Tender Loving Care: A Conceptual Analysis

Background : Combining Tender Loving Care (TLC) with the treatment of patients with recurrent miscarriages can improve pregnancy outcomes. Purpose : This study aimed to conduct a conceptual analysis of TLC and clarify its constructs to help in its performance in patients/clients who need it. Methods : This study was conducted using Walker and Avant’s concept analysis approach. Research published between the first edition of the journal until January 2022 were searched. Consequently, 25 articles, all of which were in English, were selected for conceptual analysis. They were CINAHL Plus with Full Text and MEDLINE databases were examined. Results : The results of the conceptual analysis of TLC revealed the following antecedents, defining attributes, and consequences. TLC was defined as ‘the care for mentally or physically distressed or impaired patients by health professionals, parents, and teachers based on compassion and empathy, who perceive the condition of the patient/client and respond appropriately, thereby reducing tension, distress, and anxiety, and achieving a state of mental and physical well-being’. It is characterised by empathy and patient-specific response for the patients, and consequently it it could improve quality of life. Conclusion : Conceptual analysis of this study defines TLC and clarify its attributes, antecedent requirements, and consequences. This has provided concrete practice guidelines to enhance health practices when caring for mentally and physically vulnerable patients, not only in nursing care for patients experiencing miscarriages but also in all nursing care settings, educational settings, and at home


BACKGROUND
The expression 'tender loving care' was first used by Troy (1951) in 'Tender Loving Care: That indefinable trait which makes the patient glad you are his nurse'. Since the announcement of its importance, it has been recognised as a concept that plays a vital role in the control and treatment of diseases in the nursing field in Western countries (Lachmi-Epstein, 2012). Recently, tender loving care (TLC) has been reported to improve the outcomes in women experiencing recurrent pregnancy loss. Recurrent miscarriages have psychological consequences for women, including anxiety and depression. Enhanced TLC by healthcare providers has been shown to positively affect successful subsequent pregnancy outcomes (Bayrampour et al., 2016). Although the definition of TLC and the nature of its specific practice are not clear, in a previous study reporting the results of introducing TLC to the medical treatment of patients experiencing miscarriage, it has been reported to be an effective approach (Peã' Acoba-Puente et al., 2011). It has been used psychologically without concrete phenomena. As reported by (Lachmi-Epstein, 2012) the term TLC is traditionally used to characterise nursing, and providing emotional support to vulnerable human beings. Even in diseases for which evidence-based interventions have been scientifically established, such as repeated miscarriages, TLC is considered necessary and can be assumed to play an important role.
In recent years, Japan has seen a rapid increase in the number of patients undergoing fertility treatment. In Japan, 811,604 babies were born in 2021, the lowest number to date. The number of children that a woman has in her lifetime (total fertility rate) declined for the sixth year in a row to 1.30, down by 0.03 from the previous year (Vital Statistics of Japan, Ministry of Health, Labour and Welfare). One of the causes of the declining birth rate is the tendency to give birth too late in life (Ministry of Health, 2021). According to the Vital Statistics for 2021 (the Ministry of Health, Labour and Welfare in Japan), the average age of mothers at the birth of their first child was 30.7 years, which had remained unchanged for six consecutive years since 2015; it reached 30.9 years in 2021. Simultaneously, the number of couples undergoing infertility treatments is rapidly increasing. This is linked to an increase in the age of first marriage in Japan. Additionally, some people think that it is inappropriate for single women to have babies. An increase in age at first marriage leads to a decrease in fertility and an increase in the number of infertility cases. According to the 'Basic Survey on Social Security and Population Issues in 2021' by the National Institute of Population and Social Security Research, the number of couples who have undergone examinations and treatment for infertility has increased from 18.2% to 22.7% (1 in 4.4 couples) since the previous survey five years ago. At the time of the survey, 6.7% of couples married for less than five years had been examined and treated for infertility. There are plenty of fertility treatment facilities available in Japan, and the number of infertility treatments in the country is the largest worldwide. Yet, some women repeatedly miscarry and are unsuccessful in continuing gestation even after fertility treatment. The cause of miscarriages is often unknown, as approximately half of all miscarriages are caused by foetal-chromosomal abnormalities (Sugiura & Fujisawa, 2021) since chromosomal aberrations increase with age. The average age of women undergoing fertility treatment has increased, as has the rate of miscarriages in Japan. Among the types, the instance of two or more repeated miscarriages has been specifically defined. The American Society for Reproductive Medicine (ASRM) defines recurrent pregnancy loss (RPL) as two or more repeated miscarriages. The Royal College of Obstetricians and Gynaecologists referred to it as recurrent miscarriage (RM). ASRM has provided a committee opinion on the benefit of tender loving care (TLC) as an added treatment for miscarriage (Domar & Lanonne, 2012) for the evaluation and treatment of recurrent pregnancy loss. Frequent miscarriages, such as RPL and RM, can have a negative impact on the mental health of women and their partners (Mutiso et al., 2019). The poor mental health of women and high rates of miscarriage may be linked with each other (Strumpf et al., 2021).Significant success has been reported by the introduction of TLC in couples who have had three consecutive miscarriages with no other identifiable cause (Andersson et al., 2012). Hence, TLC can benefit the maintenance of mental health during fertility treatment.
In other words, numerous patients with infertility in Japan are eager to undergo TLC in addition to their fertility treatment. However, despite several studies using TLC for patients experiencing miscarriages, TLC can only be understood to mean caring for patients in a warm and family-like manner. To introduce TLC into nursing practice, it must be defined to provide practice-specific nursing usage. Additionally, we have proposed concrete uses and possible ways of using TLC.

OBJECTIVE
The purpose of this study was to conduct a conceptual analysis of TLC and clarify its constructs and definition. The goal is to provide professionals who wish to offer TLC with a basic resource to guide them in their practice of TLC to patients who have repeated miscarriages despite their willingness to have a baby. It also clarifies the potential use of TLC in situations involving more than just patients experiencing miscarriages.

Study design
Conceptual analysis was conducted in this study.

Analysis Method
The approach of (Dawson et al., 2015) for conceptual analysis was used. It helped to clearly redefine ambiguous concepts in theory by validating concepts in terms of the attributes that structure the concept, the antecedents that precede the concept, and the consequences that result from the concept. Specifically, it follows eight steps: (1) selecting a concept; (2) determining the aim of the analysis; (3) clarifying the usage of the concept; (4) clarifying the attributes that define the concept; (5)

Data sources
The sample selection criteria were as follows: a) Year of publication: from the first edition of the journal till January 2022; b) Databases: CINAHL Plus with Full Text and MEDLINE were used; c) Search term: 'tender loving care'.
Among the accessible documents, the titles and abstracts of all the searched articles were individually reviewed to determine their suitability. Duplicate references, conference proceedings, books, and other sources were excluded. As a result, 25 articles, most of them in English, were selected for conceptual analysis (Table 1).

RESULTS
The results of the conceptual analysis of TLC yield the following defining attributes, antecedents, and consequences:

Defining attributes
The defining attributes were specified in all the references listed above, and twelve consequences were extracted from the 34 codes. The following characteristics were provided by health professionals, parents, and teachers: familial warmth, kindness, compassionate attitude, and attention; motherly love and compassion (respect, responsibility, and thoughtfulness); empathic care, giving comfort, seeing and understanding the situation and answering questions appropriately, relieving tension, and considering the feelings of the target individual.

Antecedents
Antecedents were specified in twenty of the 25 references, and three consequences were extracted from the seventeen codes (Cunico et al., 2012;Gigengack et al., 2019;Strachan-Hall, 2016). The attributes involved subjects who (1) were in mental or physical distress; (2) faced major barriers in life (illness, disability, etc.); and (3) were unable to manage their mental health well-being through their own efforts, and had the following illnesses or disabilities: habitual or recurrent miscarriage, first trimester of labour, elderly, pervasive rejection syndrome, severe sciatica, severe psychiatric disorders or depression, retinopathy of prematurity, cancer pain, wounds, and migraine.

Consequences
Consequences were specified in eleven of the 25 references, and two consequences were extracted from the seven codes (Hopstaken, 2016;Mutiso et al., 2019;Yokota et al., 2022). The benefits of providing TLC include the following: (1) psychological wellbeing: reduced tension and anxiety, and satisfaction with the care provided; and (2) physical well-being: improved wound healing, reduced pain, continued pregnancy, and childbirth. TLC improves mental and physical health, and ultimately, the quality of life in its beneficiaries. A case study model was prepared covering the main factors of the concept. The case model is as follows.
Mrs. A., who had two miscarriages: Mrs. A experienced miscarriages while expecting a baby and gradually began to feel that she could no longer be a mother. She was the only one among her friends who did not have children. Her colleagues at work, supervisor, and mother-in-law asked her why she had not yet been able to have a baby. Avoiding the topic of the children, she stopped talking and meeting with her friends altogether and began to shut herself away. Medical treatment for infertility involves physical pain. Hence, there is some uneasiness regarding clinical treatment. Previously, she had been a patient at a clinic close to her home, but after her second miscarriage, she was damaged by the cold words and unfriendly attitude of the medical staff, and no longer wanted to continue infertility treatment. Her husband did not show an interest in the treatment, and she began to feel that he did not fully appreciate her feelings, and she began to shut herself in increasingly (Lachmi-Epstein, 2012; Strumpf et al., 2021). She became sensitive to trivial things said and done around her, had difficulty sleeping well, and her depressive symptoms became stronger.
Meanwhile, she met a woman on a social networking site who had the same experience as she had. The woman recommended a clinic that had friendly and helpful medical staff, and the visit did not involve any pain. One day, she decided to try to consult the clinic, and the doctors, counsellors, nurses, and other medical staff were very supportive, saying, 'I know exactly what you're going through'. The medical staff always treated her with a smile, provided detailed explanations in an understandable manner when the examinations were conducted, provided appropriate advice to improve the relationship between Mrs. A and her husband, and supported her in the decision-making process concerning her wishes (Research, 2021). The counselling sessions that Mrs. A was able to receive without any limitations helped her express her feelings when she felt uneasy. Mrs. A was able to continue her infertility treatment and her treatment was successful. She became the mother of a baby girl.
Supplementary examples include the boundary, related, contrary, invented, and erroneous cases. In this study, the contrary examples are based on the author's past experience. In some cases, the couple's relationship breaks up during the fertility treatment and, eventually, they are unable to continue the treatment. In such cases, women complain that their husbands are reluctant to treat them, while the husbands often believe that there is no need to rush into treatment or that it is not necessary (Practice Committee of the American Society for Reproductive Medicine., 2012). In other words, there is a knowledge gap between men and women regarding the fact that women's pregnancies have time limits. However, if medical professionals do not pay attention to the patients and kindly listen to the their words, they do not intervene on behalf of the couple's respective positions, which deepens the gap between the spouses (Larsen, 2012). Women are psychologically trapped and suffer not only from infertility, but also from mental health issues. The medical professional should inform women that their husband simply lacks knowledge about female fertility and is not ignoring her feelings, while simultaneously explaining to the husband, theoretically, that fertility treatment is necessary because the probability of conception decreases with age (Rasmark et al., 2018). The husband should be made aware that the wife is not being impatient for the fertility treatment, which will prevent a difference in feelings between couples and allow them to cooperate with each other during the treatment.

DISCUSSION
TLC can be referred to as a basic caring attitude in nursing situations; however, it has been addressed as a spiritual theory. In TLC, it is also essential to have a basic attitude on the part of the care provider, such as paying attention to the patient or client, being empathetic, and putting oneself in the client's shoes. In this study, as a result of the conceptual analysis, 'tender loving care' was defined as 'the care for mentally or physically distressed or impaired subjects by health professionals, parents, and teachers based on compassion and empathy, who perceive the condition of the subject and respond appropriately, thereby reducing tension, distress, and anxiety and achieving a state of mental and physical well-being'. The results of this conceptual analysis clearly demonstrate the significance of TLC as a specific practice guideline for health promotion in the care of mentally and physically vulnerable subjects, not only in the care of miscarried patients, but in all nursing, educational, and home settings. TLC does not require any special skills and may be about being empathetic and family-like to the subject in need of care. However, it is not easy to demonstrate an empathetic attitude toward the subject, although empathy is essential for quality care. Empathy, for instance, is not naturally developed, and there are efforts underway through training to have it obtained as a skill (Salvador, 2016).
The content of TLC as defined in this study includes healthcare professionals grasping the patient's condition and providing appropriate responses based on compassion and empathy towards the patients. Treatment of infertility is physically and psychologically invasive. In a study of the psychological impact of medical examinations and operative treatment of infertility, semen screening caused feelings of shame and inferiority in men, increased fear and anxiety in women due to medical intervention, and postoperative depression was observed (Ghaedrahmati et al., 2018). The negative psychological impact can be significant when the overwhelming expectation that treatment will result in having a child is betrayed. Recognising the patient's distress situation is at the core of TLC. It is possible to understand the situation of the patient and to be closer to the patient, thereby providing a sense of reliability and comfort. TLC can heal damaged minds and bodies. A study examining the experiences of women who had undergone fertility treatment and had a baby found that subjects wished to be treated with respect and dignity. They were also expected to be provided with appropriate information and support (Domar & Lanonne, 2012). The outcome of fertility treatments is not always guaranteed. Therefore, they needed professionals to be fully aware of the difficulties that they experienced. (Domar & Lanonne, 2012) reported that the most common reason for discontinuing IVF treatment in the U.S. was stress (39%), with the two main reasons 'the negative impact on the couple's relationship, and 'anxiety and depression that prevented them from continuing'. TLC has the potential to reduce the risk of anxiety and depression caused by infertility treatment, enabling continued treatment and providing energy until childbirth; however, the end of infertility treatment does not equal childbirth per se. In fact, this treatment may be used in the long term. Patients have a high rate of depression, possibly due to anxiety about treatment with no clear outcome or stigma (Al-Khlaiwi et al., 2022). Anxiety and depression are associated with disturbances in the regulation of autonomic function. The autonomic nervous system can be balanced by reducing the risk of anxiety and depression. TLC has the potential to reduce anxiety and the risk of depression. This is expected to balance the autonomic nervous system and enable it to function properly as well. The autonomic nervous system is also expected to regulate a woman's hormonal environment and improve conception and fertility. Furthermore, although TLC can be performed by anyone, it is necessary to judge whether it has been provided based on the subjectivity of the patient or client, and there are no objective scales to measure the presence of TLC. TLC is not experienced by the care provider but is only realised by the patient or client who receives the care. The autonomic nervous system is also expected to regulate a woman's hormonal environment (Chowdhury & Chakraborty, 2019) and improve conception and fertility. Therefore, TLC can be expected to have an indirect effect on the eventual increase in fertility. TLC can improve the patients' psychological and physical health, and ultimately the quality of life for the target individuals.
Furthermore, although TLC can be performed by anyone, it is necessary to judge whether it has been provided based on the subjectivity of the patient or client, and there are no objective scales to measure the presence of TLC. TLC is not experienced by the care provider but is only realised by the patient or client who receives the care. The autonomic nervous system is also expected to regulate a woman's hormonal environment (Caruso et al., 2020;Devi et al., 2018) and improve conception and fertility. Therefore, TLC can be expected to have an indirect effect on the eventual increase in fertility. TLC is not perceived by the care provider but is only realised by the client. Hence, it is also necessary to develop an objective measure of the TLC provided because the TLC must be judged to have been provided by the subjective choice of the people who were surveyed.
The clients for whom TLC is provided are not only those with infertility, but also those in emotional and physical pain, such as patients with chronic or acute illnesses, cancer patients, adolescents, etc. TlC is not limited to nursing settings, but can be used at home or in any setting when in a position to work with hurting people. TlC has the power to heal and energize the wounded person.

CONCLUSION
In this study, a conceptual analysis of TLC was conducted using Walker and Avant's (2000) method. The results of this conceptual analysis clearly demonstrate the significance of TLC as a specific practice guideline for promotion of health when caring for mentally and physically vulnerable patients, not only in the care of patients experiencing miscarriage, but also in all nursing settings, educational settings, and at home. TLC refers to showing familial warmth, kindness, attention, compassion, empathy, comfort, understanding, and consideration of emotions towards a target individual. It can be provided by health professionals, parents, or teachers. As antecedents, the target individuals (patients) for whom TLC is provided are those with mental or physical distress, such as infertility, patients with chronic or acute illnesses or cancer, and adolescents. Consequently, after the introduction of TLC, patients can achieve their desired health and lifestyle. TLC improves the psychological and physical health, and ultimately, the quality of life of its beneficiaries.

DISCLOSURE STATEMENT
The authors declare that there are no conflicts of interest.