation; intensely emotional, depression, hopelessness, desperation, discouragement, desolation, distress, agony, and anguish Vulnerability—seeking security, feeling insecure, fear of unknown Grief—response to loss, pain of loss, deep sorrow, grievance, bemoaning, heartbreak, woe, or worry; grief could be expressed as hurt, anger, or sadness
very core. Participants were disconnected from their life prior to the disease, precipitating a need to search for peace and stability. Disconnection also illustrates the longing that is present in family caregivers as they care for a family member diagnosed with Alzheimer’s disease (Johansson, Sundh, Wijk, & Grimby, 2013; Marwit & Meuser, 2005). As the person loses his or her identity due to Alzheimer’s, the relationship with the family member—most often the spouse—no longer is rooted in shared experiences. The bond is no longer a foundation for support to help caregivers with the experiences of loss, confusion, fear, and uncertainty they experience. Family caregivers long to reconnect: to go back to what once was. Disconnection was found in situations where isolation, loneliness, or ambivalence was experienced, as in the case of moving to another country. Immigrants moving from Somalia to Sweden (Svenberg et al., 2009) expressed a sense of living in-between the sense of disconnection due to being uprooted from all that was familiar. This resulted in feelings of isolation, loneliness, and separation from family still in their home country, while feeling ambivalence or disconnection to their new home. Hope. Hope was at first thought to be an outlier, as it did not mirror the circumstances of the other attributes found in the literature. Rodgers (2000) cautioned to not disregard outliers, as they can provide insight into the concept. Taking Rodgers’ caution seriously, the frequency with which hope was found in the review, and with hope appearing in three of the disciplines, it became clear that hope was not an outlier but definitely an attribute of longing. Although a number of attributes ascribed longing to looking back to what was, hope always had the nuance of looking forward, no matter how hard the circumstances. For example, children experiencing homelessness (Baumann, 1996) transcended the feelings of fear, anger, and sadness by directing attention to another possibility—a longing and hope for a better situation. Immigrants from war-torn Somalia continued to hope that they would be able to go
Number of disciplines attribute found 4 3 3 4 3 3 3
back home (Svenberg et al., 2009). The forward view that immigrants share with their children is that “you have two countries . . . and that’s an advantage . . . and if they have the opportunity, they will go back . . . but returning is part of my own plan for the future” (p. 283). Women who were abused as children long for reconciliation—a longing for wholeness and meaning (Holm et al., 2009, p. 565). The attribute of hope in the literature reviewed was a longing for something different, not a return to the past. Existential questioning. Described as feelings of a life unfulfilled without meaning or heightened spiritual questioning, existential questioning was the third most prevalent attribute found in this review. Although the feeling of an unfulfilled life occurs frequently in times of terminal illness (Bruce et al., 2011; Spichiger, 2009), existential questioning also arose in situations of mental illness (Miller, 1996; Sheehy & Rabinor, 2005; Watanabe, Okada, Okabe, Onishi, & Morishima, 2011) and in research on the experience of burnout (Arman, Hammarqvist, & Rehnsfeldt, 2011). For a person diagnosed with burnout, the researchers concluded that the person is experiencing a conflict between his or her identity and understanding of life: shutting himself or herself off from his or her own suffering and emptiness. This produces a struggle and sense of meaninglessness as he or she often seeks to be affirmed by outsiders, yet have a “silent inner longing for interdependence with others” (p. 300). Abandoned. The tension between the longing for relationship yet the fear of being abandoned was found in research that explored the effect of being abused as children on adults (Gostecnik, Repic, Cvetek, & Cvetek, 2010), in families where a member has a mental illness (Holm & Severinsson, 2010; Miller, 1996), and when a young child experiences a traumatic event (Edmands & Marcellino-Boisvert, 2002; Holm et al., 2009). The subjects in those research studies longed for intimacy, but also feared becoming close to another person due to their prior experiences. Even though they felt they were not good 135
Longing: A Concept Analysis enough to have an intimate relationship, their earlier experiences left them with a strong tension between longing for a relationship and fear of being abandoned. Despair. Despair was one of the more intensely described attributes of longing. Participants described it as an “uncontained” and “terrific” sadness (Al-Gamal, Long, & Livesley, 2009), “terrifying” despair (Gostecnik et al., 2010), an “unmalleable grief” (Bruce et al., 2011), and a feeling of “heaviness” (Talseth, Gilje, & Norberg, 2003). Deep feelings of despair appeared in articles where participants or family members were experiencing terminal or mental illness, or in situations of abuse. The profound and intense despair created a longing in the individual and/or family for stability and peace. Vulnerability. Longing also produced feelings of vulnerability and fragility, where the individual longed for a sense of safety. Five of the articles that identified this vulnerability included children. The articles described the fears and longings for safety in children who were hospitalized (Wikstrom, 2005), children who were homeless (Farkas & Yorker, 1993), and adults who experienced abuse as a child (Baldwin, 2003; Gostecnik et al., 2010; Holm & Severinsson, 2010). Especially in instances where the adults experienced abuse as a child, this traumatic event increased their vulnerability into adulthood, making it difficult to form intimate relationships with others. This vulnerability, insecurity, and a lack of self-confidence created a tension of longing for relationships—yet fearful of allowing themselves to be vulnerable—to risk the connection with another person. Although similar to the attribute of abandonment, adults who felt vulnerable were more likely to seek relief from this longing through use of alcohol or drugs. Whether used as a substitute for an intimate relationship or as a measure to decrease the feelings of vulnerability, the destructive nature of drugs and alcohol felt safer for the adults than the tension of longing for relationship (Gostecnik et al., 2010). Fear and vulnerability were expressed in terminally ill patients experiencing pain and dependency during hospitalization (Spichiger, 2009). These patients longed to go home—to get back to the familiarity of their own homes. In another group of adults, mothers with breast cancer expressed fears for their children (Ohlen & Holm, 2006). The inability to carry on the mothering role if the mother died before the child grew up left those breast cancer patients longing for the security of knowing their children would be okay. The fears and feelings of vulnerability were related to the unknown and the inability to control the situations that the person was experiencing. Grief. This last attribute of grief has been identified by feelings of hurt, anger, and sadness, which may speak to the ambiguous nature of the loss that individuals and families encounter when experiencing longing. Pauline Boss identified the concept of ambiguous loss in the 1970s, and has provided a substantial body of research contributing to our 136
S.-R. Pehler et al. understanding of this phenomenon and how it may complicate the grief response (Boss, 1999a, 1999b; Boss & Carnes, 2012). Her work has defined the ambiguous loss that families experience when they are uncertain if their “loved person is absent or present, dead or alive” (Boss, 1999b, p. 4). Whether it is due to Alzheimer’s (Marwit & Meuser, 2005), abandonment (Edmands & Marcellino-Boisvert, 2002), or being forced to move to a new country (Svenberg et al., 2009), the uncertainty of the status of the relationship with that person or family left behind becomes very difficult for the remaining family members to understand: It can affect individual and family functioning (Boss, 2001). Boss identified that individuals or families experiencing ambiguous loss may be sad, angry, or hurt, which are all signs of grief (Boss & Carnes, 2012). When there is a death and a body, although very difficult, there is finality—a reason for the loss. The person has died. In situations of ambiguous loss, however, there may not be a body (families who lost loved ones in the World Trade Center), or there may be a body, but due to illnesses such as Alzheimer’s, there is no relationship due to loss of memory and cognitive functioning. In such situations, ambiguous loss can complicate the grief experience, leading to a longing for closure and feelings of hurt, anger, or sadness. Antecedents of Longing Most of the literature identified that longing appeared after a life-threatening illness diagnosis or after a traumatic event occurred. Not germane to life-threatening illness, longing was also found in situations of mental illnesses, chronic illness, and children with disabilities. Longing also appeared within other situations, such as the longing to be home when away at camp, in a homeless shelter, or when needing to move to another country. Longing was also experienced in situations where the adult suffered abuse as a child, children had to care for ill parents, and when children were separated from parents. The differences across these antecedents were more correlated to what the person or family longed for. In illness, it may be to restore their physical health. When a person experienced homelessness or displaced from his or her home country, it was a longing to go home. When children were displaced from parents or experienced abuse from a close family member, this set up a lifetime longing to be in a relationship with another, but fearful of the consequences. Consequences of Longing When an individual or family experienced longing, regardless of the antecedent cause, there were noted positive as well as potential negative consequences. Tied to the most frequently cited attribute of disconnection, the consequences found in the literature included detaching from the ill family member, decreased feelings of closeness, or constraints in interpersonal relationships due to an inability to trust another person. Some of the articles identified loss
S.-R. Pehler et al. of self-esteem, increased fears, and loss of hope. In situations where there was a traumatic event in childhood, common outcomes included mental illness, substance abuse, and/or prostitution. Although these negative consequences were outlined in a number of articles, research also supported that individuals and families gained the ability to accept and forgive oneself, increase trust, acceptance, and experience joy and hope. The process by which some could transcend their longing was not described, and provides a need for future research that can help identify interventions that could help others avoid or decrease the negative consequences of longing. Defining Longing The need to clarify longing was identified as the primary objective of this research study. From this study, the reason for the lack of a clear definition of longing has been due to the fact that it transcends age groups, settings, illnesses, situations, and human and family needs. A definition must, therefore, be able to encompass this vast array of attributes, circumstances, and experiences. From the data, the authors propose this definition: Longing is the earnest, heartfelt desire for something, some state, or some relationship, without which one’s life does not feel complete. It appears as a disconnection within a person’s relationships, health, and/or purpose in life due to illness, injury, disability, or death. Although an individual or family primarily experiences longing as feelings of grief, anger, sadness, despair, hurt, abandonment, and vulnerability, hope is also expressed. Implications As outlined in NANDA-I (Herdman, 2012), the first step to developing a nursing diagnosis is a concept analysis to determine the existence of that concept in the literature. From the data, longing is clearly a human and family response to loss that is found in the literature, and crosses not only illness but also situations in which nurses encounter patients in the acute, primary, and public health settings. This supports that longing needs further development as a nursing diagnosis before determining the outcomes and interventions that can relieve a person or family’s longing. Beyond the development of a nursing diagnosis, data review and analysis shows patterns that lead to further questions. Although longing is articulated in a physical sense (that a person longs for his or her health as before the disease), longing is more often expressed as the disconnection of a person in relationship. This is especially true in articles that describe the loss of relationship when a person has Alzheimer’s disease, or the anticipatory loss of a person with a terminal illness. This loss of relationship is also seen in immigrants experiencing homesickness and a longing to return to their country and relatives who were left behind.
Longing: A Concept Analysis Loss of relationship is also found in people who had traumatic or abusive relationships when younger, and now long for, yet fear, relationships with others. This leads to further questions of whether the quality of the relationships affects the longing that a person experiences or if there are potential gender differences in the feeling of longing, such as prevalence in males or females. Although some people experience hope in longing, most express longing as more negative feelings of disconnection, abandonment, and despair. Further research into these implications will help define and articulate the human and family response of longing. References Al-Gamal, E., Long, T., & Livesley, J. (2009). Development of a modified instrument to measure anticipatory grieving in Jordanian parents of children diagnosed with cancer: The Marwit and Meuser caregiver inventory childhood cancer. Cancer Nursing, 32(3), 211–219. doi:10.1097/ NCC.0b013e31819a2ae4 Arman, M., Hammarqvist, A. S., & Rehnsfeldt, A. (2011). Burnout as an existential deficiency—Lived experiences of burnout sufferers. Scandinavian Journal of Caring Sciences, 25(2), 294–302. doi:10.1111/j.14716712.2010.00825.x Arnaud, S. H. (1959). Some psychological characteristics of children of multiple sclerotics. Psychosomatic Medicine, 21, 8–22. Baldwin, M. A. (2003). Living in longing: Prostitution, trauma recovery, and public assistance. Journal of Trauma Practice, 2(3/4), 267–314. Baumann, S. L. (1996). Feeling uncomfortable: Children in families with no place of their own. Nursing Science Quarterly, 9(4), 152–159. Boss, P. (1999a). Ambiguous loss: Learning to live with unresolved grief. Cambridge, MA: Harvard University. Boss, P. (1999b). Insights. Ambiguous loss: Living with frozen grief. Harvard Mental Health Letter, 16(5), 4–5. Boss, P. (2001). Family stress management. Newbury Park, CA: Sage Publications. Boss, P., & Carnes, D. (2012). The myth of closure. Family Process, 51(4), 456–469. doi:10.1111/famp.12005 Bruce, A., Schreiber, R., Petrovskaya, O., & Boston, P. (2011). Longing for ground in a ground(less) world: A qualitative inquiry of existential suffering. BMC Nursing, 10, 2. doi:10.1186/1472-6955-10-2 Edmands, M. S., & Marcellino-Boisvert, D. (2002). Reflections on a rose: A story of loss and longing. Issues in Mental Health Nursing, 23(2), 107–119. Farkas, G. S., & Yorker, B. (1993). Case studies of bibliotherapy with homeless children. Issues in Mental Health Nursing, 14(4), 337–347. Gostecnik, C., Repic, T., Cvetek, M., & Cvetek, R. (2010). Hidden mission of the psyche in abuse and addiction. Journal of Religion and Health, 49(3), 361–376. doi:10.1007/s10943-009-9264-8 Herdman, T. H. (Ed.). (2012). NANDA International nursing diagnoses: Definitions and classification, 2012-2014. Oxford, UK: Wiley Blackwell. Holm, A. L., Berg, A., & Severinsson, E. (2009). Longing for reconciliation: A challenge for women with borderline personality disorder. Issues in Mental Health Nursing, 30(9), 560–568. doi:10.1080/ 01612840902838579 Holm, A. L., & Severinsson, E. (2010). Desire to survive emotional pain related to self-harm: A Norwegian hermeneutic study. Nursing & Health Sciences, 12(1), 52–57. doi:10.1111/j.1442-2018.2009.00485.x Johansson, A. K., Sundh, V., Wijk, H., & Grimby, A. (2013). Anticipatory grief among close relatives of persons with dementia in comparison with close relatives of patients with cancer. American Journal of Hospice and Palliative Care, 30, 29–34. Marwit, S. J., & Meuser, T. M. (2005). Development of a short form inventory to assess grief in caregivers of dementia patients. Death Studies, 29(3), 191–205. Miller, F. E. (1996). Grief therapy for relatives of persons with serious mental illness. Psychiatric Services (Washington, D.C.), 47(6), 633–637. Morrison, R., & Burgman, I. (2009). Friendship experiences among children with disabilities who attend mainstream Australian schools. Canadian Journal of Occupational Therapy, 76(3), 145–152. Ohlen, J., & Holm, A. K. (2006). Transforming desolation into consolation: Being a mother with life-threatening breast cancer. Health Care for Women International, 27(1), 18–44. doi:10.1080/07399330500377226
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Longing: A Concept Analysis Pehler, S. R., & Craft-Rosenberg, M. (2009). Longing: The lived experience of spirituality in adolescents with Duchenne muscular dystrophy. Journal of Pediatric Nursing, 24(6), 481–494. doi:10.1016/j.pedn.2008.06.008 Ready, T. (2010). Music as language. American Journal of Hospice and Palliative Care, 27(1), 7–15. doi:10.1177/1049909109338387 Rodgers, B. L. (2000). Concept analysis: An evolutionary view. In B. L. Rodgers & K. A. Knafl (Eds.), Concept development in nursing: Foundations, techniques, and applications (2nd ed., pp. 77–102). St. Louis, MO: Elsevier. Sheehy, J., & Rabinor, J. R. (2005). The therapist’s voice. Eating Disorders: The Journal of Treatment & Prevention, 13(2), 213–218. doi:10.1080/ 10640260590920123 Spichiger, E. (2009). Being in the hospital: An interpretive phenomenological study of terminally ill cancer patients’ experiences. European Journal of Oncology Nursing, 13(1), 16–21. doi:10.1016/j.ejon.2008.10.001 Svenberg, K., Mattsson, B., & Skott, C. (2009). “A person of two countries.” Life and health in exile: Somali refugees in Sweden. Anthropology & Medicine, 16(3), 279–291. doi:10.1080/13648470903295984
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S.-R. Pehler et al. Tallis, F. (2005). Crazy for you. The Psychologist, 18(2), 72–74. Talseth, A. G., Gilje, F., & Norberg, A. (2003). Struggling to become ready for consolation: Experiences of suicidal patients. Nursing Ethics, 10(6), 614– 623. Thurber, C. A. (1999). The phenomenology of homesickness in boys. Journal of Abnormal Child Psychology, 27(2), 125–139. Thurber, C. A., Sigman, M. D., Weisz, J. R., & Schmidt, C. K. (1999). Homesickness in preadolescent and adolescent girls: Risk factors, behavioral correlates, and sequelae. Journal of Clinical Child Psychology, 28(2), 185–196. doi:10.1207/s15374424jccp2802_6 Watanabe, K., Okada, A., Okabe, N., Onishi, M., & Morishima, T. (2011). A one-message question in a structured interview: Investigating psychological needs of children and adolescents with eating disorders directed toward their mothers. Acta Medica Okayama, 65(3), 185–192. Wikstrom, B. M. (2005). Communicating via expressive arts: The natural medium of self-expression for hospitalized children. Pediatric Nursing, 31(6), 480–485.
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Longing: A Concept Analysis Shelley-Rae Pehler, PhD, RN, Stephanie Sjostrom, and Michelle Markwardt Shelley-Rae Pehler, PhD, RN, is an Associate Professor in the Department of Nursing, University of Wisconsin-Eau Claire, Eau Claire, Wisconsin, Stephanie Sjostrom is a Baccalaureate Nursing Student at the Department of Nursing, University of Wisconsin-Eau Claire, Eau Claire, Wisconsin, and Michelle Markwardt is a Baccalaureate Nursing Student at the Department of Nursing, University of Wisconsin-Eau Claire, Eau Claire, Wisconsin.
Search terms: Concept analysis, longing, nursing diagnosis development Author contact: [email protected], with a copy to the Editor: [email protected] Funding: Funding for this project came from the University of Wisconsin-Eau Claire Blugold Commitment-Funded Faculty/Student Research Collaboration.
PURPOSE: This paper uses Rodgers’ evolutionary view of concept analysis to define the human response of longing. The purpose is to develop a definition of longing as the first step in diagnosis development. DATA SOURCE: A literature review was conducted by searching the Cumulative Index to Nursing and Allied Health Literature, American Theological Library Association Religion, JSTOR Philosophy, JSTOR Religion, PsycINFO, and PubMed databases to yield an across-discipline sample of articles. DATA SYNTHESIS: Three researchers identified the attributes, antecedents, consequences, situational context, and surrogate terms of longing. CONCLUSIONS: An operational definition was developed. IMPLICATIONS FOR NURSING PRACTICE: Longing is clearly a human response to loss, crossing illness and situations in which nurses encounter patients in multiple settings. This supports the need to further develop longing into a nursing diagnosis.
The art of what nurses do is often invisible. Documentation in nursing is more often about patient physiological measures and procedures done with or for the patient. Yet it is the very essence of nursing to try to assess the patient’s response to a diagnosis or life circumstance from a holistic lens. Longing is one type of human response that has been identified in patients. Most often associated with chronic or terminal illnesses, where patients have longed for the life they had before the illness (Arnaud, 1959; Morrison & Burgman, 2009; Ohlen & Holm, 2006; Pehler & Craft-Rosenberg, 2009; Ready, 2010), additional studies are finding longing in areas of life not necessarily associated directly with illness. Longing is found in people who are homeless (Baumann, 1996; Farkas & Yorker, 1993) or in instances of child abuse (Baldwin, 2003; Holm, Berg, & Severinsson, 2009)—areas that are still within the domain of nursing care. To be able to identify and treat longing in patients, nursing must have a clear definition of the concept (Herdman, 2012). When the assessment of a patient’s response identifies a need, the use of standardized nursing languages, such as NANDA-I (Herdman, 2012), provides an avenue to share that need with other healthcare providers. Nursing diagnoses are “clinical judgments of actual or potential health problems/life processes that lead to the selection of nursing interventions to help patients achieve outcomes” (Herdman, 2012, p. 515). As tools of communication, nursing diagnoses share with other healthcare providers the clinical judgments that guide the patient’s plan of care. As a foundational tool, the concepts from which nursing diagnoses are developed must come from a clear © 2014 NANDA International International Journal of Nursing Knowledge Volume 25, No. 3, October 2014
set of criteria so that nurses can easily identify this phenomenon. As one of the first steps in developing a nursing diagnosis, a concept analysis is crucial to clarify how a concept is being used in nursing. Longing is a concept that has not been clearly identified or defined in nursing despite articles and research studies that have begun to explore longing in patients. This research study, using Rodgers’ evolutionary view of concept analysis (Rodgers, 2000), was the first step to develop a nursing diagnosis by suggesting a conceptual definition of longing. Method Rodgers’ evolutionary view of concept analysis (Rodgers, 2000) was used to guide this study. This nursingbased analysis tool is a method used to further develop nursing concepts based on how the concept is used in the literature. In addition to finding the attributes that define the concept, Rodgers’ method uses a rigorous analysis through inductive inquiry to learn the nature of the concept, and the sociocultural, disciplinary, and interdisciplinary contexts. The primary activities used in this concept analysis methodology are outlined in Table 1. Literature Search/Sample A literature search was conducted in the spring of 2011 using the databases of the Cumulative Index to Nursing and 133
Longing: A Concept Analysis
S.-R. Pehler et al.
Table 1. Activities in Rodgers’ Evolutionary View of Concept Analysis 1 2 3
4 5 6
Identify the concept of interest and associated expression Identify and select setting and sample for data collection Collect data, identifying the attributes, contextual basis including the interdisciplinary, sociocultural, and temporal (antecedent and consequential occurrences) Analyze data according to the above characteristics Identify an exemplar Identify implications, hypotheses, and implications for further development of the concept
Rodgers (2000).
Table 2. Literature Search Results Discipline of first author
Number of articles
Nursing Psychology Physician Clergy Sociology Occupational therapy Public health
44 10 6 4 1 1 1
Allied Health Literature (CINAHL), American Theological Library Association (ATLA) Religion, JSTOR Philosophy, JSTOR Religion, PsycINFO, and PubMed. Based on a prior research study where longing was a key theme of spirituality in illness (Pehler & Craft-Rosenberg, 2009), the search terms longing and illness were used. The initial search yielded 1,105 resources. Sources were exported to EndNote (Thomson Reuters, Carlsbad, CA, USA), where duplicates, books, book reviews, and articles not written in English were removed. Of the 127 articles remaining, an additional 60 were eliminated because the search yielded the term belonging (and no longing) as the concept in the article, or the content of the article was from the author’s perspective rather than from a patient’s perspective. The final sample yielded 67 articles, which were used in the analysis, and were from the disciplines of (based on first author) medicine, occupational therapy, nursing, psychology, public health and health services, religion, and sociology (Table 2). Data Analysis Three researchers reviewed the articles, identifying the attributes, antecedents, consequences, situational context, and surrogate terms of longing in the data analysis. Once any of the items were identified and agreed upon by at least two members of the research team, the findings were further reviewed to identify the themes. Articles from each database (e.g., CINAHL, PubMed, and ATLA) were analyzed 134
separately, then combined to identify consensus across disciplines. Although not a requirement of Rodgers’ evolutionary view of concept analysis, saturation was achieved as no new attributes were identified after approximately 95% of the articles were reviewed. Attributes of Longing The variety of contexts in which the term longing was revealed in the literature not only emphasized and supported the need to more clearly define the term longing, but also provided an opportunity to explore the breadth of how longing has been used. Beyond describing the human response when a person has a physical illness, longing was also used to describe the experience of lovesickness (Tallis, 2005) and homesickness (Thurber, 1999; Thurber, Sigman, Weisz, & Schmidt, 1999). There were distinct similarities in the attributes and consequences of those articles compared with articles where the context of longing occurred within physical and mental illnesses. In the broadest sense, all of the articles discussed longing within the context of loss. Losses are experienced not only with a physical or mental health concern, but also loss of country (as in immigrants who needed to move to a new country) (Svenberg, Mattsson, & Skott, 2009), the feelings of loss that children experience when away at a summer camp (Thurber, 1999), and the loss of a love relationship (Tallis, 2005). It is because of those commonalities that the articles were kept in the final sample, adding to the breadth of contexts in which longing was found in the literature. From the articles reviewed, seven major attributes were found. Disconnection was the attribute that was the most prevalent and present in four of the seven disciplines (Table 3). The attribute of hope was found second in frequency and appeared in the literature from three of the disciplines. Although initially thought of as an outlier (Rodgers, 2000), final analysis confirmed hope as an attribute, not only due to its frequency and presence across three disciplines, but also due to the theoretical insights into the nature of longing. Disconnection. The theme of disconnection was the most frequently found attribute. Authors described a profound disconnection of what used to be and the longing to get back to what was. This disconnection was described in a physical sense, as when an illness takes away a person’s physical abilities. Authors described this as sense of living in-between (Bruce, Schreiber, Petrovskaya, & Boston, 2011; Ohlen & Holm, 2006). The person was living in-between what he or she now could functionally do, yet longed for his or her former physical self and abilities. There was also a feeling of disconnection when Bruce et al. (2011) compared the suffering of people with lifethreatening cancer and their family caregivers. The participants’ experience of groundlessness occurred as the disease shook the patient and family caregivers to their
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Table 3. Attributes of Longing Attribute in order of frequency, with descriptions of how used in the literature Disconnection—separation, isolation, interruption of life, had something but now do not have (e.g., relationship, health, home country, self—who they were/are), missing (missed activities, missed time together, missing home) Hope—looking forward, not backward in time and space, looking for a new normal Existential questioning—seeking meaning and purpose to life Abandoned—feeling of isolation, deserted, not a part of, left out Despair—feeling of total unacceptability, powerless over situation; intensely emotional, depression, hopelessness, desperation, discouragement, desolation, distress, agony, and anguish Vulnerability—seeking security, feeling insecure, fear of unknown Grief—response to loss, pain of loss, deep sorrow, grievance, bemoaning, heartbreak, woe, or worry; grief could be expressed as hurt, anger, or sadness
very core. Participants were disconnected from their life prior to the disease, precipitating a need to search for peace and stability. Disconnection also illustrates the longing that is present in family caregivers as they care for a family member diagnosed with Alzheimer’s disease (Johansson, Sundh, Wijk, & Grimby, 2013; Marwit & Meuser, 2005). As the person loses his or her identity due to Alzheimer’s, the relationship with the family member—most often the spouse—no longer is rooted in shared experiences. The bond is no longer a foundation for support to help caregivers with the experiences of loss, confusion, fear, and uncertainty they experience. Family caregivers long to reconnect: to go back to what once was. Disconnection was found in situations where isolation, loneliness, or ambivalence was experienced, as in the case of moving to another country. Immigrants moving from Somalia to Sweden (Svenberg et al., 2009) expressed a sense of living in-between the sense of disconnection due to being uprooted from all that was familiar. This resulted in feelings of isolation, loneliness, and separation from family still in their home country, while feeling ambivalence or disconnection to their new home. Hope. Hope was at first thought to be an outlier, as it did not mirror the circumstances of the other attributes found in the literature. Rodgers (2000) cautioned to not disregard outliers, as they can provide insight into the concept. Taking Rodgers’ caution seriously, the frequency with which hope was found in the review, and with hope appearing in three of the disciplines, it became clear that hope was not an outlier but definitely an attribute of longing. Although a number of attributes ascribed longing to looking back to what was, hope always had the nuance of looking forward, no matter how hard the circumstances. For example, children experiencing homelessness (Baumann, 1996) transcended the feelings of fear, anger, and sadness by directing attention to another possibility—a longing and hope for a better situation. Immigrants from war-torn Somalia continued to hope that they would be able to go
Number of disciplines attribute found 4 3 3 4 3 3 3
back home (Svenberg et al., 2009). The forward view that immigrants share with their children is that “you have two countries . . . and that’s an advantage . . . and if they have the opportunity, they will go back . . . but returning is part of my own plan for the future” (p. 283). Women who were abused as children long for reconciliation—a longing for wholeness and meaning (Holm et al., 2009, p. 565). The attribute of hope in the literature reviewed was a longing for something different, not a return to the past. Existential questioning. Described as feelings of a life unfulfilled without meaning or heightened spiritual questioning, existential questioning was the third most prevalent attribute found in this review. Although the feeling of an unfulfilled life occurs frequently in times of terminal illness (Bruce et al., 2011; Spichiger, 2009), existential questioning also arose in situations of mental illness (Miller, 1996; Sheehy & Rabinor, 2005; Watanabe, Okada, Okabe, Onishi, & Morishima, 2011) and in research on the experience of burnout (Arman, Hammarqvist, & Rehnsfeldt, 2011). For a person diagnosed with burnout, the researchers concluded that the person is experiencing a conflict between his or her identity and understanding of life: shutting himself or herself off from his or her own suffering and emptiness. This produces a struggle and sense of meaninglessness as he or she often seeks to be affirmed by outsiders, yet have a “silent inner longing for interdependence with others” (p. 300). Abandoned. The tension between the longing for relationship yet the fear of being abandoned was found in research that explored the effect of being abused as children on adults (Gostecnik, Repic, Cvetek, & Cvetek, 2010), in families where a member has a mental illness (Holm & Severinsson, 2010; Miller, 1996), and when a young child experiences a traumatic event (Edmands & Marcellino-Boisvert, 2002; Holm et al., 2009). The subjects in those research studies longed for intimacy, but also feared becoming close to another person due to their prior experiences. Even though they felt they were not good 135
Longing: A Concept Analysis enough to have an intimate relationship, their earlier experiences left them with a strong tension between longing for a relationship and fear of being abandoned. Despair. Despair was one of the more intensely described attributes of longing. Participants described it as an “uncontained” and “terrific” sadness (Al-Gamal, Long, & Livesley, 2009), “terrifying” despair (Gostecnik et al., 2010), an “unmalleable grief” (Bruce et al., 2011), and a feeling of “heaviness” (Talseth, Gilje, & Norberg, 2003). Deep feelings of despair appeared in articles where participants or family members were experiencing terminal or mental illness, or in situations of abuse. The profound and intense despair created a longing in the individual and/or family for stability and peace. Vulnerability. Longing also produced feelings of vulnerability and fragility, where the individual longed for a sense of safety. Five of the articles that identified this vulnerability included children. The articles described the fears and longings for safety in children who were hospitalized (Wikstrom, 2005), children who were homeless (Farkas & Yorker, 1993), and adults who experienced abuse as a child (Baldwin, 2003; Gostecnik et al., 2010; Holm & Severinsson, 2010). Especially in instances where the adults experienced abuse as a child, this traumatic event increased their vulnerability into adulthood, making it difficult to form intimate relationships with others. This vulnerability, insecurity, and a lack of self-confidence created a tension of longing for relationships—yet fearful of allowing themselves to be vulnerable—to risk the connection with another person. Although similar to the attribute of abandonment, adults who felt vulnerable were more likely to seek relief from this longing through use of alcohol or drugs. Whether used as a substitute for an intimate relationship or as a measure to decrease the feelings of vulnerability, the destructive nature of drugs and alcohol felt safer for the adults than the tension of longing for relationship (Gostecnik et al., 2010). Fear and vulnerability were expressed in terminally ill patients experiencing pain and dependency during hospitalization (Spichiger, 2009). These patients longed to go home—to get back to the familiarity of their own homes. In another group of adults, mothers with breast cancer expressed fears for their children (Ohlen & Holm, 2006). The inability to carry on the mothering role if the mother died before the child grew up left those breast cancer patients longing for the security of knowing their children would be okay. The fears and feelings of vulnerability were related to the unknown and the inability to control the situations that the person was experiencing. Grief. This last attribute of grief has been identified by feelings of hurt, anger, and sadness, which may speak to the ambiguous nature of the loss that individuals and families encounter when experiencing longing. Pauline Boss identified the concept of ambiguous loss in the 1970s, and has provided a substantial body of research contributing to our 136
S.-R. Pehler et al. understanding of this phenomenon and how it may complicate the grief response (Boss, 1999a, 1999b; Boss & Carnes, 2012). Her work has defined the ambiguous loss that families experience when they are uncertain if their “loved person is absent or present, dead or alive” (Boss, 1999b, p. 4). Whether it is due to Alzheimer’s (Marwit & Meuser, 2005), abandonment (Edmands & Marcellino-Boisvert, 2002), or being forced to move to a new country (Svenberg et al., 2009), the uncertainty of the status of the relationship with that person or family left behind becomes very difficult for the remaining family members to understand: It can affect individual and family functioning (Boss, 2001). Boss identified that individuals or families experiencing ambiguous loss may be sad, angry, or hurt, which are all signs of grief (Boss & Carnes, 2012). When there is a death and a body, although very difficult, there is finality—a reason for the loss. The person has died. In situations of ambiguous loss, however, there may not be a body (families who lost loved ones in the World Trade Center), or there may be a body, but due to illnesses such as Alzheimer’s, there is no relationship due to loss of memory and cognitive functioning. In such situations, ambiguous loss can complicate the grief experience, leading to a longing for closure and feelings of hurt, anger, or sadness. Antecedents of Longing Most of the literature identified that longing appeared after a life-threatening illness diagnosis or after a traumatic event occurred. Not germane to life-threatening illness, longing was also found in situations of mental illnesses, chronic illness, and children with disabilities. Longing also appeared within other situations, such as the longing to be home when away at camp, in a homeless shelter, or when needing to move to another country. Longing was also experienced in situations where the adult suffered abuse as a child, children had to care for ill parents, and when children were separated from parents. The differences across these antecedents were more correlated to what the person or family longed for. In illness, it may be to restore their physical health. When a person experienced homelessness or displaced from his or her home country, it was a longing to go home. When children were displaced from parents or experienced abuse from a close family member, this set up a lifetime longing to be in a relationship with another, but fearful of the consequences. Consequences of Longing When an individual or family experienced longing, regardless of the antecedent cause, there were noted positive as well as potential negative consequences. Tied to the most frequently cited attribute of disconnection, the consequences found in the literature included detaching from the ill family member, decreased feelings of closeness, or constraints in interpersonal relationships due to an inability to trust another person. Some of the articles identified loss
S.-R. Pehler et al. of self-esteem, increased fears, and loss of hope. In situations where there was a traumatic event in childhood, common outcomes included mental illness, substance abuse, and/or prostitution. Although these negative consequences were outlined in a number of articles, research also supported that individuals and families gained the ability to accept and forgive oneself, increase trust, acceptance, and experience joy and hope. The process by which some could transcend their longing was not described, and provides a need for future research that can help identify interventions that could help others avoid or decrease the negative consequences of longing. Defining Longing The need to clarify longing was identified as the primary objective of this research study. From this study, the reason for the lack of a clear definition of longing has been due to the fact that it transcends age groups, settings, illnesses, situations, and human and family needs. A definition must, therefore, be able to encompass this vast array of attributes, circumstances, and experiences. From the data, the authors propose this definition: Longing is the earnest, heartfelt desire for something, some state, or some relationship, without which one’s life does not feel complete. It appears as a disconnection within a person’s relationships, health, and/or purpose in life due to illness, injury, disability, or death. Although an individual or family primarily experiences longing as feelings of grief, anger, sadness, despair, hurt, abandonment, and vulnerability, hope is also expressed. Implications As outlined in NANDA-I (Herdman, 2012), the first step to developing a nursing diagnosis is a concept analysis to determine the existence of that concept in the literature. From the data, longing is clearly a human and family response to loss that is found in the literature, and crosses not only illness but also situations in which nurses encounter patients in the acute, primary, and public health settings. This supports that longing needs further development as a nursing diagnosis before determining the outcomes and interventions that can relieve a person or family’s longing. Beyond the development of a nursing diagnosis, data review and analysis shows patterns that lead to further questions. Although longing is articulated in a physical sense (that a person longs for his or her health as before the disease), longing is more often expressed as the disconnection of a person in relationship. This is especially true in articles that describe the loss of relationship when a person has Alzheimer’s disease, or the anticipatory loss of a person with a terminal illness. This loss of relationship is also seen in immigrants experiencing homesickness and a longing to return to their country and relatives who were left behind.
Longing: A Concept Analysis Loss of relationship is also found in people who had traumatic or abusive relationships when younger, and now long for, yet fear, relationships with others. This leads to further questions of whether the quality of the relationships affects the longing that a person experiences or if there are potential gender differences in the feeling of longing, such as prevalence in males or females. Although some people experience hope in longing, most express longing as more negative feelings of disconnection, abandonment, and despair. Further research into these implications will help define and articulate the human and family response of longing. References Al-Gamal, E., Long, T., & Livesley, J. (2009). Development of a modified instrument to measure anticipatory grieving in Jordanian parents of children diagnosed with cancer: The Marwit and Meuser caregiver inventory childhood cancer. Cancer Nursing, 32(3), 211–219. doi:10.1097/ NCC.0b013e31819a2ae4 Arman, M., Hammarqvist, A. S., & Rehnsfeldt, A. (2011). Burnout as an existential deficiency—Lived experiences of burnout sufferers. Scandinavian Journal of Caring Sciences, 25(2), 294–302. doi:10.1111/j.14716712.2010.00825.x Arnaud, S. H. (1959). Some psychological characteristics of children of multiple sclerotics. Psychosomatic Medicine, 21, 8–22. Baldwin, M. A. (2003). Living in longing: Prostitution, trauma recovery, and public assistance. Journal of Trauma Practice, 2(3/4), 267–314. Baumann, S. L. (1996). Feeling uncomfortable: Children in families with no place of their own. Nursing Science Quarterly, 9(4), 152–159. Boss, P. (1999a). Ambiguous loss: Learning to live with unresolved grief. Cambridge, MA: Harvard University. Boss, P. (1999b). Insights. Ambiguous loss: Living with frozen grief. Harvard Mental Health Letter, 16(5), 4–5. Boss, P. (2001). Family stress management. Newbury Park, CA: Sage Publications. Boss, P., & Carnes, D. (2012). The myth of closure. Family Process, 51(4), 456–469. doi:10.1111/famp.12005 Bruce, A., Schreiber, R., Petrovskaya, O., & Boston, P. (2011). Longing for ground in a ground(less) world: A qualitative inquiry of existential suffering. BMC Nursing, 10, 2. doi:10.1186/1472-6955-10-2 Edmands, M. S., & Marcellino-Boisvert, D. (2002). Reflections on a rose: A story of loss and longing. Issues in Mental Health Nursing, 23(2), 107–119. Farkas, G. S., & Yorker, B. (1993). Case studies of bibliotherapy with homeless children. Issues in Mental Health Nursing, 14(4), 337–347. Gostecnik, C., Repic, T., Cvetek, M., & Cvetek, R. (2010). Hidden mission of the psyche in abuse and addiction. Journal of Religion and Health, 49(3), 361–376. doi:10.1007/s10943-009-9264-8 Herdman, T. H. (Ed.). (2012). NANDA International nursing diagnoses: Definitions and classification, 2012-2014. Oxford, UK: Wiley Blackwell. Holm, A. L., Berg, A., & Severinsson, E. (2009). Longing for reconciliation: A challenge for women with borderline personality disorder. Issues in Mental Health Nursing, 30(9), 560–568. doi:10.1080/ 01612840902838579 Holm, A. L., & Severinsson, E. (2010). Desire to survive emotional pain related to self-harm: A Norwegian hermeneutic study. Nursing & Health Sciences, 12(1), 52–57. doi:10.1111/j.1442-2018.2009.00485.x Johansson, A. K., Sundh, V., Wijk, H., & Grimby, A. (2013). Anticipatory grief among close relatives of persons with dementia in comparison with close relatives of patients with cancer. American Journal of Hospice and Palliative Care, 30, 29–34. Marwit, S. J., & Meuser, T. M. (2005). Development of a short form inventory to assess grief in caregivers of dementia patients. Death Studies, 29(3), 191–205. Miller, F. E. (1996). Grief therapy for relatives of persons with serious mental illness. Psychiatric Services (Washington, D.C.), 47(6), 633–637. Morrison, R., & Burgman, I. (2009). Friendship experiences among children with disabilities who attend mainstream Australian schools. Canadian Journal of Occupational Therapy, 76(3), 145–152. Ohlen, J., & Holm, A. K. (2006). Transforming desolation into consolation: Being a mother with life-threatening breast cancer. Health Care for Women International, 27(1), 18–44. doi:10.1080/07399330500377226
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