Meaning of wellness in caring science based on Rodgers's evolutionary concept analysis

Background: Wellness is a holistic, multidimensional, and process-oriented property on a continuum. It has been used interchangeably with and is undifferentiated from concepts such as health and well-being without an in-depth clarification of its theoretical foundations and a reflection on its meaning. The concept of wellness is frequently used, but its definition remains unclear. Aim


INTRODUCTION
The Swedish Research Council [1], as a response to a government commission, carried out an evaluation of Swedish healthcare research, which indicated a fragmented, overlapping and weakly developed national collaboration.It summarises that there is a need to strengthen the scientific basis of care sciences research.Against this background, a network of colleges and universities has started a collaboration named 'Nursing Research in Collaboration'.There are several ongoing research projects within the network, of which this study is one.The network has developed the Wellness model, as the starting point for its work.This network model focuses on the care contexts and its organisations, diversity in care, learning, design, and implementation in practice.However, it has been discussed in the network what the theoretical and conceptual meaning of wellness is.Is it the same as health, wellbeing, poor physical fitness, or something else?Hence, there seems to be a knowledge gap to fill in regarding the theoretical meaning of the concept of wellness.
Since the 1980s, the Nordic College of Caring Sciences has focused on concept and theory development in caring sciences, whilst the 2000s shed light on conceptual discussions [2].In the 2000s, Rodgers and Knafl [3, p. 80] stated that the 'clarification of concepts is an important step in the process of developing concepts that are meaningful in the discipline.It is not an end point, but a critical step in the process of developing knowledge related to concepts of interest in nursing.Further, by analysing the common use of the concept makes it possible for the researcher to identify the cluster of attributes that constitute the concept and thereby define the concept [3, p. 81].Concept analyses following Rodgers and Knafl [3] are frequently used in nursing research [4][5][6].Nevertheless, there is a need to provide clarity to enhance the concept development process.Based on the early policy documents of the World Health Organisation (WHO), its constitution (1948), and the Ottawa Charter for Health Promotion [7,8], one can question whether wellness is the same as health or something else.Does it matter what words are used?In our opinion, it is challenging to conceptualise wellness because it means different things for different persons and disciplines.In an editorial in Scandinavian Journal of Caring Sciences the importance of theoretical perspectives in caring science is highlighted [9].Fagerström argues that they are supposed to affect not only how we conduct education, research, and development but also how we perceive, interpret, and understand the patient in clinical situations [9].Hence, it is important to define wellness and its relation to caring science, as caring embraces the whole person, the unity of mind body spirit as one in relation to environment at all levels [10].
Based on early policy documents of WHO, in its constitution (1948) and in the Ottawa Charter for Health Promotion [7], wellness can be understood as everything from overall health and well-being to pure physical fitness.It is argued that the Ottawa Charter retains its relevance to the present day and that all policymakers and professionals working to promote health should revisit and take heed of its principles [11].The concept of wellness remains unclear and difficult to define, so it is often misunderstood [12][13][14], with possible negative consequences in caring science and in health care practice.The results of the present study may thus presumably contribute to making the concept more distinct and useful in health care practice and to the process of developing theories for caring science.

BACKGROUND
In the late 1940s, WHO introduced a new definition of wellness in its constitution by stating that 'health is not only the absence of disease and infirmary but a state of complete well-being in a physical, mental and social meaning' [15, p. 1].The term was first used conceptually by Halbert Dunn [16].He defines wellness as 'an integrated method of functioning which is oriented towards maximizing the potential of which the individual is capable.It requires that the individual maintain a continuum of balance and purposeful direction within the environment where he is functioning ' [16, p. 4].Dunn describes various levels of wellness: individual, group (family), community, environmental (nature), and social wellness.All these levels are interrelated and together create wellness [16].Ardell [17, p. 38] argues that 'wellness is a conscious and deliberate approach to an advanced state of physical and psychological/spiritual health' as well as a dynamic, fluctuating state of being'.It is a balanced and positive approach.
is frequently used interchangeably with health and well-being without an in-depth clarification of its theoretical foundation.

K E Y W O R D S
caring science, health, health care, literature review, Rodgers' concept analysis, well-being, wellness Cangelosi [18] defines wellness 'as a set of attitudes and behaviours indicating a person's perception of their ability to have some control over their physical wellbeing'.Wellness is about 'harmony of the body, mind and spirit' [19, p. 57] and is a way of life orientation towards optimal health and well-being in which body, mind, and spirit are integrated by the individual to live more fully within the human and natural community' [20, p. 252].According to Corbin and Pangrazi [21, p. 3], wellness is a 'multidimensional state of being describing the existence of positive health in an individual as exemplified by quality of life and a sense of well-being'.This definition is close to that in the WHO Health Promotion Glossary, in which wellness is described as 'an optimal state of health of individuals and groups.It is about the realisation of the fullest potential of an individual physically, psychologically, socially, spiritually, and economically [22, p. 344].Wellness is also the fulfilment of one's role expectations in the family, community, place of worship, workplace, and other settings.The latter definition is consistent with statements in the Ottawa Charter for Health Promotion [7], in which health is considered a resource for everyday life, not the objective of living.Health is a positive concept emphasising social and personal resources, as well as physical capacities.However, the theoretical and philosophical foundations of the concept of wellness remain unclear.In a review of theory and measurement, Roscoe [14, p. 222] states that there is little consensus on the definition of wellness and that an integrated definition that included several dimensions has not yet been created.She defines wellness as a 'synergistic and multidimensional construct that is represented on a continuum, not as an end state' [14].Wellness can also be considered a 'purposeful process of individual growth, integration of experience, and meaningful connection with others, reflecting personally valued goals and strengths, and resulting in being well and living values' [23, p. 48].It is a worldwide phenomenon and a legal concept [24].
However, criticism of the concept has been directed on, first, its economic and results orientation; second, its normative or more theoretical basis, in which wellness is described as an ideology that suppresses human variation and focuses on achievements in lifestyle practices; and, third, its sociological aspect, in which wellness is considered to be akin to a culture in organisations [25].
The concept of wellness is widely used in caring science and health care practice.However, its definition remains unclear, and the concept can therefore be misunderstood, with negative consequences.The results of the present study can presumably contribute to clarifying the concept of wellness, making it more distinct and useful for caring science and health care practice.

AIM OF THE STUDY
This study aimed to conceptually and theoretically explore the concept of wellness to contribute to a deeper understanding in caring science.

METHOD Rodgers' evolutionary concept method
In research, it is essential to understand the meaning of the content of various concepts used in the specific context.Clarifying the meaning can increase the understanding of the concept, but the meaning has always to be placed in a historical (here background) and cultural context (here caring science).There are several techniques and methods for concept analysis.Rodger's evolutionary concept analysis is developed by nurses to advance nursing knowledge, its philosophical foundation is sound, and it is frequently used in nursing over time, which creates a solid foundation for the study [4,26].
Rodgers' evolutionary concept analysis was used for the theoretical analysis of the data.It is congruent with the theory of caring science, which uses the heuristic inductive approach to develop the very foundation of the theory.According to Rodgers and Knafl [3], a concept can be defined by analysing the ways in which it is used in a specific context.Furthermore, 'concepts are formed by the identification of characteristics common to a class of objects or phenomena and the abstraction and clustering of these characteristics' [3, p. 78].Consequently, the concept of wellness in caring science was identified in the current study as the concept of interest.

Data collection and the critical literature search process
Initially, the identification of the concept of interest (wellness), surrogate terms and relevant uses of the concept was conducted through a critical literature search process that included the following steps: development of keywords and search strategies, a manual review of the reference sections of papers to identify useful studies, online database searches for relevant papers and screening of abstracts to identify relevant studies for further review.The search strategy applied and the criteria for inclusion were peer-reviewed papers in English and papers published in scientific journals using the surrogate terms 'wellness', 'health', 'health care', and 'health care and wellness', either in titles or abstracts, by September 2022.No time limit was set.The search was run in CINAHL and PubMed via EBSCO and in ProQuest.A manual search in reference lists and in the International Journal of Wellness and Society supplemented the online search.
Thereafter, an appropriate sample for data collection was identified and selected for a closer review.Papers that met the inclusion criteria and dealt particularly with the theoretical aspects of the concept of wellness were included.The results of the search process are shown in Figure 1.Papers that did not deal with the theoretical aspects of the concept, papers focusing only on testing various instruments for measuring wellness and/or papers that only reported different programmes for maintaining or strengthening wellness were excluded.

Analysis of the data
According to Rodgers and Knafl [3], a method is 'a means of identification, simply seeing what is common in the existing use of the concept'.The method involves several phases [28, p. 333]: (1) identifying and naming the concept of interest; (2) identifying surrogate terms and relevant uses of the concept; (3) determining and selecting an appropriate sample for data collection; (4) identifying the attributes of the concept; (5) determining the references, antecedents and consequences of the concept (if possible); (6) identifying concepts that are related to the concept of interest; and (7) determining a model case of the concept (if possible).Hence, consistent with Rodgers and Knafl [3], the collected data in the present study were analysed in terms of antecedents, attributes, consequences, surrogate and related terms.The analysis covers contextual references only related to caring science, because of the limitations of the study.

Credibility
The credibility of the analysis and findings was ensured by keeping an audit trail for the work process [3].All authors jointly agreed on the surrogate terms, the delimitation of the study and the databases for the search.Analytical rigour was achieved by having all the authors independently review the abstracts first and then the full papers of interest to check their relevance according to Rodgers' evolutionary concept analysis and the aims of the study.A dialogue process was performed in which a consensus was achieved about the papers to be included in the analysis.A detailed study protocol was established for each of the selected papers.This included the reviewer's name, date of the review, author name(s) of the paper reviewed, title, bibliographic information, antecedents, attributes, consequences, surrogate and related terms, contextual references, and additional notes, if necessary.Several F I G U R E 1 Results of the search process consistent with the method of Moher et al. [27].
workshops focusing on the outcome of the analysis and the preparation of the article were also conducted to achieve agreement.All authors contributed substantially to reviewing and discussing the papers included and in the analyses performed up to the development of the final manuscript.The composition of the research group represents different disciplines, such as nursing sciences and public health/health promotion, as well as many years of experience in education and nursing practice.

RESULTS
After the papers were read, words and sentences related to antecedents, attributes, consequences, surrogate and related terms and concept definitions (presented in the background) were extracted.Table 1 shows the papers reviewed and the core characteristics identified.

Identified antecedents
The antecedents of caring are the characteristics associated with what happens after or because of a concept [3,26].The identified antecedents of wellness from this study are a strength-based approach, salutogenesis, personcentred care, illness-wellness dichotomy, attitudes, and behaviour.
Wellness approaches to health and disability are radical alternatives to the medical model [29] and mean a balance between the dimensions in the wellness model, which is salutogenically rather than pathogenically focused.Testing the wellness model, the study finds that life purpose, optimism and sense of coherence are related to perceived wellness [30].This is supported by Bezner and Hunter [31], as they consider the concept of wellness a salutogenic or health-causing orientation rather than a pathogenic orientation.The focus is the multiple dimensions of the individual, including components of the mind, body, and spirit; there is a restriction to the subjective or perceptual realm.The focus is also on the whole person and how each dimension is dependent on the other dimensions.DiClemente et al. [32] discuss overcoming obstacles and barriers in which individuals reveal their own strengths necessary to cope with life stressors.This is achieved by creating systems for coordinating services that are person centred and that build on strengths and resilience.Only the journey of life helps in the development of each dimension [33].The results are a model of comprehensive wellness [34], theory development and use in practice [14], and improved perceived wellness [35].
A conceptual understanding helps explain how it is possible to experience wellness despite illness [13].
Understanding and experiencing wellness are the most significant underlying reasons for wellness consumption.The experiences of bodily wellness can support a sense of personal competence and, through this, a sense of mastery of one's life [36].According to Glik [37], spiritual healing practices play a social support function.Wellness is strongly related to cognitive health and predictors of cognitive health protection in community dwellings.Evidence provides an opportunity to develop patient-specific interventions [38].The long-term maintenance of a healthy lifestyle after initial changes has been accomplished is paramount [39].Demographic characteristics (i.e.age, gender [female], marital status [married], educational level, and income class [higher]) are positively related to the preventive health care (PHC) index [18].Jensen and Allen [40] argue that the promotion of wellness means the prevention of illness behaviour.Furthermore, Kreitner [41, p. 29] states that 'personal wellness is just good business', meaning that managers should take care of one's body like a business; the principles of good business need to be translated into specific self-management in terms of nutrition, stress management, and exercise.

Identified attributes
Attributes represent characteristics associated with factors that must take place for a concept to occur, and they assist in the differentiation between similar concepts [3, p. 91].The attributes of caring derived from the analysis by Rodgers and Knafl [3, p. 257] included knowledge-based competence, resources, and intentional moral commitment.The identified attributes of wellness in this study are holistic, multidimensional, process oriented, health related, and lifestyle oriented.
The concept of wellness refers to holistic functioning and works as a definition of health [29,30]; it is related to multidimensional and interdisciplinary or trans-disciplinary teams [30].Wellness includes the physical, psychological, intellectual, emotional, and spiritual dimensions [31,33].It is a complex process [23,31] and a way of life oriented towards optimal health and wellbeing as the integration of the body, mind, and spirit [35].Kreitner [41] describes wellness as a harmonious and productive balance of physical, mental, and social well-being, as living mentally, spiritually, and physically well [42] with one's body, mind, and environment [43].Wellness is a positive view of sets of health states that are both individually and socio-culturally determined and referred to as subjective health on a wellness-illness continuum [34,37] or as spiritual, social, emotional, physical, occupational, and intellectual health on a continuum [34]; it is a synergistic construct, not just the absence of illness  [14].Roscoe [14] continues to explain wellness as something positive, a holistic multidimensional concept, and a process in which the body, mind, and spirit harmonise towards an optimal state of health.Therefore, wellness is a social setting necessary for reflection on, for example, personal aging experiences and the strengthening of the wellness skills that are necessary for self-care and the management of life [36].According to Kirkland [44], wellness is the prevention of diseases, which creates hierarchies based on achievement.It promotes homogeneity and prescribes one specific way of life for everyone [44].It is a matter of lifestyle and health behaviour [45] and personal responsibility [41], such as creating an eating plan, ensuring increased steps per day, using a weighing scale and pedometer, and being aware of nutrition and body weight [39].

Identified consequences
Consequences represent what happens after or because of a concept [3].The identified consequences of wellness in this study are health promotion, quality of life, integration in clinical practice, maintenance and development of health, and commercialisation of health.
Wellness approaches to health and disability are radical alternatives to the medical model [29] and mean a balance between dimensions, or salutogenesis [30].As a result of wellness, a salutogenic or health-causing orientation rather than a pathogenic one is adopted; the focus is on multiple dimensions of the individual, including components of the mind, body and spirit, and there are restrictions to the subjective or perceptual realm [31].Furthermore, the focus is the whole person and how each dimension is dependent on the other dimensions.Only the journey of life helps to develop each dimension [33].Understanding and experiencing wellness are the most significant underlying reasons for wellness consumption.Wellness is strongly related to cognitive health and predictors of cognitive health protection in community dwellings.Evidence provides an opportunity to develop patient-specific interventions [38].The longterm maintenance of a healthy lifestyle once initial changes has been accomplished is paramount [39].Demographic characteristics (i.e.age, gender [female], marital status [married], educational level, and income class [higher]) are positively related to the PHC index [18].The promotion of high-level wellness is a diagnostic criterion for determining levels of wellness [46].According to Jensen and Allen [40], the promotion of wellness means the prevention of illness behaviour.Personal wellness is 'just good business'.It is something that managers can live with [41].
Consequences are constituted in a nest of intersectional identity categories that help enact what wellness means in practice [44].Working together to address health disparities and restore hope, forming partnerships with health care organisations, government agencies, and social service providers [47].School-based health promotion and wellness programmes should also be established [45].Improving employee health, well-being and productivity is common across countries and their respective cultures [24], but it also means being empowered and proactive in the preservation of health and having personal control over it [48].Being well is based on personally defined living values [23] and a way of life that leads to optimal wellbeing [49].The perception of wellness is that it requires a culturally appropriate education and interventions [43], as well as a rehabilitation counselling education [42].

Identified surrogate terms
According to Rodgers and Knafl [3, p. 92], it is 'important to carefully distinguish between surrogate and related terms, which are concepts that bear some relationship to the concept of interest but do not seem to share the same set of attributes.They explain that 'Surrogate terms are means of expressing the concept other than the word or expression selected by the researcher' (here wellness) [3, p. 92].To capture the meaning of surrogate terms, one can ask whether other words say the same thing as the chosen concept [3,26].The identified surrogate terms of wellness from the selected papers in this study are health and well-being, which are concepts that seem to be used interchangeably with the concept of wellness, without a further clarification of its theoretical foundations [23,37,41,42].
Glik [37, p. 579] equates subjective health with wellness and discusses subjective health as 'an emic construct' (culturally specific).Corbin and Pangrazi [21, p. 3] describe wellness as a 'state of being, as the existence of positive health exemplified by quality of life and a sense of wellbeing'.Their view of the wellness concept is based on WHO's [50] definition of health, in which wellness represents the positive component of health.Thus, wellness is seen here as a state, not a process, and as part of health, not a phenomenon beyond health in which quality of life and well-being are the descriptors of wellness [21].The use of the term 'positive health' is somewhat complicated.The question is, what is negative health?
The review of the selected papers results in two different tracks on the view of health: health as a process on a continuum [14,34] and health as a dichotomy between health and disease (objective health) and/or wellness/ illness (subjective health) [40].McMahon and Fleury [23, p. 43] state that the concept of wellness has a 'wideranging relevance, but may be used differently across 14716712, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/scs.13196by University West, Wiley Online Library on [30/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License contexts, disciplines, and populations.They continue, 'much of the medical literature has shifted from describing the concept of wellness, to describing the implementation of health programs applying the word wellness to health promotion strategies [23, p. 43].In line with this development of health promotion, it is important for the authors of this study to clearly clarify our approach to health, that is, a holistic strength-based approach that comes close to the statements in the Ottawa Charter for Health Promotion [7].Two overall contrasting views of health appear to be apparent: the biomedical perspective of pathogenesis and the resource-oriented salutogenic perspective [51,52].The pathogenic meaning of health represents the absence of disease or illness, in which health and disease are viewed as a dichotomy.Health is described as well-being and an ongoing process of transition towards increased awareness [53][54][55].Positive mental health includes factors of resilience, such as acceptance, faith, hope, meaningfulness, and meaningful relationships [56] and must be promoted at the individual level [57].Valid and reliable measures of a positive multidimensional concept of health need to address aspects such as autonomy, social involvement, and comprehensibility [58].Health cannot sufficiently be explained in a negative way as the absence of symptoms because this explanation tends to neglect the positive aspects of health, such as dimensions of well-being and the ability to develop relationships and to achieve subjective desirable goals [59].The concept of health needs to be understood as a holistic concept that embraces positive aspects far beyond the limits of the negative pathogenetic perspective of health as solely being about the absence of symptoms of disease [60,61].Plank and Gould [62,p. 74] define health consciousness as 'an individual's preoccupation with their health'.A higher level of health consciousness means that a person is more aware of their own health status.

Identified related terms
Related terms are concepts that 'bear some relationship to the concept of interest but do not seem to share the same set of attributes [3, p. 92].The terms related to wellness in this study are lifestyle, resilience, optimism, flow, and positive psychology.Several studies equate wellness with lifestyle.Cangelosi and Markham [18] discuss behaviour and attitudes towards health, whilst others focus on exercise and nutrition [39,45,49] or health habits [48].Bezner and Hunter [31] and DiClemente et al. [32] highlight the concept of resilience, which is the physical dimension of the concept here.Resilience is a much broader concept, a way of bouncing back and beating the odds when faced with negative life events and strains and the capacity to mobilise protective factors and stay well [63,64].In the early 2000s, Marini and Chacon [42] shift attention from the disease-oriented model of human functioning to an examination of the unique qualities of healthy people that lead to overall wellness.Wellness relates to the aspects and concepts of positive psychology, which are optimism and flow in this study.

Identified contextual references
According to Rodgers and Knafl [3, p. 91], in identifying the contextual basis of wellness, the focus is to 'gain an understanding of the situations in which the concept is used and how its use by people with potentially diverse perspectives'.Thus, references indicate the actual situations in which the concept is applied.The contextual basis of this study is limited to caring science which makes it difficult to draw conclusions about how the concept of wellness has been used over time and in different disciplines.This is a task for further research.

Conceptual model of wellness
Based on the findings from the analysis, a conceptual model of wellness is presented in Figure 2.
Based on the findings from the concept analysis and considering that the concept of wellness consists of multidimensional processes, a definition of wellness was created.The conceptual definition of wellness that we developed is as follows: 'a holistic and comprehensive multidimensional concept represented on a continuum of being well that goes beyond health'.Wellness aims to call attention to the positive aspects of human functioning and experience by applying the salutogenic perspective on health promotion to caring science and health care practice.

DISCUSSION
The study aimed to explore the concept of wellness to contribute to a deeper understanding of how to use the concept in caring science and health care practice.Based on the findings from the concept analysis and considering that the concept of wellness consists of multidimensional processes, a definition of wellness was created.The conceptual definition of wellness that we developed is as follows: 'a holistic and comprehensive multidimensional concept represented on a continuum of being well that goes beyond health'.Accordingly, the result of this study is a model of comprehensive wellness [34], theory development and use in practice [14], and improved perceived wellness [35].
The concept of health is often used with a negative meaning that is related to the absence of disease and ill health.Wellness may capture a holistic salutogenic meaning.If the concept is not made clear, there is a risk that it will lose its own inherent positive meaning, and wellness cannot be used as synonym to the absence of illness.The definition of wellness as involving 'harmony of the body, mind and spirit' [19, p. 57], as a 'balance with one's body, mind, and environment' [43, p. 791], and as 'a way of life orientation toward optimal health and well-being in which body, mind, and spirit are integrated by the individual to live more fully within the human and natural community' [20, p. 252].A clear definition of wellness may be able to support the somewhat fading concept of health to describe and capture the overall goal of research in caring science and health care practice as the optimal state of health of individuals and groups and as the provision of support care actions aiming for the realisation of the fullest potential of an individual physically, psychologically, socially, spiritually and economically.
If we return to the core policy document of health promotion, the Ottawa Charter [7], one of the strategies for health development was reorienting health services.This approach appears to have received little attention, and its development has been particularly slow [65][66][67].With a salutogenic perspective on health care, the focus on both patients and professionals can be strengthened.Mjøsund et al. [65, p. 544] have found that acquiring and applying personalised knowledge and skills about health and disorder, called 'an appetite of learning' and 'putting the knowledge into practice' [65, p. 545], are perceived as promoting mental health.In this aspect, nurses have a unique opportunity in their holistic approach to care to identify resources and capabilities, as well as obstacles, to promote patients' health.Seah et al. [67] argue that in the shift in focus from health care to health, there is a need to develop salutogenic enquiry and examine the capacity of future nurses to promote health in the community by exploring nursing students' perspectives on utilising salutogenic theory in community health promotion.
The findings from the concept analysis reflect that wellness and health are used as synonyms, often together without defining either wellness or health; they are exemplified by one's quality of life and well-being [21].Still, wellness seems to be much about lifestyle and health behaviour [18,39,45], even if a trend towards a more holistic and synergistic view of life or life orientation can be seen [14,29].It is somewhat problematic, though, that wellness is used interchangeably with other concepts.
The Swedish Research Council has found that international and Swedish research in care sciences is broad but fragmented, thus recommending greater research collaboration on theory and concept development [68], which this study aimed to achieve.The overall goal of caring science and health care practice is to promote, support, and maintain individuals' subjectively perceived health.The most important tools in health care practice to promote health in each care discipline are the words and concepts used in the dialogues between professionals and between professionals and their care recipients.A lack of words to sufficiently describe the inherent meaning and importance of the goal of care has consequences for the quality of care and the opportunities to achieve the main goal of care.
In the review of the selected papers, the clarification of the meaning of wellness was complicated using different concepts.For instance, Larson [69, p. 129] describes a wellness model in which health is considered the strength and ability to overcome illness or to have a 'reserve of health'.Wellness involves progress towards a higher level of functioning or an optimistic view of the future.

Methodological considerations
Rodgers, Jacelon and Knafl [4] highlight the importance of clarifying and developing the conceptual foundation of commonly used concepts, which will benefit to caring science.The conclusion is 'that the absence of effective concepts impedes the ability to recognize, discuss, define, and conduct studies that are important for clinical practice and research' [4, p. 451].
In a review, Rodgers, Jacelon and Knafl [4] report 43 distinct methods of concept analysis, in which Rodgers' evolutionary method [3] is one of the most frequently used.The present study adopts such a method.We made it a point to carefully follow its different phases, from identifying the concept of interest through a critical search and collection of data, to analysing antecedents, attributes, consequences, surrogate and related terms, and contextual references, and to determining an example of implication for health care science and health care practice.According to Rodgers and Knafl [3], this is necessary to meet the requirements of completeness in terms of the method.

Strengths and limitations of the study
Concept analyses have steadily increased since the 1990s [4].Regarding the present study, the strength is that concept analysis fills an existing knowledge gap by making the concept of wellness more distinct and useful for caring science.This helps increased awareness of the importance of different concepts and their content, which can be considered a strength.As Fagerström [9] states, clarifying concepts has an impact on nurse education, how research is carried out and how the patient in clinical situations is perceived, interpreted, and understood.
The selected studies are all related to health care.Excluded were wellness programmes and interventions, as well as empirical studies testing the number of wellness measures.Only papers defining or discussing the theoretical content of wellness, to some extent, were included.Another limitation is that 'grey literature' is not included in the search.When designing a research plan there is always a discussion what you want to do and at the same time what is possible to do.Limitations are always a fact, so also for this study.To involve 'grey literature' was beyond the prerequisites for the study.This is a task for further research.
A deeper examination of the contextual references was not carried out because of the study's limitation of covering only the health care sector.The inclusion criteria can be seen as a limitation as we may have missed out on some papers that discuss the concept of wellness.From a theoretical point of view, alongside the main purposes of the study, a concrete context can be a strength, as it increases clarity.

Relevance to caring science and health care practice
A concrete example of a result of clarifying wellness is that the concept can now capture the holistic salutogenic meaning that the concept of health sometimes loses in the mainly medical context of health care practice.
Health is often used in its negative meaning as the absence of disease and thus loses its own inherent positive meaning.The concept of wellness cannot, in the same way as the concept of health, be used in a negative sense as the absence of illness.A prerequisite to use the concept of wellness is to strengthen the positive meaning of the concept of health.By that wellness is not as easily misunderstood as, for example, pure physical fitness.

Further research
Further research could interview health care professionals about how they perceive the concept of wellness and its meaning.This could further strengthen our conceptual analysis and potentially contribute to a deeper understanding of wellness.In addition, expanding the review of the concept of wellness to other settings and sciences is important.Finally, an exploration of different questionnaires for measuring wellness can provide deeper knowledge of its dimensions.This could lead to the development and validation of new questionnaires measuring wellness.This may contribute to consider the positive aspects of applying the salutogenic perspective to health promotion in caring science.

CONCLUSION
The use of wellness is worldwide and the concept holistic and multidimensional concept that is represented on a continuum of being well that goes beyond health.The analysis reflects that wellness and health are used as synonyms and are frequently interchangeable with well-being.Still, wellness seems to be more about lifestyle and health behaviour, although a trend towards a more holistic and synergistic view of life or life orientation can be seen.Based on the findings from this concept analysis, a definition of wellness was developed.

F I G U R E 2
Conceptual model of wellness based on the findings from the analysis.
Papers reviewed and core characteristics identified.Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/scs.13196by University West, Wiley Online Library on [30/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/scs.13196by University West, Wiley Online Library on [30/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/scs.13196by University West, Wiley Online Library on [30/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License T A B L E 1