Sense of Coherence and Caregivers of Persons with Dementia

Unpaid caregivers (CG) provide most of the assistance to persons with dementias (PWD) living in the community. This study explores the current state of knowledge regarding the concept of sense of coherence (SOC) and CG of PWD via a concept analysis. The identified defining attributes were health, health-related quality of life (HRQoL), CG burden, CG stress, coping as a strength, gender, and decreasing sense of CG coherence over the progression of the disease (dementia). Further study by health care professionals using clinical observations, large samples of respondents, a consistent theory, valid and reliable instruments used to measure defining attributes consistently, and critical reviews of the literature are needed.

CGs confront chronic stressors while caring for a person with progressive dementia. CGs of PWD may experience an absence of resources (GRRs) and thus have a low SOC [4][5][6], thereby limiting the CG's ability to positively cope with the caregiving role. The CG must make logical sense (comprehensibility) of the disease process, the care recipient's changing behaviors, and erosion of the past relationship (spouse, parent, sibling), and assign value to helping the PWD (meaningfulness). In order to help with activities of daily living and meet the needs of the care recipient, and at the same time help the loved one through alien events, the CG must understand the disease process (comprehensibility), know of available resources (comprehensibility and manageability), and effectively manage the use of the reserves. In order to truly care for a loved one with dementia, the CG believes the labor merits the time and emotional, financial, and physical investment (meaningfulness). The SOC concept and salutogenesis can guide health care professionals to strengthen a person's existing strengths (GRRs) and develop positive ways to manage stress, coping, and health.
The purposes of this concept analysis are to develop further understanding of SOC as it relates to CGs of PWD, and begin to examine the instruments used to measure SOC in CGs PWD.

Materials and Methods
Walker and Avant [2] identify several reasons to complete a concept analysis including fine-tuning and understanding concepts in a theory, developing a standardized language do describe the concept, developing a new tool, and evaluating existing instruments. There are several methods to complete a concept analysis, but Walker and Avant [2] recommend eight steps as follows: 1.
Select a concept.

2.
Determine the aims or purposes of analysis.

3.
Identify all uses of the concept that one can discover. 4.
Determine the defining attributes. 5.
Identify a model case. 6.
The steps are not done necessarily in a sequence, but are repetitive, as the analyst continues revising as new understanding evolves during analysis [2].

Selecting a Concept
The concept of SOC was chosen because the literature about CGs of PWD includes both negative and positive aspects to the CG role. Antonovsky's [4][5][6] central question about how some survivors of stressors maintain health while other survivors do not is similar to the question of why some CGs of PWD find joy and meaning in the carer role, and others experience ill-health and a negative quality of life.

Determine the Aims or Purposes of Analysis
The aims of this analysis are to better understand SOC and how it relates to CGs of PWD, and begin to review instruments of measure of SOC and the empirical referents. During the analysis, the researcher must write down the purpose or aims and keep focused [2]. Walker and Avant [2] advise using dictionaries and reviewing the literature to identify as many uses of the concept as possible. The literature review guides the researcher to the defining attributes and evidence for the concept analysis [2].

Identify Uses of the Concept
Walker and Avant [2] guide the researcher to consult dictionaries and the research literature to define and describe the concept. The medical dictionary defines SOC as "a view that recognizes the world as meaningful and predictable" [8]. Merriam Webster's online dictionary included definitions for the word sense as both a noun and a verb [9]. Sense as a noun [9] is defined as: "a meaning conveyed or intended, the faculty of perceiving by means of sense organs, conscious awareness or rationality, a particular sensation or kind or quality of sensation, a definite but often vague awareness or impression, a motivating awareness, or a discerning awareness and appreciation".
Sense as a verb [9] is defined as: "to perceive by the senses; to be or become conscious of; to grasp, comprehend; or to detect automatically especially in response to a physical stimulus (such as light or movement)". Merriam Webster [9] identifies synonyms of sense as "feel, feeling, sensation, perceive, scent, see, smell, or taste".
Coherence in Merriam Webster's Dictionary [10] is defined as "the quality or state of cohering: such as systematic or logical connection or consistency or integration of diverse elements, relationships, or values; or the property of being coherent". Synonyms for coherence [10] are: "balance, concinnity, consonance, consonancy, harmony, orchestration, proportion, symmetry, symphony, or unity".
Antonovsky [4][5][6] defined the concept as: a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli from one's internal and external environments in the course of living are structured, predictable, and explicable; (2) the resources are available to one to meet the demands posed by these stimuli; and (3) these demands are challenges, worthy of investment and engagement.
A review of the literature using the following databases was conducted: Academic Search Complete, Academic Search Premier, Ageline, CINAHL with Full Text, Health Source: Nursing/Academic Edition, MEDLINE, PsycARTICLES, PsycINFO, and Women's Studies. Keywords that were used were SOC, CG, dementia, and dementia patient. The terms were added into the keyword function and combined using the AND function. Limits to the literature search were CGs of PWD, human subjects, and English language. The date range was January 1979 to August 2018, to evaluate SOC as it relates to CGs of PWD. The studies chosen for inclusion were published from 1994 to 2014 and involved both qualitative and quantitative research methods. The author provides tables of instruments and findings from the literature in the Results section.

Determine the Defining Attributes
Walker and Avant [2] instruct the researcher to try to disclose the collection of attributes most often connected with the concept and that permit the strongest discernment of the concept. Antonovsky [4][5][6] used the terms comprehensibility, manageability, and meaningfulness frequently and routinely. The author expected revisions or additions to the defining attributes following the review of the literature.

Identify a Model Case
Walker and Avant [2] recommend a researcher find (from the literature or real-world examples) or create a model case, using the best description of the concept, including all the major attributes of the concept. The model case can be simple but assists the researcher to clarify and possibly revise the defining attributes [2]. The researcher uses the model case to understand the concept (SOC of CGs of PWD), clarify understanding, and identify the internal structures of the concept [2].

Identify Borderline, Related, Contrary, Invented, and Illegitimate Cases
The researcher next examines other cases of the concept, which may be comparable or opposite the model case [2]. The borderline, related, contrary, invented, and illegitimate cases [2] allow the researcher to refine the defining attributes and clearly understand what does and does not define the concept [2]. A borderline case [2] covers most but not all of the defining attributes of the concept. A related case [2] again is related to the main concept, but does not contain all the defining attributes, conflicting when carefully investigated. A contrary case [2] is a clear example of "not the concept" (p. 166). An invented case [2] is when the researcher takes the concept outside his or her "own experiences" (p. 166) to examine the relationship to the concept from another point of view. An illegitimate case [2] provides an example of a concept term used inappropriately.

Identify Antecedents and Consequences
According to Walker and Avant [2], antecedents are actions or occurrences in place prior to the existence of the concept. Consequences can occur in response to the concept [2].

Define Empirical Referents
Walker and Avant [2] require the researcher to investigate how the concept might be measured in the final step (empirical referents) of a concept analysis. Empirical referents guide the development of instruments, add to validity and reliability of instruments, and are useful in practice [2]. Empirical referents are not instruments used to measure the concept, but are usually methods of measuring the defining attributes of the concept. For example, the term considerate may be an empirical referent of the concept of caring.

Results
For this paper, the operational definition of SOC in CGs of PWD indicates the CG incorporates knowledge of dementia including progression and treatment of the disease, utilizes appropriate and varied coping resources to meet the demands of caregiving, and values the CG role to achieve the highest HRQoL, to decrease burden and stress, and enhance coping skills and strengths, regardless of gender, with the possibility considered the CGs SOC may decrease over the progression of dementia.

Analysis SOC and CGs of PWD
Walker and Avant [2] describe concepts as the foundation of a theory. Concepts help one organize sensory information, and determine similarities and differences. The words concept and variable are sometimes used interchangeably [2] critical review of the included studies revealed five commonalities of the concept of SOC in CGs of PWD. The first two steps of concept analysis, selecting a concept, and determining the aims or purposes of analysis were completed in the methods section.

Identify all Uses of the Concept One can Discover
After reviewing dictionary definitions of SOC (SOC), and the individual terms sense and coherence, the author compiled a list of frequently recurring words. Some of the frequently recurring terms were: comprehensibility, manageability, meaningfulness, GRRs, dynamic and widespread feeling of confidence, structure, sensation, meaning, awareness, logical, balance, and predictable.
The following five ideas about SOC and CGs of PWD were identified in the literature: health, health-related quality of life, CG burden and stress, coping and strengths, gender, and decreasing SOC over disease progression. Please see Appendix A for a complete list of terms identified in the search. SOC is a resource promoting health, improving resilience, and leads to more positive mental and physical health, as well as quality of life and wellbeing [11]. Eriksson and Lindström [12] reported SOC as a resource improving quality of life either directly or with good perceived health as a mediator. The Orientation to Life and SOC scale [5] have been used in over 33 languages, in 32 countries, with multiple cultures (at least 15 different versions of the questionnaire from both Western and Eastern cultures), populations ranging from very young (children) to very old age (adults), in multiple professions, and in groups with multiple disease-specific conditions (rheumatic disease, depression, mental illness, circulatory problems, dementia, etc.) [5,11,12].

SOC, Health, and Health-Related Quality of Life (HRQoL)
According to the World Health Organization (WHO), health is not the absence or presence of disease or disability, but a condition including physical, psychological, and social well-being [13]. Researchers define quality of life (QoL) as "multidimensional" wellbeing, including physical wellbeing, psychosocial wellbeing, safety, and self-fulfillment [14] (p. 51) Health-related quality of life (HRQoL) is defined as "an individual's subjective view of the impact of a health condition on various aspects of his/her well-being" [15] (p. 800) For this concept analysis, the elements of the HRQoL are multidimensional, including physical, psychological, social, and environmental aspects of wellbeing. Two studies specifically addressed HRQoL, while five other studies reported both mental and physical aspects, totaling six research studies [15][16][17][18][19][20][21]. A high HRQoL was predicted by having low distress and being female [15]. SOC was stated to be a strong predictor of quality of life [16]. Ekwall et al. [18] stated a higher mental health quality of life was predicated by a high SOC and using "self-sustaining coping strategies" (outside interests such as work, hobbies, etc.) (p. 592). Mockler et al. [19] screened CGs health for psychiatric morbidity, and reported higher a SOC correlated with lower psychiatric morbidities in CGs. Valimaki et al. [15] reported a significant correlation between SOC and depression (r = −0.632), and distress (r = −0.579) (p. 802), noting depression and distress had significant correlations to SOC and HRQoL. Table 1 shows the measures used, reliability and validity as reported, and associations or findings of SOC, health, and health-related quality of life. High scores on SOC predict high scores on MCS12 (p-value <0.001), but PCS12 was not significant Asking for social and practical support predicted low quality of life  (21) NSU 147 (22) SU 113 (28) [26] Did not vary significantly between SU and NSU groups There was an inverse relationship between SOC and GHQ (r = −0.46, p <0.0006). SOC ↑ as psychiatric morbidity ↓ GHQ-28 scores significantly higher in CG of PWD than normative data indicated SOC scale (13 items)Uses a 7-point scale, possible range from 13 to 91 Higher score = higher SOC α = 0.86 [5] Adult children reported lower SOC than spouses or other relatives outside the immediate family Health Authors used one self-rating question of how CGs rated their own health considering age and gender 1 = not good at all, 2 = fair, 3 = good, 4 = very good, 5 = perfect CG health also measured by self-reported if diagnosed by health care provider with high blood pressure or hypertension, any heart disease or condition, and trouble with anxiety in the past year. --

Health
No specific measures of health. GHQ 12 item version used not to measure health but to measure extent of distress in this study α = 0.016 [26] HRQOL 15D questionnaire and Visual Analogue Scale (VAS) 15D asks items about mobility, vision, hearing, breathing, sleeping, eating, speech, elimination, usual activities, mental function, discomfort and symptoms, depression, distress, vitality, and sexual activity The VAS assesses overall HRQoL, a 10-cm scale. α = 0.649 Not reported [27] Not reported Statistically significant differences between ♂and ♀in dimensions of sleeping and feelings of distress (♀feel worse). The total amount of drugs used, severe depressive symptoms, and distress were significant predictors of low HRQoL (R 2 = 0.46) Good HRQoL was correlated with strong SOC Depressive symptoms are strongly associated with low HRQoL Males reported overall better quality of life Males had higher % of natural killer (NK) cells and lower % of T helper cells than females When Thompson et al. [24] compared NK cell number data to gender and age-matched records using data bank in S. Lewis's laboratory, no gender differences between male CGs of PWD and non-CGs Female spousal CGs had significantly lower NK cell numbers than female non-CG controls

SOC and CG Burden and Stress
Eight articles focus on burden or stress as experienced by CGs of PWD living at home [15][16][17][18][19][20]. CG burden incorporates the physical, psychological, socioeconomic, and emotional distress or strain one may experience when caring for another [17,38] described CG burden as the physical and psychological challenges experienced when caring for an ill loved one. Gallagher and colleagues [38] specifically used the term "role overload" as a measure of CG burden, mostly in relation to Pearlin's model of the stress process.
Potgeiter and Heyns [39] do not specifically define burden or stress, but report CGs of PWD experience psychological burden and mental distress. CGs of persons with Alzheimer's dementia describe feelings of "anger, loss, social isolation, entrapment, sadness, anxiety, and guilt" [17] (p. 548). Mockler et al. [19] described CGs' expressed emotion as associated with strain and distress, but did not specifically define stress or burden. Chumbler et al. [40] stated CGs providing care for someone at home may experience stress and exhaustion, both comparable to the definition of burden.
A high QoL was predicted by having low distress and being female [15]. SOC was stated to be a strong predictor of quality of life [10]. The researchers identified above agree that there is burden or stress associated with the CG role. The investigators used different instruments to measure CG burden, role-overload, and/or stress (ors). Table 2 includes measures used, reliability and validity, and associations or findings.   SOC increases opposition to stress (a strong SOC inclines a person to experience life as more secure, predictable, and manageable.

CG burden
Screen for Caregiver Burden A 25-item measure for objective (number of potentially negative experiences) and subjective burden (considered as suffering or stress in response to experiences) α = 0.88-0.89 internal consistency and test-retest reliability of 0.64-0.70 [53] No significant gender differences in objective burden scores Significant differences in subjective CG burden scores in response to experiences (considered as suffering or stress) Females reported greater level of burden than males.

CG stress
Perceived Stress Scale (PSS) 14-item instrument measures appraised degree of stress in situations of one's life. Items measure degree to which respondents perceive life unpredictable, uncontrollable, and overwhelming Rated 5-point scale (0-4). 0 = never, 4 = very often α = 0.84-0.86 Test-retest stability: 2-day delay 0.85, and 6-week delay 0.55 [54] Males significantly lower amounts of depression, stress, anxiety, and anger/hostility than females Females reported more emotional stress in measures of depression, stress, and anxiety Males also had lower mental health scores and fewer somatic and total symptoms than females Male NonKiller (NK) cell number was negatively correlated with perceived stress and total symptom score, but no significant correlations among those variables in females SOC and Coping as Strengths Both Chumbler et al. [40] and Ekwall et al. [18] identified coping as a strength or ability. However, Chumbler et al. [40], Gallagher et al. [38], and Potgieter and Heyns [39] do not define the word coping; both research groups consider effective coping as a measure of SOC, or salutogenesis. It is important to consider that SOC with burden and stress, as well as with coping and strengths, were not measured with separate instruments. The elements were not collapsed together because of the different definitions of burden and stress versus coping and strength.
Ekwall et al. [18] expressed SOC as a coping strategy. Both Chumbler et al. [40] and Ekwall et al. [18] identified coping as a strength or ability, while Gallagher et al. [38] and Potgieter and Heyns [39] related effective coping as a measure of SOC. Ekwall et al. [18] used Lazarus and Folkman [55] to guide their description of coping, using the concepts of internal and external resources to inform the definition of coping. Internal coping resources depend on the CG relationship to the care recipient, the carer's personality, and the understanding of the CG role. One may argue that spirituality is an internal coping mechanism. Spirituality in an organized or personal form was one of the most common coping strategies as well as sources of support to rural CGs [56]. CGs who reported using religious coping were more likely to score lower on caregiver burden instruments [57]. External coping resources include the care recipient's abilities to assist with care, and services such as home health, meal delivery, housekeeping, and the like. There are emotional-and problem-focused coping strategies one uses to solve problems [18]. Ekwall et al. [18] describe emotion-focused tactics as a change to the meaning of the threat or distract a person's focus from the problematic situation. Problem-focused strategies define the threat and attempt to overcome the issue. The most positive coping methods for CGs were seeking support, remaining future oriented, and religiosity/spirituality [58]. Please see Table 3 for SOC and coping as strengths.  [55,59] The top five coping strategies after factor analysis were "keeping my emotions tightly under control", " 'taking one day at a time", "remembering the good times I used to have with the person I care for", "establishing priorities and concentrating on them", and "realizing that there is someone worse off than me" SOC Used as measure of coping resources in a specific situation [38]   Coping and strengths Coping Resources Inventory 60-item tool to measure coping resources in 5 domains. Domains: cognitive (positive self-worth, positive outlook about others, optimism in life); social (supportive social networks); emotional (able to accept and express emotions to ameliorate stress); spiritual/philosophical (religious, family, cultural tradition or personal philosophy); and physical (health promoting behaviors for well-being) 4-point scale α = 0.89-0.94 [58] No gender differences in age, length of time being primary CGs of PWD, social support, or coping resources

SOC and Gender
Seven of the studies focused on gender, although male or female sex is identified in the studies [19,29,38,62]. Chumbler et al. [40] and Ekwall et al. [18] both asked participants to self-identify gender. Pretorius and colleagues [62] used semi-structured interviews, where the data collector could see the respondent to determine gender. Thompson and colleagues [29] used surveys with self-report of gender, but also used bioinstrumentation and blood tests. There were no specific instruments used to determine gender. The research results have varied as to whether women and men experience more, less, or similar burden. Male CGs of spouses with dementia appear to have higher SOC, use more task-oriented problem solving approaches, and manage support resources more effectively than women [29,62]. Thompson et al. [29] suggested men experience less negative effects of caregiving such as depression, anxiety, anger, hostility, and somatic symptoms than women do. Nonetheless, male CGs reported relying on their adult daughters for a great deal of support and help [62].

Decreasing SOC over Disease Progression
CGs' SOC may diminish over time [63]. The researchers reported a decrease in SOC over a three-year progression of dementia. CG SOC was measured using Antonovsky's SOC scale (29 item) [5]. Depressive symptoms were assessed using Beck's Depression Inventory (BDI) [64]. The 15D [27] and the Visual Analogue Scale (VAS) for wellbeing [65] measured QoL. Goldberg and Hillier's [26] General Health Questionnaire (GHQ) was used to measure CG distress. The Clinical Dementia Rating scale (CDR) [66] was used to measure the severity of dementia. Structured interview protocols and scores were used to obtain a sum of boxes scores for the CG interview [67]. Researchers used the inventory to assess activities of daily living for clinical trials in Alzheimer's disease (ADCS-ADL) CG interviews [65] to evaluate activities of daily life. Finally, the Neuropsychiatric Inventory (NPI) used the CG interview to assess behavioral symptoms of dementia [68].

Determining the Defining Attributes
The characteristics of SOC seeming most obvious in defining the attributes were comprehensibility, manageability, and meaningfulness, but after review of the literature, the following attributes were added: health; health-related quality of life; burden/stressful situation; coping as a strength; gender; and decreased SOC over the progression of dementia.

Identify a Model Case
A married couple attends a medical appointment with the primary care provider. The husband and wife discuss her symptoms of forgetting how to follow recipes and paying monthly bills, getting lost when driving in neighborhood of ten years, and difficulty finding words. They receive a diagnosis of dementia. They ask the health care provider for information about dementia symptoms, treatment, and progression. Both are emotional, but holding hands, agree they are a team and have been through wonderful and difficult times throughout their lives. They acknowledge their strength as a couple, support systems in place, and are referred to a dementia support in the local community.
Identify Borderline, Related, Contrary, Invented, and Illegitimate Cases Borderline case. A daughter-in-law is caring for her father-in-law who has moved in with her family after a diagnosis of dementia. The health care provider supplied an informational pamphlet about dementia and referred both to a local dementia support network. The father-in-law has health insurance and a pension, but she has four children ranging in age from six years to 14 years. Her children are each in two or three sports or activities, she and her husband both work 40 or more hours per week, and her father-in-law requires more assistance with grooming, bathing, dressing, and meals. She and her husband decide to place her father-in-law in a dementia care facility because they lack the time and energy to continue caring for him at home and know "it is only going to get worse".
Related case. A related case could be about resilience, coping, or stress management. These concepts are related to SOC, but not the same.
Contrary case. A daughter discovers her mother has dementia. She "doesn't want to remember her mother this way", changes her phone number and moves across the country.
Invented case. A being from another planet arrives on earth and moves into a home of a PWD. The being understands the PWD needs help to take care of the house, prepare meals, and get dressed. The being contacts friends from its planet, and three more beings arrive on earth, move into the home, take six-hour shifts to help their host with dementia, and all live happily ever after.
Illegitimate case. A young man uses his five senses of sight, hearing, smell, taste, and touch to determine which restaurant is his favorite.

Identify Antecedents and Consequences
After reviewing the model case and the other cases (borderline, related, contrary, invented, and illegitimate), antecedents and consequences of SOC in CGs of PWD were identified. Antecedents included: the ability to recognize individual interaction with the environment; ability to recognize disorder and change as a normal part of one's daily life; and the ability to find strategies and resources to cope with chaos as part of daily life. Consequences of SOC in CGs of PWD included an impact on coping skills, quality of life, health (physical and emotional), stress, and burden.

Discussion
The purposes of the study were to develop further understanding of and begin to examine measures of SOC in CG of PWD. An additional use of a concept analysis is to develop an operational definition [2]. The operational definition of SOC in CGs of PWD indicates the CG incorporates knowledge of dementia including progression and treatment of the disease, utilizes appropriate and varied coping resources to meet the demands of caregiving, and values the CG role to achieve the highest level of health, HRQoL, to decrease burden and stress, and enhance coping skills as strengths, regardless of gender, with the possibility SOC may diminish over the progression of dementia (Childers, 2018).

SOC in CGs of PWD.
Caregiving for a PWD has both positive and negative effects on CGs. Because of the unpredictable behaviors and challenges of the PWD, CGs at times may experience stressors that impact both physical and emotional health. Male and female CGs also experience caregiving, coping, and physical and emotional responses differently [29]. SOC was associated with health, HRQoL, burden and stress levels, role overload, and coping as a strength. CGs routinely participate in the practice of sustaining comprehension, manageability, and meaning.

SOC, Health, and HRQoL
There is a relationship between CG SOC and health [16,17]. The direction of the relationship with mental and physical health and SOC is not clear. Researchers [20] reported high SOC levels are associated with high levels of physical health, but two results of two other studies [18,19] indicate a high SOC is related to high scores in mental health with fewer diagnosable psychiatric disorders, but did not find the same to be true of physical health. The variance in findings can be from many issues, however, the instruments of measure of physical and mental health were varied.

SOC, CG Burden and Stress
SOC has a negative correlation with burden and CG role overload, indicating those with a higher SOC reported less burden/role overload [16,20,21,38,46]. Gallagher and colleagues [38] found the high SOC score helps adjust to burden by focusing on the meaning of the caregiving experience. CG levels of stress and SOC with the PWD Mini-Mental Status Exam are related to burden scores [21,46].

SOC, Coping as a Strength
CGs with a high SOC reported using more positive coping strategies such as managing meaning and learning about dementia, as well as keeping interests outside of caregiving [13,38,44]. Strengths of the CG for coping were support seeking, remaining future oriented, and a belief in a higher power [39]. Potgeiter and Heyns [39] reported CGs who attended group meetings were contributing to the comprehension of the caring experience. Male CGs described coping and strengths as asking for support from their daughters and finding meaning in duties of caregiving [39,44]. CGs who reported a belief in a higher power found meaning and manageability in the caring role [39].

SOC, Gender, and Decreasing SOC of the Progression of Dementia
Male CGs reports stressors to include cognitive impairment of spouses with dementia, lack of free time, problem behaviors of the PWD, erosion of the marital relationship, family conflict, and financial worries [44]. Males also reported higher levels of SOC, mental health, social and physical function, and had a higher number of natural killer cell numbers than their female counterparts [29]. Female CGs reported more chronic stress, worry, and fear of incompetence with the caring role [29]. Males tended to manage the carer role as a job or task to be completed, and reported receiving fulfillment when the job was completed [29].
One group of researchers described the SOC of CGs may decrease as the disease of dementia progresses [63]. As the demands of the caring role require more effort, the CG's SOC tended to decrease as the stage of dementia increased. 4.1.5. Health Care Professionals role in SOC of CGs of PWD Health care professionals need to recognize the risks of caregiving early and intervene to improve the quality of life for both the CGs and PWD [15]. Health care professions can assess CGs when the PWD attends an appointment or is in the hospital. Early and routine assessment assists to identify potential strains, concerns, dysfunctional coping, and expectations [15][16][17]. A nurse is in the perfect position to offer education, support services, and lead training programs for CGs of PWD. Understanding SOC can guide the coping of CG and positively impact both emotional and physical health. Health care professionals can refer CGs of PWD to local support groups such as the Alzheimer's Association of the Family CG Alliance National Center on Caregiving. The associations offer CG classes and support groups. The CG may need evaluation for depression and/or anxiety and can be encouraged to speak to a health care provider about the potential benefits and risks of medication, and the benefits of supportive emotional/behavioral/cognitive therapy. The health care professional evaluating and/or treating the PWD can make suggestions for supportive services (home health, home health aide, delivered meals, etc.) as the activities of daily living and instrumental activities of daily living become harder for the PWD. By increasing the GRRs, the health care provider may help increase the CGs SOC.

Beginning Examination of Measures of SOC in CGs of PWD
The measures for SOC were either the 29-item or 13-item SOC scale [5]. However, the SOC scales were also used to measure coping and stress, in addition to SOC [16,17,21,39]. A variety of instruments were used to measure health, health related quality of life, burden, stress, and coping as strengths. The lack of consistent measures across studies can create problems with correlation, understanding of results, and inconsistent findings. Researchers exploring SOC in the future may use valid and reliable instruments, and measure defining attributes specifically, in addition to SOC.

Advantages and Limitations to Concept Analysis
One advantage of using the Walker and Avant [2] method of concept analysis is the meticulous theoretical and operational definitions for use in research and theory development. Other benefits of concept analysis include clarification in health care jargon or language, and the helpfulness in instrument development [2]. While there are other methods of concept analysis, the steps recommended by Walker and Avant [2] are useful in professions other than nursing, and can be implemented by other health care professionals.
There are many limitations to concept analysis, including the bias one has when choosing a concept to analyze [2]. The steps are arduous and the analysis can be overwhelming to researchers (particularly novice researchers). Another shortcoming is the impulse to analyze multiple terms and not be able to stop the analysis [2]. Walker and Avant [2] also note there is a fear of sharing the analysis with others, fearing criticism.
The concept analysis of SOC in CGs of PWD provided a view of this moment in time and is not to be considered a terminal analysis. The study resulted in an operational definition, a clearer understanding of SOC of CGs of PWD, and a brief examination of some instruments used previously to study SOC.
Funding: This research received no external funding.

Conflicts of Interest:
The author declared no conflict of interest.