Sofia Almerud ÖsterbergpersName, Ulrica HörbergpersName, Lise-Lotte OzolinspersName, Carina Werkander HarstädepersName, Carina ElmqvistpersName (2023date). “Exposed - a semantic concept analysis of its origin, meaning change over time and its relevance for caring science..” International Journal of Qualitative Studies on Health and Well-beingtitle·j.
Object of study — the Swedish concept 'exposedterm·dom' (utsattterm·dom) and its relevance for caring scienceterm·key
Research question — how the dictionary meaning of 'exposedterm·dom' changed between the 2004date analysis and a repeat analysis fifteen years later
Contribution — a semantic account of 'exposedterm·dom' that deepens understanding of a patient's exposedterm·dom situation in nursing care
phenomenon · claim-type · cross-domain-transfer · mechanism · claim-relation · replication-status · limitation — grounded in the full text| phenomenon | patients made dependent, exposed and vulnerable by illness and reliance on carers — “A sick person relies on and surrenders to carers and is therefore dependent, exposed and vulnerable (Almerud et al., 2008 ; Dahlberg et al., 2003 ).” | |
| claim-type | existence — “The findings show that over time, the degree of binding of the following synonyms has become stronger; unprotected/defenseless, naked/bare, pressed/jostled and unsafe/unprotected and can easily be transferred to a clinical nursing context.” | |
| method — evidence | — “A semantic concept analysis in two phases was conducted.” | |
| object of study — evidence | — “Based on this, we argue that exposed is a concept whose relevance for caring science should be ascertained.” | |
| research question — evidence | — “To elucidate how the concept’s meaning changed over time, a new concept analysis, using the same method, was conducted fifteen years later, in 2019.” | |
| contribution — evidence | — “This concept analysis can help in deeper understanding a person’s unique exposed situation and adds to the knowledge base of exposedness within nursing care.” | |
| mechanism | vulnerability Impermanence and instability in life, with little control over one's immediate conditions, give rise to fragility and vulnerability. — “Temporality and instability in our lives, along with the inability to control our closest living conditions, are a basis for experiencing both fragility and vulnerability in existence (Arman, 2015 ).” | mechanisms[0] |
| sense | exposed (Almhult 1955) - a post or position exposed to danger or criticism — “Almhult (Almhult, 1955 ) describes the meaning of exposed as “post or position exposed to danger or criticism”” | senses[0] |
| sense | exposed (caring science) - patients suffering both from poor health and from the care they receive or are denied — “From a caring science perspective, our findings showed that the concept exposed needs to be highlighted, as it entails patients suffering both from poor health and from the care they receive or do not receive, which in turn can be related to loss of dignity.” | senses[1] |
| note | exposed —same-as→ utsatt — A translation equivalence given in apposition; the English word renders the Swedish one. — “The term exposed (utsatt) is used in the Swedish language in various ways, e.g., for people in vulnerable positions.” | concept_edges[0] |
| relation | exposed —same-as→ utsatt — The term exposed (utsatt) is used in the Swedish language in various ways, e.g., for people in vulnerable positions. — “The term exposed (utsatt) is used in the Swedish language in various ways, e.g., for people in vulnerable positions.” | concept_edges[0] |
| weight | exposed —same-as→ utsatt — 0.8 — “The term exposed (utsatt) is used in the Swedish language in various ways, e.g., for people in vulnerable positions.” | concept_edges[0] |
| relation | interpretation phase —part-of→ discrimination analysis — The discrimination analysis consists of three phases: matrix, paradigm and interpretation phase. — “The discrimination analysis consists of three phases: matrix, paradigm and interpretation phase.” | concept_edges[1] |
| weight | interpretation phase —part-of→ discrimination analysis — 0.8 — “The discrimination analysis consists of three phases: matrix, paradigm and interpretation phase.” | concept_edges[1] |
| note | suffering caused by care —causes→ exposedness — Drawn from Eriksson (2006) as cited; unsigned because creating names an outcome, not a change in a quantity. — “Suffering caused by care is the suffering that the health care providers cause to the patient by violating the patient’s dignity, for example exercising power or failing in their care (Eriksson, 2006 ), thereby creating an exposedness of the patient.” | concept_edges[2] |
| relation | suffering caused by care —causes→ exposedness — Suffering caused by care is the suffering that the health care providers cause to the patient by violating the patient’s dignity, for example exercising power or failing in their care (Eriksson, 2006 ), thereby creating an exposedness of the patient. — “Suffering caused by care is the suffering that the health care providers cause to the patient by violating the patient’s dignity, for example exercising power or failing in their care (Eriksson, 2006 ), thereby creating an exposedness of the patient.” | concept_edges[2] |
| weight | suffering caused by care —causes→ exposedness — 0.7 — “Suffering caused by care is the suffering that the health care providers cause to the patient by violating the patient’s dignity, for example exercising power or failing in their care (Eriksson, 2006 ), thereby creating an exposedness of the patient.” | concept_edges[2] |
| replication | not-applicable | |
| limitation | Only the meaning dimension 'in an exposed situation' was examined; a broader view might have given a different understanding. — “In this concept analysis of the word exposed, we chose to further investigate the meaning dimensions in an exposed situation , since this meaning is most related to clinical caring practice. This may be seen as a limitation.” | limitations[0] |
| limitation | The analysis was done in Swedish and translated into English, and the choice of language may limit it. — “The choice of language may be considered as a limitation.” | limitations[1] |
finding · quantity · variable · definition · key-term — grounded in the full text| finding | By the 2019 analysis the concept had become stronger and more stringent in the dimension 'in an exposed situation'. — “In the second semantic analysis (in 2019) it became obvious that the concept exposed had become stronger and more stringent in the meaning dimension in an exposed situation .” | content_tags.findings[0] |
| finding | Precarious no longer appears as a synonym in dictionaries published after 2006. — “Precarious does not appear as a synonym in dictionaries published after 2006.” | content_tags.findings[1] |
| quantity | 1553 — — “The Dictionary of the National Encyclopedia (Nationalencyklopedin, N.d. ) states that the adjective form exposed has been used in text since 1553.” | content_tags.quantities[0] |
| quantity | 8 — — “The concept was examined in eight dictionaries selected based on their scientific authority (Eriksson, 2010 ), i.e., they had a high author competence and were published by well-known, established and high quality publishers.” | content_tags.quantities[1] |
| key-terms | exposed, exposedness, vulnerability, semantic concept analysis, degree of synonymy, discrimination paradigm, caring science, human dignity, suffering caused by care, insiderness |
| concept | exposed — being unprotected as a human being in a vulnerable situation — “Being exposed means being unprotected as a human being in a vulnerable situation (Todres et al., 2009 ).” | concepts[0] |
| concept | utsatt — not defined in this paper's own words; the Swedish word the authors render in English as exposed — “The term exposed (utsatt) is used in the Swedish language in various ways, e.g., for people in vulnerable positions.” | concepts[1] |
| concept | semantic concept analysis — an etymological description and analysis of the definitions of linguistic expressions taken from dictionaries — “A semantic concept analysis entails an etymological description and analysis of the definitions of linguistic expressions taken from dictionaries (Eriksson, 2010 ; Koort, 1975 ; Sivonen et al., 2010 ).” | concepts[2] |
| concept | binding — either that the lexical description of the concept includes the synonym, or the reverse — “A binding entails either that the lexical description of the concept includes the synonym, or the reverse.” | concepts[3] |
| concept | degree of synonymy — the concordance in percent according to the chosen dictionaries — “The heading “Degree of synonymy between two words” means the concordance in percent according to the chosen dictionaries; this enables the understanding and interpretation of dimensions within the family of concepts (Koort, 1975 ).” | concepts[4] |
| concept | discrimination analysis — to investigate how the concept and its synonyms are related, by exploring possible bindings — “Thereafter, a discrimination analysis was made to investigate how the concept and its synonyms are related, by exploring possible bindings.” | concepts[5] |
| concept | interpretation phase — not defined in this paper's own words; the last step, where the pattern of synonyms is read for meaning — “The discrimination analysis consists of three phases: matrix, paradigm and interpretation phase.” | concepts[6] |
| concept | human dignity — the right to be confirmed as a unique person — “Human dignity, meaning the right to be confirmed as a unique person, precedes everything else.” | concepts[7] |
| concept | suffering caused by care — the suffering that the health care providers cause the patient by violating the patient’s dignity, e.g., exercising power or failing in their care — “Suffering caused by care is the suffering that the health care providers cause the patient by violating the patient’s dignity, e.g., exercising power or failing in their care (Eriksson, 2018 ).” | concepts[8] |
| concept | exposedness — not defined in this paper's own words; the condition of a person left open to harm — “Suffering caused by care is the suffering that the health care providers cause to the patient by violating the patient’s dignity, for example exercising power or failing in their care (Eriksson, 2006 ), thereby creating an exposedness of the patient.” | concepts[9] |
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Exposedterm·dom - a semantic concept analysisterm of its origin, meaning change over time and its relevance for caring scienceterm·key.
Abstract A patient is vulnerable and exposedterm·dom due to illness, relies on and surrender to other people. In caring this means a special dependency. The aim of this study was to describe the origin of the concept ‘exposedterm·dom’, to elucidate how the definition of this term has changed over time, and to outline its relevance in caring scienceterm·key.
A semantic concept analysisterm in two phases was conducted.
The findings show that over time, the degree of bindingterm of the following synonyms has become stronger; unprotected/defenseless, naked/bare, pressed/jostled and unsafe/unprotected and can easily be transferred to a clinical nursing context.
This study provides a deeper understanding of the concept 'exposedterm·dom' semantically. Being exposedterm·dom is a profound experience for patients who need to be seen as the person they really are. A life-world led care has an existential power that can support professionals, strengthen patients’ health processes, and alleviate the patient’s suffering.
Introduction Being human includes existential vulnerabilityterm·key. Temporality and instability in our lives, along with the inability to control our closest living conditions, are a basis for experiencing both fragility and vulnerabilityterm·key in existence (Arman, 2015 ). To be human is to be exposedterm·dom, to be a patient is to be twice as exposedterm·dom, both by life and the health care system (Almerud et al., 2008 ). Based on this, we argue that exposedterm·dom is a concept whose relevance for caring scienceterm·key should be ascertained. The term exposedterm·dom (utsattterm·dom) is used in the Swedish language in various ways, e.g., for people in vulnerable positions.
Caring ethics is the basic approach towards the patient and the care, regardless of the ethical guidelines that exist for each health care profession. Human dignityterm·dom, meaning the right to be confirmed as a unique person, precedes everything else. Suffering raises the ethical requirement for care (Eriksson, 2018 ). The ethical demand is directed towards the caregiver and emanates from the patient (Dahlberg et al., 2003 ). The demand is absolute, i.e., it is an ethical obligation for the caregiver directed towards meeting this demand and to reduce exposednessterm·dom. Lögstrup (Lögstrup, 2009 ) states that trust is the ground for our existence. In the encounter with the unknown, we trust the Other and thereby trust is also the core of a caring relation. A sick person relies on and surrenders to carers and is therefore dependent, exposedterm·dom and vulnerable (Almerud et al., 2008 ; Dahlberg et al., 2003 ). The goal of caring is to alleviate suffering and create conditions for well-being (Lögstrup, 2009 ; Martinsen, 2012 ). Suffering can also emanate from care. Suffering caused by careterm·dom is the suffering that the health care providers cause the patient by violating the patient’s dignity, e.g., exercising power or failing in their care (Eriksson, 2018 ). Neglect and denial of care in health care are examples of suffering caused by carers due to insecurity and lack of information and incomprehensibility in the care environment (Dahlberg et al., 2003 ).
A conceptual understanding is important in search of knowledge. Eriksson (Eriksson, 2010 ) states that it is through concepts that reality is shaped; selection and exploration of core concepts is the first phase of knowledge formation. Concepts are labels of phenomena. They are construction parts in building theories. Through concepts, one can also understand peoples’ ways of being as well as their practical, everyday lives and professional thinking (Arman, 2015 ). Concept determination may thus be seen as an important component for basic caring scienceterm·key research (Eriksson, 2010 ). The theoretical ground for this paper is the concept’s relevance within caring scienceterm·key.
Aim The aim of this study was to describe the origin of the concept “exposedterm·dom”, to elucidate how the definition of this term has changed over time, and to outline its relevance in caring scienceterm·key.
Method A semantic concept analysisterm entails an etymological description and analysis of the definitions of linguistic expressions taken from dictionaries (Eriksson, 2010 ; Koort, 1975 ; Sivonen et al., 2010 ). It creates an understanding of the conceptual meaning in the language of one time period at a time (Sivonen et al., 2010 ). Furthermore, a semantic concept analysisterm can help determine the ontological and contextual perspectives (Eriksson, 2010 ) and create a deeper understanding of a concept in a caring scienceterm·key context (Sivonen et al., 2010 ). By developing theories and concepts, caring scienceterm·key can move towards a deeper understanding of the essence of caring (Arman, 2015 ). The Koort (Koort, 1975 ) tradition of semantic analysis contributes to a useful exploration and definition of central concepts within caring scienceterm·key (Sivonen et al., 2010 ). The method enables a deeper and broader understanding of caring scienceterm·key phenomena on an ontological level, thereby offering solid ground for theoretical, contextual and practical understanding and development. Analysing the concept semantically can deepen the understanding of a person’s sense of being exposedterm·dom in the context of health care (Koort, 1975 ; Sivonen et al., 2010 ).
The semantic analysis of concepts, originally created by Koort (Koort, 1975 ) and further developed by Eriksson (Eriksson, 2010 ), is a common method within Nordic caring scienceterm·key research to add knowledge when a concept or phenomenon needs clarification. Thus, a concept is not merely a combination of words or letters but is closely intertwined with human life and lived experiences (Eriksson, 2010 ; Werkander HarstädepersName et al., 2012 ). By defining concepts within specific contexts, knowledge relevant for caring scienceterm·key can be established (Eriksson, 2010 ). A semantic analysis can show a pattern of meaning, give a more complete picture of the concept and illustrate the metamorphosis of the concept over time (Nåden & Eriksson, 2003 ). Furthermore, a semantic analysis aims to analyse the meaning of linguistic expressions (Koort, 1975 ). The method includes two phases: 1) etymological and 2) semantic.
Material, inclusion and exclusion Sample In a semantic analysis, the researcher should avoid mixing verbs, adjectives and nouns (Sivonen et al., 2010 ). The adjective form exposedterm·dom was chosen as it appears in more and earlier dictionaries than the verb expose and the noun exposednessterm·dom .
Data The material used is dictionaries chosen to span as long a period of time as possible (Koort, 1975 ) to ensure that a development of the concept and its meaning and synonyms can be established. The first time exposedterm·dom appears is in Illustrated Swedish Dictionary from 1964. The concept was examined in eight dictionaries selected based on their scientific authority (Eriksson, 2010 ), i.e., they had a high author competence and were published by well-known, established and high quality publishers. The dictionaries in the 2004date semantic analysis were published between 1964 and 2002 ( Tables 1 and 2 ). To elucidate how the concept’s meaning changed over time, a new concept analysis, using the same method, was conducted fifteen years later, in 2019. Eight dictionaries, published between 2006–2017, were used ( Table 2 ). Table I. Dictionaries used in the semantic concept analysisterm in 2004date. Johannisson, T. & Ljunggren, K-G. (1977). Svensk handordbok: konstruktioner och fraseologi. (Swedish handbook of words: constructions and phraseology). Stockholm: Norstedt. Malmström, S. (2002). Bonniers svenska ordbok. (Bonnier’s Swedish dictionary). Stockholm: Bonnier. Molde, B. (Red.). (1964). Illustrerad svensk ordbok. (Illustrated Swedish dictionary). Stockholm: Natur och Kultur Nationalencyklopedins ordbok Bd 3. (1996). (The Dictionary of the National Encyclopaedia). Höganäs: Bra böcker. Ord för ord: svenska synonymer och uttryck. (1992). (Word by word—Swedish Synonyms and Phrases). Stockholm: Norstedt. Strömberg, A. (1988). Synonymordboken. (Thesaurus). Stockholm: Strömberg. Svensk ordbok (Swedish Dictionary). (1986). Uppsala: Norstedt. Walter, G. (2000). Bonniers synonymordbok. (Bonnier’s Thesaurus). Stockholm: Bonnier. Table II. Dictionaries used in the semantic concept analysisterm in 2019. Gerhardsen, H. (red.) (2009). Svenska synonymordbok. 5 uppl. (Swedish thesaurus, 5th ed.). Stockholm: Norstedt Köhler, P.O. & Messelius, U. (2006). Natur och kulturs stora svenska ordbok. (Natur och Kultur’s large Swedish dictionary). Stockholm: Natur och Kultur Nationalencyklopedin. ( n.d. ). Svensk ordbok. (Swedish dictionary). Höganäs: Bra Böcker ( www.ne.se ) Nationalencyklopedin. ( n.d. ). Svenska synonymer. (Swedish thesaurus). Höganäs: Bra Böcker ( www.ne.se ) Sjögren, P.A., Györki, I., Malmström, S. (2010). Bonniers svenska ordbok. (Bonnier’s Swedish dictionary). Stockholm: Bonnier Svenska Akademiens ordlista. (2015). 14 uppl. (Swedish Academy glossary). Stockholm: Svenska Akademien Svenska Akademiens ordbok. (2012). (Swedish Academy dictionary). Stockholm: Svenska Akademien. Svensk ordbok. (2009). (Swedish dictionary). Stockholm: Svenska Akademien.
First, an etymological description was made using dictionaries to indicate the concept’s age, origin and change over time. Thereafter, a discrimination analysisterm was made to investigate how the concept and its synonyms are related, by exploring possible bindingsterm. A bindingterm entails either that the lexical description of the concept includes the synonym, or the reverse. The discrimination analysisterm consists of three phases: matrix, paradigm and interpretation phaseterm.
The matrix phase To create a family of concepts, synonyms were chosen. The choice of synonyms for the concept exposedterm·dom was formed by the strongest quantitative concept dimension in an exposedterm·dom position . Words that seemed relevant for caring scienceterm·key, i.e., words related to human existence, were chosen ( Table 3 ). How the synonyms are related to each other has not been explored in this paper. Table III. Matrix over bindingsterm and degree of synonymyterm to the concept”exposedterm·dom”. Synonyms to the concept EXPOSEDterm·dom (Utsattterm·dom) Number of times the concept is bound to the synonym Number of times the synonym is bound to the concept Total number of bindingsterm Number of dictionaries in which the concept is found Number of dictionaries in which the synonym is found Degree of synonym % 2004date 2019 2004date 2019 2004date 2019 2004date 2019 2004date 2019 2004date 2019 Exposedterm·dom (Utsattterm·dom) 8 8 Precarious (Prekär) 2 0 1 0 3 0 8 0 2 0 30 0 Perilous (Riskabel) 4 3 2 2 6 5 8 8 4 8 50 31 Threatened (Hotad) 2 2 1 0 3 2 8 8 2 1 30 22 Dangerous (Farlig) 3 3 1 2 4 5 8 8 3 6 36 36 Vulnerable (Blottställd) 3 3 3 2 6 5 8 8 3 5 55 38 Unprotected/Defenceless (Oskyddad)* 2 2 4 8 4 33 Naked/Bare (Blottad)* 2 1 3 8 3 27 Pressed/jostled (Trängd)* 2 2 4 8 4 33 Unsafe/unprotected/exposedterm·dom (Exponerad)* 3 1 4 8 2 40 Note: *In 2004date, these synonyms were only discovered in one dictionary and they were therefore not chosen for the analysis. In 2019, however, the bindingterm is strong.
The paradigm phase consists of the construction of a discrimination paradigmterm·key ( Figure 1 ). This shows the relation between the concept and its synonyms (Koort, 1975 ). The heading “Degree of synonymyterm between two words” means the concordance in percent according to the chosen dictionaries; this enables the understanding and interpretation of dimensions within the family of concepts (Koort, 1975 ). If the degree of synonymyterm is lower than 50%, it can be questioned whether the word is an actual synonym. However, this can be interpreted as a nuance of meaning (Eriksson, 2010 ; Koort, 1975 ). For the concept exposedterm·dom , relevant synonyms, regardless of the degree of synonymyterm, were chosen if they were regarded relevant for caring scienceterm·key, which is the context of the aim of this study. The degree of synonymyterm, expressed in percent, was calculated according to Koort’s (Koort, 1975 ) formula: Figure 1. Discrimination paradigmterm·key for the concept exposedterm·dom between 1964–2017. The numbers correspond with degrees of synonymy in percent. Links are illustrated by arrows. The words within brackets are the Swedish words.
(existing bindingterm + existing bindingterm) x 100/possible bindingterm + possible bindingterm For example, exposedterm·dom (utsattterm·dom) is bound to the synonym perilous (riskabel) in four of the eight dictionaries; perilous (riskabel) is bound to the concept exposedterm·dom (utsattterm·dom) in two of these dictionaries. The concept exposedterm·dom (utsattterm·dom) is an entry in all eight dictionaries; the synonym perilous (riskabel) is an entry in four of these dictionaries. The degree of synonymyterm is calculated according to the formula: (4 + 2)×100/8 + 4 = 50%.
Ethical considerations All research, empirical or theoretical, raises ethical questions. By striving for as open and well-founded argumentation as possible, we have strived to follow the directions for good scientific practice, claiming both transparency and stringency ( 2004date , 2013 ). Sivonen et al (Sivonen et al., 2010 ) highlights areas to be considered while conducting a semantic concept analysisterm. A reflective process guided the analysis by striving to clearly show what choices were made in both data gathering and analysis. When choosing dictionaries, the aim was to gather a broad and wide source of materials to avoid a narrow perspective.
Results The results start with an etymological and historical description of the concept followed by a matrix phase where dimensions of meaning and synonyms are presented. The paradigm phase shows how the different synonyms are related to the concept, and the concept’s change over time is described.
Etymological and historical description Bring (Bring, 1930 ) does not address the word exposedterm·dom separately, but refers to the hypernym “unfree/not free” where, for example, exposedterm·dom to and vulnerable are listed as synonyms (cf. discrimination matrix, Table 2 ). Almhult (Almhult, 1955 ) describes the meaning of exposedterm·dom as “post or position exposedterm·dom to danger or criticism”. Exposednessterm·dom as a noun does not exist in older dictionaries, e.g., the word exists in the Swedish Academy glossary, 11th edition ( 1986 ), but not in the 10 th edition ( 1973 ). However, the adjective form exposedterm·dom exists in both. The Dictionary of the National Encyclopedia (Nationalencyklopedin, N.d. ) states that the adjective form exposedterm·dom has been used in text since 1553.
Matrix phase The word “exposedterm·dom” (utsattterm·dom), in its adjective form, existed in most of the selected dictionaries in three different meaning dimensions ( Table 4 ). Table IV. Matrix phase. Exposedterm·dom (utsattterm·dom) – adjective form with three different meaning dimensions With exposedterm·dom name (Med utsattterm·dom namn) On scheduled time (På utsattterm·dom tid) In an exposedterm·dom situation (I utsattterm·dom läge) – the focus in this study “Which can easily be attacked” and “which is a target of attack” are two expressions that the dictionaries specify as synonymous for exposedterm·dom (utsattterm·dom). However, the word attack does not appear as a synonym. This meaning shows that the person who is exposedterm·dom is passive and exposedterm·dom by someone else. It is interesting to note the expression “put yourself at risk” ( 1973 ). Thus, it is the subject who is active and no one else creates the exposednessterm·dom. In more recent dictionaries, no distinction is made between who exposes whom; the synonyms are listed without specifying the active part.
In the concept analysis, synonyms from the dimension “in an exposedterm·dom situation”, with at least two bindingsterm to the concept were included in the first calculation of degree of synonymity, and synonyms with at least a 27% degree of synonymyterm were included in the subsequent analysis. The synonym “threatened” had only a 22% bindingterm. However, this synonym was chosen in the 2004date analysis, with a 30% bindingterm, and therefore it was also included in 2019. The synonyms are: precarious ( prekär ), perilous ( riskabel ), threatened ( hotad ), dangerous ( farlig ), vulnerable ( blottställd ), unprotected/defenceless ( oskyddad ), naked/bare ( blottad ), pressed/jostled ( trängd ) and unsafe/unprotected/exposedterm·dom ( exponerad ).
Paradigm phase In the discrimination paradigmterm·key ( Figure 1 ) the synonyms are presented in relation to the concept. For descriptions of the synonyms, see Table 5 . Table V. Paradigm phase. Precarious (prekär), adjective. Entry in only two of the chosen dictionaries from 2004date. A double bindingterm between the concept and the synonym. In 2019 the synonym is no longer found in any dictionaries. Perilous (riskabel), adjective. Entry in four of the chosen dictionaries from 2004date and in all eight of the chosen dictionaries from 2019. A strong initial bindingterm that weakened between 2004date and 2019. Threatened (hotad), adjective. Entry in only two of the chosen dictionaries from 2004date and one from 2019. The only synonym that has a single bindingterm from the concept, but not back from the synonym to the concept. The bindingterm has weakened between the two concept analyses. Dangerous (farlig), adjective. Entry in three chosen dictionaries from 2004date and in six chosen dictionaries from 2019. A moderately strong bindingterm that is stable between 2004date and 2019. Vulnerable (blottställd), adjective. Entry in three chosen dictionaries from 2004date and in five chosen dictionaries from 2019. The synonym with the strongest degree of bindingterm. However, the bindingterm weakened from 55% to 38% between 2004date and 2019. Unprotected/defenceless (oskyddad), adjective. The synonym was only found in one chosen dictionary from 2004date and had a weak bindingterm. Therefore, the synonym was not chosen for the original analysis. In 2019, however, the entry was in two of the chosen dictionaries and the bindingterm was moderate. Naked/bare (blottad), adjective. The synonym was only found in one of the selected dictionaries from 2004date and had a weak bindingterm. Therefore, the synonym was not chosen for the original analysis. In 2019, however, the entry was in all eight of the chosen dictionaries and the bindingterm was moderate. Pressed/jostled (trängd), adjective. The synonym was only found in one of the chosen dictionaries in 2004date and had a weak bindingterm. Therefore, the synonym was not chosen for the original analysis. In 2019, however, the entry was in four of the chosen dictionaries and the bindingterm was moderate. Unsafe/unprotected/exposedterm·dom (exponerad), adjective. The synonym was only found in one of the chosen dictionaries from 2004date and had a weak bindingterm. Therefore, the synonym was not chosen for the original analysis. In 2019, however, the entry was in two of the chosen dictionaries and the synonym had the strongest degree of bindingterm (40%).
Metamorphoses over time Precarious does not appear as a synonym in dictionaries published after 2006. The one synonym that is stable regarding its degree of bindingterm is Dangerous. Precarious, Perilous and Threatened have weakened. Synonyms that have become stronger bindingsterm are unprotected/defenceless, naked/bare, pressed/jostled and unsafe/unprotected/exposedterm·dom ( Table 6 ). Table VI. The lexical change of the concept over time (2004date–2019). Degree of bindingterm in 2004date Degree of bindingterm in 2019 Change from 2004-2019 Precarious (Prekär) 36 Synonym not found Disappears as a synonym Perilous (Riskabel) 50 31 Weaker degree of bindingterm Vulnerable (Blottställd) 55 38 Weaker degree of bindingterm Dangerous (Farlig) 36 36 Same degree of bindingterm Threatened (Hotad) 30 22 Weaker degree of bindingterm Unprotected/Defenceless (Oskyddad) * 33 Stronger degree of bindingterm Naked/Bare (Blottad) * 27 Stronger degree of bindingterm Pressed/jostled (Trängd) * 33 Stronger degree of bindingterm Unsafe/unprotected/ exposedterm·dom (Exponerad) * 40 Stronger degree of bindingterm Note: * Only discovered in one dictionary in 2004date and was therefore not chosen for the analysis. In 2019, however, the bindingterm is stronger.
Discussion Of methods A concept analysis gives definitions to the use of a concept in both theory and research and can also help clarify terms in nursing that have become catch phrases and hence either have lost or changed their meaning (Eriksson, 2010 ; Sivonen et al., 2010 ). In this concept analysis of the word exposedterm·dom, we chose to further investigate the meaning dimensions in an exposedterm·dom situation , since this meaning is most related to clinical caring practice. This may be seen as a limitation. Perhaps a broader view of the concept might have given a different understanding but our results show a robust description of the concept related to caring. To ensure a robust analysis of the concept exposedterm·dom and determine its relevance for a caring scienceterm·key, a semantic analysis was conducted to get a sense of the meaning of the concept. To elucidate how the term might have changed over time, the analysis was made twice, with a 15 year gap in time. In the analysis from 2004date, only printed books were used. Since then, digital sources have become available. Thus, in the second analysis, digital as well as printed sources were used.
Koort (Koort, 1975 ) states that the degrees of synonymy give a picture of the relationship between synonyms and concepts. A degree of synonymyterm below 50% may be questionable in terms of relevance and the meaning of the concept can become too vague. On the other hand, weaker synonyms can constitute a nuance of meaning, which is important for the understanding of the concept (Nåden & Eriksson, 2003 ). In this study, synonyms regardless of the degree of synonymyterm, were chosen if the authors regarded them as relevant for caring scienceterm·key. Nuances of a concept might be valuable while trying to understand a concept in a complex context such as human existence. All authors have long and both broad and deep knowledge in caring scienceterm·key.
The choice of language may be considered as a limitation. However, Sivonen et al (Sivonen et al., 2010 ). states that a semantic concept analysisterm should preferably be carried out in the native language of the researcher. However, we consider the knowledge generated to be of wider common interest and therefore wanted to create a semantic understanding of the concept with relevance to clinical caring practice in a broader and international perspective. The semantic part of the analysis was made in Swedish and translated into English. Translation has been challenging and great effort has been made to find English words that correspond closely to the meaning content of the original Swedish words. Presenting the analysis in English was important to reach as many readers as possible. A linguistic expert has helped in proofreading the text. When difficulties occurred, discussions about the different alternatives took place among the authors resulting in that, on some occasions, two English words were chosen when no specific word corresponded sufficiently with the Swedish word.
Of results Origin of the concept and changes over time Over the last fifteen years, the concept’s relevance for clinical caring practice has strengthened. The degree of bindingterm of the synonyms has become stronger for those synonyms that easily can be transferred to a clinical nursing context i.e., unprotected/defenceless, naked/bare, pressed/jostled and unsafe/unprotected (c.f. Figure 1 and Table 4 ). In the second semantic analysis (in 2019) it became obvious that the concept exposedterm·dom had become stronger and more stringent in the meaning dimension in an exposedterm·dom situation .
Relevance for caring scienceterm·key A semantic analysis can be further developed by connecting theoretical and clinical caring scienceterm·key from specific or more general caring contexts. The results can thereby create a deeper understanding of the data, support the analysis and further develop the understanding of the concept and the experiences in a caring context (Eriksson, 2010 ; Werkander HarstädepersName et al., 2012 ).
Overall, the findings ( Figure 1 ) can be related to exposednessterm·dom as an existential vulnerabilityterm·key (Arman, 2015 ). The patient role involves vulnerabilityterm·key, a sick person relies on and surrenders to other people. In care, this implies a special dependency, as a patient is vulnerable and exposedterm·dom due to illness. This vulnerabilityterm·key also affects the next-of-kin (Dahlberg et al., 2003 ). The caregivers also have a vulnerable position. Cuts in care, staff shortages and a feeling of not being sufficient lay a foundation for stress problems and can have consequences for the quality of care. The phenomenon of vulnerabilityterm·key thus affects three parties: the patient, the caregiver and related persons.
From a caring scienceterm·key perspective, our findings showed that the concept exposedterm·dom needs to be highlighted, as it entails patients suffering both from poor health and from the care they receive or do not receive, which in turn can be related to loss of dignity. Objectification of human beings in health care settings is an aspect of being naked and exposedterm·dom . Being exposedterm·dom means being unprotected as a human being in a vulnerable situation (Todres et al., 2009 ). The authors (Todres et al., 2009 ) describe a conceptual framework for a humanizing care which can be understood in relation to the concept dehumanization and describe a continuum between these dimensions and the huge difference between being seen as a subject (insidernessterm·key) or as an object. There is a continuum between, for example, togetherness and isolation, sense-making and loss of meaning, sense of place and dislocation, embodiment and reductionist body, and this points to how care should be provided to support human dignityterm·dom, wellbeing and prevention or alleviation of suffering (ibid).
Maintaining human dignityterm·dom means maintaining the right to be confirmed as a unique person. The presence of suffering and vulnerabilityterm·key raises the human ethical obligation to care for a unique person. The power lies in the hands of carers or of the health care system that risks the patient’s dignity. Patients can be denied alleviation of their suffering as persons and human beings, and feelings of worthlessness can arise. The power is related to lack of knowledge, the patients’ insecurity and not being understood. This exposednessterm·dom means a vulnerabilityterm·key that can be experienced as overpowering and annihilating (Dahlberg, 2018 ; Eriksson, 2006 ).
There is a strong relationship between existence and caring. Carers ought to become much more attuned to the importance and value of the experience of the person who is suffering (Galvin & Todres, 2011 ). Galvin and Todres (Galvin & Todres, 2015 ) describe human vulnerabilityterm·key as “Honour-Wound”, a metaphor utilized in a poetic way to describe both possibilities and existential and literal vulnerabilities. Further, the “wound” nuance is related to terms such as vulnerabilityterm·key , exposednessterm·dom , finitude, frailty, unprotectedness, insecurity etc. According to Zaner (Zaner, 2000 ), clinical encounters with interpersonal relationships constitute specific moral aspects and challenges. Critical issues of illness experiences can be related to dialogue, trust, vulnerabilityterm·key , being pressed/jostled , violence, and power, leading to precarious situations for the person’s own being that is being threatened .
Suffering caused by careterm·dom is the suffering that the health care providers cause to the patient by violating the patient’s dignity, for example exercising power or failing in their care (Eriksson, 2006 ), thereby creating an exposednessterm·dom of the patient. Furthermore, dignity can be painfully ruptured, in danger and in need of restoration. Alas, some degrees of rupture are very difficult, perhaps impossible, to restore (Galvin & Todres, 2015 ).
Cubellis (Cubellis, 2018 ) describes care wounds as a result of precarious vulnerabilityterm·key and potential exposure. The care can wound those who offer it (the carers) in a rigid and unfeeling system. It can wound when it demands exposure of the carer’s own hurt and when exposure is seized on as a means to mitigate the fissures in a larger broken system. This can mean increased exposure and suffering for the patients, who need to be handled as more than objects. Vulnerabilityterm·key and suffering can be sensitive issues for carers as they can be like a “sore point” that both can serve as an eye-opener and can cause “blind spots” (Thorup et al., 2012 ). Suffering and vulnerabilityterm·key, like sore points, can form the caregivers’ courage in care situations. Courage expresses itself as the courage to help patients face their vulnerabilityterm·key and suffering. It also bears witness to patients’ vulnerabilityterm·key and suffering. It also means that the carers have faith in themselves and can argue for and provide professional care. This can prevent patients’ feelings of being exposedterm·dom. Todres, Galvin and Dahlberg (Todres et al., 2014 ) put forward the important concept of openheartedness, along with the help of life-world knowledge, as an interpretative framework for the care and understanding of others through the complex self. In care and understanding, the dialogic act is a dialectic between vulnerabilityterm·key and power, an immense hope and a profound risk. The hope for help in the form of cure and/or alleviated suffering and comfort are at hand. Furthermore, in every dialogue there is vulnerabilityterm·key, and one aspect is related to the questioner’s existential situation and the openness to a form of vital not-knowing or inability to know. The vital need is to understand and to be understood and also to know and be known in order to overcome the experiential exposednessterm·dom that is intertwined with the illness (Galvin & Todres, 2015 ). This can be related to Dahlberg (Dahlberg, 2018 ) and Todres, Galvin and Dahlberg (Todres et al., 2014 ), who emphasize the need to be aware of the art of understanding in care. Understanding of the other can never be absolute but, in caring, one can always strive for insidernessterm·key, to fully understand the other. More often, reaching for insidernessterm·key can be experienced as more important than knowledge of details of another person such as a patient. An overreliance on the body-object gaze may shift attention away from insidernessterm·key. Thus, in care, a shift of focus is needed from mere bodily behaviour or symptoms to focus on what the living body is trying to say about the person’s insidernessterm·key. Wiklund (Wiklund Gustin, 2017 ) addresses the importance of the caregiver as being emotionally engaged with the patient’s stories and experiences, as opposed to being emotionally passive or distant. Leget (Leget, 2013 ) states that to listen, open minded, to vulnerable people is an expression of respect and attentiveness, and points to the interrelation of subjective and relational dignity. Dignity is then constituted and upheld by people interrelated in caring relationships. This has been described as a dignity experience and gives a sense of one’s interpersonal value and worthiness. When a sense of valuing the interpersonal exists, individuals are participating in an interpersonal world of mutuality (Galvin & Todres, 2015 ). This means a gift to one another, being intrinsically important to one another, being in community in mutual ways. According to Dahlberg (Dahlberg, 2018 ), just to be open to the possibility of others’ experiential worlds has profound ethical meaning within a caring context. The challenge is to empower understanding in such a way that the manifold of nuances of the life-world are displayed and come into play.
Conclusion Exposednessterm·dom is a profound experience for patients. This concept analysis can help in deeper understanding a person’s unique exposedterm·dom situation and adds to the knowledge base of exposednessterm·dom within nursing care. Life-world led care has existential power that can support professionals in strengthening patients’ health processes. By this is meant finding balance as opposed to being exposedterm·dom and experiencing human vulnerabilityterm·key. This balance alleviates the patient’s suffering and reduces the risk of suffering by care. Since caring scienceterm·key as a science is not connected to one specific profession, everyone who meets exposedterm·dom human beings in their daily work, e.g., all health care professionals, teachers, policemen, social workers, can use this knowledge to further understand exposednessterm·dom from a human perspective.