First, a comprehensive examination of the meaning of “ proactive” in the general and academic areas was done. Identifying all uses of the concept helps to acquire a deep understanding of its meaning [12].

Dictionaries define proactive as either “ acting in advance” or “ behaving actively.” The Merriam-Webster [23] describes it as “ acting in anticipation of future problems, needs, or change.” Similarly, the Cambridge University Dictionary [24] defines it as “ intending or intended to produce a good result or avoid a problem, rather than waiting until there is a problem.” Both dictionaries’ definitions focus on acting in advance of potential future events. On the other hand, the Oxford English Dictionary [25] highlights the behavioral dimension of proactive behavior, which involves "creating or controlling a situation rather than merely responding to it after it has occurred." Accordingly, being proactive entails assuming responsibility and effecting change.

The term “ proactive” has been extensively studied in business management, where it refers to the ability of employees to take initiative to overcome obstacles and achieve organizational goals [26]. Based on business management research, efforts have been made to investigate the proactive behaviors of nurses. Studies have investigated the proactive behaviors of nurses, using proactive personality scales [27,28], and proactive work behavior scales [26] to explore the influence of nurses’ competencies, work engagement, and proactive work behaviors [4,29]. However, these studies have primarily focused on describing nurses’ work attitudes, while proactive nursing also has connotations directly related to nursing practice and clients who are expected to receive and participate in nursing care [4,5]. To summarize the comprehensive examination of definitions pertaining to the concept, it was revealed that the majority of the documents referred to proactive nursing without providing an accurate definition.

The results of the concept analysis contain three parts: attributes, antecedents, and consequences (Figure 2). The attributes are characteristics that define the essence of the concept and that differentiate it from other concepts [12]. Through the critical evaluation of the scientific use of the concept, four attributes of proactive nursing were identified: surveilling to surface problems, employing practices beyond established protocols, tailoring a path toward the care goal, and arranging resources in advance.

Surveilling to surface problems means directly or indirectly observing clients to identify any risk of deterioration or unmet needs [2,5,30-32]. Such surveillance is a preemptive measure to bring hidden problems to the surface, for spotting emerging implicit problems, and for maintaining the ongoing care process rather than a reactive response to adverse events or client demands [30,32]. This proactive practice enables nurses to plan for and address impending problems in a timely manner [33].

Employing practices beyond established protocols involves active behaviors for solving unfolding issues in an innovative way [34]. Nurses’ initiatives that go beyond their standard job description can make positive changes in healthcare [35]. Such proactivity contrasts with traditional reactive practice, in which nurses take a peripheral position and behave passively when dealing with adverse events [30].

Proactive nursing is a process of adjusting an individual client's path toward a healthcare goal [35,37]. It focuses on the individual client's goals at a macro level, optimizing care plans by placing the client at the center of the care process [31,37]. Nurses’ proactivity is the initiative process of maintaining clients’ care continuum by shifting the care pathway in response to clients’ changing health status or to environmental circumstances that could affect them [5,21].

Additionally, proactive nursing entails the ability to prepare and arrange necessary resources in advance of an anticipated future [4,10,21,37]. Proactive nurses facilitate clients’ access to various resources, such as healthcare experts, treatment instruments, and community services [8,18,30,32,38]. The proactive behaviors of making referrals and coordinating with resources is enhanced by col-laborating with multidisciplinary healthcare professionals [3,33,36].

A model case is an example that includes all the attributes of a concept and helps to clearly understand its essence [12].

Nurse A is caring for Mr. W, a 62-year-old patient who underwent a decompressive craniectomy for a traumatic brain injury over a month ago. Despite stable vital signs, Mr. W has shown no improvement in his mental status and is mentally confused. Recently, the doctor advised Mr. W's daughter to find a nursing home for him as the acute stage was over. Nurse A aims to maintain the patient's optimal condition for moving to a nursing home without complications. During her rounds, Nurse A notices that Mr. W looks too still and does not respond to any stimuli. She immediately checks his mental status and deduces that his fever of 37.7°C (99.86°F) is the cause of his mental status change. She puts the patient in a head-up position, applies an oxygen saturation monitor, and performs tracheal suction to prevent pneumonia, a common complication of immobilization among patients who are not mentally alert. After applying ice packs to reduce the fever, she calls the doctor to inform him of the situation and checks Mr. W's temperature again. She then contacts the radiology department to check their schedule and informs them about the possibility of an emergency scan. In preparation for the anticipated scan, she ensures informed consent is obtained, identifies suitable IV sites, and prepares additional oxygen supply devices such as a ventilator.

In this model case, Nurse A's actions demonstrate the attributes of proactive nursing. Her vigilant surveillance allowed her to promptly surface the risk at hand. If she had only visited Mr. W during the minimum required times, she would have noticed the patient's fever too late. Additionally, she proactively took the initiative to address Mr. W's fever and prepared for the anticipated care process, instead of waiting for the doctor's orders. These actions could be considered employing proactive practices beyond routine protocols. Furthermore, while focusing on the goal of transferring Mr. W to a nursing home, she provided acute care to address his potential complications. Concentrating on the best practice in response to changing situations is an essential aspect of proactive nursing, which tailors the care path toward the ultimate goal. Moreover, Nurse A's preparation for a CT scan shows her proactive behavior in arranging resources in advance. This careful, preemptive arrangement ensured Mr. W's care continuum is effective and efficient.

A borderline case is an example that includes some partial meaning of the concept and helps to identify a clear boundary that distinguishes it from other concepts [12].

Nurse B, a diabetes specialist, is responsible for the care of Ms. X, a 55-year-old outpatient. Nurse B conducts regular phone call checkups, during which she discovers that Ms. X's blood sugar levels are increasing and that there are several gaps in her food diary. Ms. X complains about restrictions on her food intake and the difficulty of planning a healthy diet every day. Nurse B's primary goal is to control Ms. X's blood sugar levels and maintain them within the normal range. She tells the patient, “ I know it is hard and annoying, but keep checking your blood sugar. It is of the utmost importance for your health. Let me remind you of your schedule. You are scheduled for the community diabetes program this Friday at 3 p.m. I will send you some handouts for education. Is there anything else I can do for you?”

In this borderline case, Nurse B exhibited some short-comings in proactive nursing. Although she identified Ms. X's deteriorating state through regular telephone checkups, she only reviewed the report's data and did not attempt to identify implicit problems. To exhibit creative practice in proactive nursing, Nurse B could have paid more attention to Ms. X's struggle with food control by asking about her food preferences and recommending recipes, which can be counted as creative practices with a more tailored approach that focused on client's individual needs and current problems. Additionally, Nurse B could have been more proactive in referring Ms. X to other services beyond the scheduled diabetes program, such as a nutritionist or counselor, to address her concerns about food control and any underlying issues.

A related case is an example of a similar concept that helps to clarify the core meaning of the main concept [12].

Nurse C is preparing to receive her new patient, Mr. Y, who is transferring from the ICU. He suffered a C6 spinal cord injury in a car accident and is paralyzed below the hips. Nurse C reviews his chart, noting his weak hand grip and his goal to adapt to a rehabilitation program and be discharged without complications. While conducting initial assessment, Mr. Y suddenly starts crying, saying his life is ruined and questioning why he has to live. Nurse C listens carefully and shows empathy. “ I truly understand your discomfort. Your wife and daughter both believe in you and support you. I also believe in you!” She also arranges his possessions and a call bell where Mr. Y can easily reach them. She tells him, “ I am sure you can expand the areas you can reach for your stuff. Exercise your range of motion as much as you can. If you need me, please don’ t hesitate to press this call bell. Is there anything else I can do for you?”

In this case, Nurse C's approach in caring for Mr. Y was patient-centered rather than proactive nursing. While proactive nursing focuses on preventing risks and arranging resources in advance, Nurse C's actions centered on Mr. Y's current condition, providing psychological and physical support, and organizing his surroundings within his range of motion Although her approach was not tailored to Mr. Y's care process, it exemplified the attributes of patient-centered care, including respect for his autonomy and providing holistic and individualized care [40], which are distinct from those of proactive nursing.

A contrary case is an example that opposes all aspects of a concept and that helps to understand why and how the concept consists of its defining attributes [12].

Nurse D is providing care for Ms. Z who is undergoing several perioperative tests for surgery for a cerebral aneurism and is being strictly managed for hypertension. One day, Ms. Z's daughter reports to Nurse D that her mother's mental state has suddenly changed, prompting Nurse D to check on the patient. Nurse D finds that Ms. Z is drowsy and has difficulty opening her eyes, which is a significant change from her earlier alert state. Nurse D immediately calls the doctor and records the orders. The doctor soon arrives and asks for details about the mental change. However, Nurse D cannot understand what is going on and is puzzled by the situation. After the doctor requests that vital signs be checked, the systolic blood pressure is found to be high at 183mmHg. In response, the doctor asks a series of questions: “ Did Ms. Z take the hypertensive medication properly? Was a pre-op CT scan done? When? Prepare for surgery!” Nurse D becomes panicked as additional questions arise in her mind: “ What should I do first? What did the doctor say to me at the very beginning? I have so many things to do…”

In this contrary case, Nurse D demonstrated anything but proactive nursing. First, she only became aware of Ms. Z's mental deterioration after her daughter requested that she check on her. Furthermore, she appeared passive and uncertain of how to handle the situation, waiting for the doctor's orders without taking any initiative. During the emergency, she seemed helpless and had difficulty understanding the doctor's questions and orders. This is the complete opposite of proactive nursing.

The antecedents of proactive nursing, which are the prerequisites for the concept to occur [12], included that nurses have their own theoretical and experiential knowledge, possess a professional identity, understand clients’ status, and have accessible resources. Nursing knowledge forms the basis of practical judgement and behavior, allowing nurses to make optimal decisions [35]. In addition to knowledge, nursing wisdom gained from practical experience allows nurses to solve impending problems proactively [6,38,40]. Nurses’ professional identity also drives proactive practice through intrinsic motivation, commitment, and responsibility toward clients [4]. Proactive nursing requires nurses to identify their professional roles and to be aware of the value and impact of their behavior [37]. Understanding clients’ status is another necessary condition of proactive nursing. To identify underlying problems and then prevent them, nurses should create clear care plans and goals based on sufficient information about clients [35]. Through such actions, proactive nurses play a central role in understanding and assessing clients and in being change agents for effective care [41]. Lastly, proactive nursing requires accessible resources for preparing and arranging in advance of an anticipated care process. Access to organizational and administrative supports, such as human and material resources including community services, are necessary for nurses to provide proactive care and improve care continuity by sustaining and improving nurse referrals [29,35,40].

The consequences of proactive nursing included ensuring client safety, achieving the care goals efficiently, and improving nurses’ job satisfaction. Proactive nursing ensures client safety by setting care priorities, preventing deterioration of clients’ condition, and stabilizing their health status [4,10]. Addressing complex hidden problems through proactive interventions and concentrating on the individual needs can prevent suffering and uncertainty in care, such as unplanned invasive procedures and prolonged hospital stays [30], resulting in providing clients with a positive care experience and a higher level of safety [31,35]. Proactive care also aims to achieve care goals efficiently by following a prepared path that avoids or prevents obstacles and reduces the time and cost of the care process [5,11,29,32]. Collaboration among multiple disciplines facilitates the selection of the best practices, ensures consistency of care, and targets the same goals with other staff, which allows for innovative steps to be taken in responding quickly to expected harm while avoiding potential obstacles and achieving the care goal more efficiently [8,10,35]. Proactive nursing also positively impacts nurses’ competency, work engagement, and performance, leading to better job satisfaction [6,27,35]. Additionally, managing underlying needs or problems with a focus on the client gives nurses greater control over workloads, more confidence, and a clear role identity by reducing un-necessary procedures and stress [40].

Empirical referents are categories of actual practices in the real world that demonstrate the existence of a concept [12]. Instruments such as the proactive personality scale [27,28] or the proactive work behavior scales [26] have been utilized to assess nurses’ proactivity within the nursing profession. However, it is important to acknowledge that these instruments originate from a different discipline, leading to inherent limitations in accurately capturing the intricacies of proactive nursing and aligning interpretations with its true essence. Instead, any nursing practice in which a nurse identifies a patient's concerns, anticipates the care process, prepares for upcoming events, and makes the best decisions in the current circumstances can be an empirical referent of proactive nursing. Proactive rounding is a representative empirical referent of proactive nursing in clinical settings.

Nurse rounding is a basic component of nursing practice that entails regular patient assessment [42]. Reflecting the contextual demands of patient safety, emphasis on proactive rounding has been increasing. Proactive nurse rounding is regular rounding that places a greater focus on intentionally assessing patient needs and addressing them, greatly influencing patient safety [31,33]. The authentic manifestation of proactive nursing occurs when initiative practice is implemented following proactive rounding.