729_Swan_Final_Manuscript_Unblinded_3.20.23_graves+final+edits+ARformatted Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 2 Familiarity: A Concept Analysis on Rural Life Marilyn A. Swan, PhD, RN1 Barbara B. Hobbs, PhD, RN2 Luke J. Gietzen, MA3 1 Associate Professor, Minnesota State University, School of Nursing, marilyn.swan@mnsu.edu 2 Professor Emerita, South Dakota State University, College of Nursing, bbarbh64@gmail.com 3 Clinical Psychology PhD Student, University of North Dakota, Department of Psychology, luke.j.gietzen@und.edu Abstract Purpose: To fully conceptualize familiarity, delineating it from other rural concepts and understanding its role in rural life. Background: Rural nurse researchers identify familiarity as a concept found in rural life. Familiarity is a term used in rural literature, nursing research, and theory but lacks comprehensive conceptual understanding. To advance rural nursing science, concepts need updating to support rural research and advance theory development. Method: A scoping review of the literature was completed using the Joanna Briggs Institute methodology and supported by the seminal work of Arksey and O’Malley (2005). Using Walker and Avant’s (2019) eight-step method, the scoping review findings informed this familiarity concept analysis. Findings: The familiarity analysis revealed three defining attributes, ‘repeated exposure’, ‘knowledge’, and ‘deep understanding’. Antecedents which proceed familiarity include: (i) varied contexts; (ii) lack of anonymity; (iii) novelty. Consequences which result from familiarity are: (i) Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 3 trust; (ii) vulnerability; (iii) over-familiarity; and (iv) physiologic reactions. Model and alternate cases developed are presented along with identified empirical referents. Conclusion: This paper presents findings supporting familiarity as a concept in rural life and form a conceptual foundation for future research and further exploration. The findings also provide the components needed when defining familiarity in rural research. Understanding familiarity is necessary for recognizing how rural nurses experience familiarity and its influence in their personal and professional lives. Keywords: familiarity, scoping review, rural, nursing, theory Familiarity: A Concept Analysis on Rural Life “Small towns are sometimes like that; familiarity runs high, while regard for personal space is low, if nonexistent” (Notaro, n.d.). Rural, including small towns, means living in sparsely populated locations (Lee & Winters, 2022). Familiarity is a feature of rural living in which individuals come to know and are familiar with details about the people, environment, history, and culture of a community. Thus, it makes sense that rural nurse researchers identify familiarity as a concept found in rural life and a concept present in rural nursing research and theory (McNeely & Shreffler, 1998; Lee & Winters, 2022). Although the term familiarity is used in rural literature, it lacks comprehensive conceptual understanding and definition. McNeely and Shreffler (1998) conducted a partial concept analysis on familiarity, developing a preliminary definition and defining attributes, however, antecedents (what precedes familiarity), consequences (what results from familiarity), and empirical referents (how revealed in everyday life) were not identified (Lee et al., 2022; Walker & Avant, 2019). To Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 4 advance rural nursing science, rural concepts need updating and fully conceptualized to support rural nursing research and advance rural nursing theory (Williams et al., 2012; Fahs, 2016). Beyond McNeely and Shreffler’s early work on familiarity, there exists a research gap on familiarity and its role in rural life. This gap was identified when familiarity was determined to be a consequence of lack of anonymity and rural life (Swan & Hobbs, 2018; Swan & Hobbs, 2022). An initial literature search, completed with the intent of clarifying familiarity’s meaning, resulted in volumes of literature mentioning familiarity; however, few publications addressed familiarity and rural life. Thus, information about familiarity and rural life obtained was insufficient to draw any conclusions (Swan & Hobbs, 2018; Swan & Hobbs, 2022). To clarify familiarity as a rural concept, a scoping review of the literature was completed, leading to the following concept analysis. The purpose of this work is to present a concept analysis on familiarity using Walker and Avant’s (2019) method. The aim is to fully conceptualize familiarity to delineate it from other rural concepts and to understand its role in rural life. Background Familiarity often has ambiguous meanings. Felder (2021) suggests the ambiguity of familiarity is that it “refers to both knowing well and knowing superficially” (p. 180). As such, the word familiarity can imply anything from trivial knowledge to in-depth knowing. The sheer broadness of the definition presents challenges for explaining the word in daily use, let alone nursing practice and research. Over time, the perception of familiarity has changed. Titchener (1921) described familiarity as a pleasant reaction or feeling. This contrasts with Zajonc’s (1968) idea that familiarity results from mere exposure. Mandler (1980) expanded further by making the case that familiarity results from repeated exposure. Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 5 In their analysis of the term familiarity as a rural concept, McNeely and Shreffler (1998) found that familiarity is “…related to informality, friendship, close relationships/acquaintances, and intimacy” (p. 97). They suggest familiarity has an antithetical quality, making it sometimes welcomed, and at other times, unwelcomed (McNeely & Shreffler, 1998, p. 97). Swan and Hobbs (2017) identified familiarity as a consequence of lack of anonymity, describing the interconnectedness in rural communities that leads to the formation of intimate knowledge of people and places. The ongoing evolution of familiarity hampers our ability to fully understand the role of familiarity in rural life. There is a substantial body of research supporting the idea that familiarity has a physiologic component, involving the encoding of memories and experiences in the brain (Gimbel et al., 2017; Melton, 1963; Squire, 1987). Exploration into familiarity branches into neurocognitive psychology, specifically into memory storage within the brain (Wang et al., 2016; Kihlstrom, 2020). Memories created by repeated exposure are stored in two areas of the brain, named familiarity and recollection, and have been extensively researched (Wang et al., 2016; Kihlstrom, 2020). Acknowledging the physiologic process supporting familiarity is foundational in exploring the concept. What is familiar, or internally known, may be deeply embedded and surface without conscious recall. Internal knowing may be triggered by our senses through complex brain processes of recognition and familiarity (Wang et al., 2016). Consider the emotional response when smelling freshly baked chocolate chip cookies, hearing a favorite childhood song, or remembering 9/11. The unexpected retrieval of memories is not always positive, welcomed, or expected (Iyadurai et al., 2019). Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 6 What is familiar to an individual is observable in everyday life and activities: a commute to work, a walk around the neighborhood, and seeing familiar people and places. Driving a familiar route can result in the realization of not remembering the drive. A walk around the neighborhood is made without any conscious thought or plan. Riding a regular bus route means encountering familiar strangers—people and faces you see regularly in a specific place but who are not actually known to you (Mandler, 1980; Mandler, 2008). Everyday activities are completed without much thought. Method The approach to investigating a topic with the breadth of familiarity drew on the authors’ previous experience in conducting a concept analysis of lack of anonymity in rural life. Given the wide use of familiarity and the diverse ways the concept is perceived across disciplines, we expected the search to result in a large amount of literature. The authors gained insight on the quantity of literature on familiarity, and lack of literature of familiarity in rural contexts, when writing for other publications. This awareness identified methodological issues needing consideration. Additionally, the wide use of familiarity also presented a challenge in deciding which literature to include. The method would need to support locating a manageable but representative amount of literature. The method selected was a scoping review of the literature. The data collected informed the concept analysis outlined by Walker and Avant (2019). The scoping review of the literature was completed using the Joanna Briggs Institute (JBI) methodology (Aromataris & Munn, 2020) supported by the seminal work of Arksey and O’Malley (2005). The research question guiding the scoping review was, “What is known from the existing literature about the concept of familiarity?” (Swan et al., 2022, para. 7). Information on the scoping review and concept analysis protocol is Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 7 published in an open access journal and available for review at https://www.research protocols.org/2022/6/e36930/ (Swan et al., 2022). The located literature was uploaded into CovidenceTM software which automatically removed duplicates and provided a platform for the literature review. Each article underwent a two-step review process. First, a title and abstract review was conducted to determine if the inclusion criteria were met. Inclusion criteria included articles that defined or directly discussed familiarity as a concept, applied to human beings, indicated a study result or finding on familiarity, were published between 2016 to 2022, and were available in the English language. International literature was included in the review. Each abstract was reviewed independently by a research pair of the three-member research team based on the defined inclusion/exclusion criteria. Disagreements regarding inclusion were resolved in research team meetings. During this step, modifications to the inclusion/exclusion criteria were made as the researchers gained understanding of the literature (Swan et al., 2022). Iteratively adjusting the inclusion and exclusion criteria is consistent with the method outlined by Arksey and O’Malley (2005). Similarly, the full-text review was independently completed by a research pair of the three- member research team. Additional literature was located from two different sources: reference list scanning and the reference list used to write a book chapter on familiarity (Swan & Hobbs, 2022; Swan et al., 2022). Following this same process, additional literature underwent a full text review to determine eligibility for inclusion. Disagreements regarding inclusion were resolved in research team meetings. Once deemed relevant, the full text articles were uploaded into the CovidenceTM software. Data extracted from the scoping review provided the relevant literature for the concept analysis (See Swan et al., 2022). This concept analysis was conducted using Walker and Avant’s Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 8 (2019) eight step method: the concept was selected; the purpose of the analysis was determined; uses of the concept were discovered; defining attributes were established; a model case was written followed by case examples; antecedents and consequences were identified; and empirical referents defined. Findings Scoping Review Results Following the scoping review protocol (Swan et al., 2022), eight databases were searched using 22 search terms. The search resulted in an extensive amount of literature for review (see Figure 1). Figure 1 PRISMA Flow Diagram for Scoping Review Note. From “The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews,” by M. J. Page, J. E. McKenzie, P. M. Bossuyt, I. Boutron, T. C. Hoffmann, C. D., Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 9 Mulrow, et al., 2021, BMJ, 372(71), p. 10 (https://doi.org/10.1136/bmj.n71 ). Copyright by the BMJ. In total, 6,252 articles were included in the title and abstract review. As expected, and despite efforts to narrow the search, the amount of literature was vast and speaks to the wide use of the word familiarity contained in the literature and across disciplines (See Table 1). Table 1 Disciplines Included in Scoping Review Business/Management Nursing Social Media/Gaming Communication Studies Occupational Health Social Work Criminal Justice Pharmacy Sociology Education Philosophy Sports Science Engineering Politics Transportation Geography Psychology Travel/Tourism History Public Health Urban Development Medicine Public Policy Urban Studies Mental Health Recreation/Leisure Military Religion/Spirituality Note. Disciplines are presented alphabetically. As the team’s knowledge on familiarity in the literature grew, the two exclusion criteria, literature referring to animals or non-humans and genetics, were deemed insufficient. Four additional exclusion criteria were added: 1. Articles or studies on brand familiarity 2. Articles or studies that involve brain dysfunction (e.g., dementia, autism) 3. Articles or studies on language development and education 4. Articles or studies on brain mapping for recollection and familiarity Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 10 To assess the level of agreement between research pairs, a proportionate agreement calculation was completed as a pilot review prior to the title and abstract and full text reviews. In both review levels, each research pair (Rrange = .83-.91) exceeded the protocol minimum of .75 (Swan et al., 2022). In total, 186 articles were included in the scoping review analysis and represent a multidisciplinary and international perspective of literature (See Table 2). Table 2 Included Literature by Continent and Country Continent and Country No. of Participatio n Continent and Country No. of Participation Africa Ireland 1 Burkina Faso 1 Italy 9 Rwanda 2 Netherlands 7 South Africa 1 Norway 2 Zimbabwe 1 Poland 1 Asia Portugal 2 Bangladesh 1 Spain 4 China 14 Switzerland 3 India 2 United Kingdom 26 Iran 1 North America Israel 2 Canada 18 Japan 2 United States 67 Malaysia 1 Oceania South Korea 3 Australia 11 Europe New Zealand 3 Albania 1 South America Belgium 1 Argentina 1 Denmark 6 Brazil 2 Finland 2 Other France 5 Undisclosed 1 Germany 7 Note. More than one country may be represented in an article. Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 11 The large amount of data extracted was analyzed according to the two major categories: familiarity definition/description and relevant findings. The definition data was qualitative in nature and resulted in a content analysis. The relevant findings were specific research findings from studies that involved familiarity. The data was analyzed separately and then together to provide rigor to the analysis. The findings from the data sets matched and aligned. Concept Analysis Familiarity is unique to the individual; what is familiar to one person may be unfamiliar to another. As such, familiarity is relative to the person who is perceiving it. The uniqueness of familiarity is based on the context and a lack of a universal understanding. Perhaps this contributes to the ambiguous quality of familiarity and our ability to understand it as a concept. The sheer uniqueness of familiarity can be a limiting factor. Therefore, no single definition can be used to describe familiarity in daily life as found in the literature review. The analysis of familiarity revealed three defining attributes that emerged from both the definition and relevant findings data. Antecedents, consequences, along with empirical referents were identified. To assist in understanding what familiarity is, and isn’t, borderline, related, contrary, invented, and illegitimate cases will be presented. Based on our extensive review of the literature, we believe that this is the first full conceptualization of familiarity. Defining Attributes The data strongly supports the presence of three defining attributes which include repeated exposure, knowledge, and deep understanding. Table 3 presents the defining attributes with definitions developed from the review. These findings are consistent with Baloglu (2001) who identified three types of familiarity related to tourism: information, experience, and self-rating. Table 3 Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 12 Defining Attributes and Definitions When interacting with the novel stimulus the mere exposure effect starts the process of making the unfamiliar, familiar (Zajonc, 1968). This process occurs over time and is a sensory experience, including sight, sound, and smells (Felder, 2021). Repeated exposures, or the number of times a person is exposed (Devue et al., 2019; Felder, 2021), can generate a long-term memory from as little as three interactions with a stimulus (Larzabal et al., 2018). Exposure is augmented when recalling or recognizing a familiar stimulus from memory (Mandler, 1980). The memory recognition or recall of a stimulus reinforces the memorable exposure to the stimuli. Thus, memory recall contributes to developing familiarity (Carr et al., 2017). Repeated exposure is linked to our sense of knowing (Carr et al., 2017), whether it be recalling a song or when to turn on an unmarked country road. Exactly when repeated exposure moves into knowledge is unknown. Yet, evidence suggests it happens: the ability to sing lyrics to a childhood song that comes on the radio or knowing the shortest route to a destination. Repeated exposure and the knowledge that develops supports improved performance and our ability to anticipate what is coming next (Shen et al., 2018). Through interactions with others, we gain personal knowledge that increases our familiarity with people, places, objects, and ideas (Richaud, 2018). Defining attribute Attribute definition Repeated Exposure Recollections of and often repeated interactions with people, places, objects, or ideas that makes the unfamiliar familiar. Knowledge Deep Understanding Acquiring information through exposure, experience, and nurtured environments with people, places, objects or ideas. Intimacy (non-romantic) with people, places, objects, or ideas that prompts interconnectedness and a sense of belonging. Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 13 Over time, knowledge continues to grow, so much so, that an individual develops deep, intimate understanding with long-term involvement in a community, people, places, objects, and ideas. This intimate familiarity is associated with positive memories and experiences and can be incorporated into an individual’s identity (Preston & Gelman, 2020). In rural life, a farmer may have generational connection and knowledge with a piece of land, having memories that extend over a lifetime. Rural communities share the same social and professional space, which supports the development of common rituals and other cultural elements (Mock, 2017). As such, nurses and health care workers who live and work in their community, will have unique insights into the people they care for, and may even be able to predict a course of action (or not) and understand why a decision was made (Tonin & Lucaroni, 2017). Deep understanding of community creates family-like bonds that represent the closeness and shared life of rural relationships (Busza et al., 2018). Ryan and McKenna (2013) identified that rural families placing an older adult in a local nursing home had “a sense of familiarity” with the nursing home and owners and had “access to the local grapevine” which informed the family’s understanding of the history of the home and the care provided (p. 4). In addition, the family knew many of the staff through social and professional connections. Collectively, the unique information rural families had access to informed decision making on nursing home placement (Ryan & McKenna, 2013). Antecedents and Consequences The antecedents are an important component of the analysis as they must be “in place prior to the occurrence of the concept” (Walker & Avant, 2019, p.178). In turn, consequences occur as Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 14 a result of familiarity (Walker & Avant, 2019). The results of this analysis identified three antecedents for, and four consequences of familiarity discussed below. Three antecedents of familiarity were identified: varied contexts, lack of anonymity, and novelty. A setting or context must exist for familiarity to occur. As such, knowing the context is necessary to recognizing the presence of familiarity. Lack of anonymity, defined as “identifiable, establishing boundaries for public and private self, and interconnectedness in the community” (Swan & Hobbs, 2017, p. 1078), precedes the development of familiarity (Hayfield & Schug, 2019). Lastly, before anything becomes familiar, it is new, or novel. Through repeated exposure, novel experiences become encoded into memory transitioning the novel to familiar (Duncan & Shohamy, 2016). For example, a nurse from a rural farming area moves to a new state and similar community. The rural community feels familiar to the nurse, but being new, the nurse knows no one and is not known to people in the community (anonymity) and is considered a stranger. Through repeated exposure, the nurse comes to know people in the community and people come to know the nurse (lack of anonymity). Over time, the nurse becomes familiar with the people, history, and culture of the community. The data reveal four consequences of familiarity: trust, vulnerability (risk exposure), over- familiarity, and physiologic reactions. Evidence supports the idea that familiarity must be present for trust to develop (Korstjens et al., 2021; Theron & Pelser, 2020). For example, a well-known nurse living in a rural community may be extended trust by individuals they have never met. In contrast, trust resulting from familiarity is not without risk to the individual; a patient may choose to stay with a trusted rural provider rather than transfer care to an unfamiliar specialist in an urban location. Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 15 We may encounter people who are familiar strangers; the individual moves within our daily routines but is a stranger in that we have no knowledge of them (Felder, 2021). Through repeated exposures, the stranger becomes familiar. Familiarity may affect people’s vulnerability and may impair our objectivity or ability to unbiasedly assess potential risks (Felder, 2021). For example, a rural elderly couple may trust an unfamiliar workman who is related to a lifelong friend. Without knowing the workman, the couple could be vulnerable in ways not fully understood. Furthermore, becoming over-familiar may present risks to oneself or another. Over-familiarity between two individuals may lead one individual to believe they know the other well enough to speak for them (Mapson & Major, 2021). Team research findings suggest familiarity improves team function, but over-familiarity may have a detrimental effect and impair team performance (Parker et al., 2020; Sieweke & Zhao, 2015). Additionally, the individual may see what they want to see without seeing what actually is (Harms et al., 2021). For example, care providers familiar with an elderly rural patient might not offer an aggressive procedure, believing the patient would decline, even though the patient is generally healthy and remains active in the community. Finally, not all forms of familiarity are welcomed. For example, familiarity is unwelcome when a person feels nervous or uncomfortable around or being with another person, especially if the second person seeks to deepen the relationship. In this case, the over-familiarity is unwelcomed. Empirical Referents Based on this review, six empirical referents associated with familiarity were identified as being present in everyday life (see Table 4). Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 16 Table 4 Empirical Referents for Familiarity Empirical referents Sub-category Selected citations* Security and Comfort Safety, comfort, culture, sense of belonging, home, like and positivity (Carr et al., 2017; Hayfield & Schug, 2019) Connection 1. Personal 2. Professional 1. Relationships, social and family bonds, environment 2. Team-familiarity (Maynard et al., 2019; Rodrigues et al., 2021) (McCullough et al., 2016; Rolland, 2017) Problem-solving None (Noordzij & Wijnia, 2020; Shen et al., 2020) Fixation Option generation (Schweizer et al., 2016; Viswanathan et al., 2016) Inattention Automaticity, blasé, routines (Burdett et al., 2016; Felder, 2021) Judgement Decision making, risk taking (Garcia-Marques et al., 2016; Karabon & Steiner, 2020) *Note. Selected citations are presented; a full list of included citations available on request. Familiarity can be observed in everyday experiences in various ways. Security and comfort are revealed through the feelings of safety, comfort, a sense of belonging, and a general sense of positivity and liking what is familiar (Garcia-Marques et al., 2016; Lu et al., 2018; Sidenius et al., 2017; Yoo & Kim, 2016). There is a feeling of being at home and having a cultural connection (Cosgrave et al., 2019; Tong et al., 2019). Interpersonal and interprofessional connections are visible through relationships, including social and family bonds, with ties to a place or environment (Cosgrave et al., 2019; Cranmer et al., 2017). Being familiar with people, places or work supports faster problem solving, efficiency, and increased confidence (Noordzij & Wijnia, 2020; Shen et al., 2020). Facing a familiar problem may increase one’s confidence in having the ability to solve a problem versus tackling an unfamiliar one (Borgonovi & Pokropek, 2019). Similarly, being familiar with a hard problem supports competence. For example, a student studying math may perform better with problems previously encountered (Shen et al., 2020). Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 17 Familiarity also brings about unrecognized challenges in everyday life. Fixating on what is familiar and comfortable may limit the ability to consider and generate new or different options (Viswanathan et al., 2016). When freed from the constraints of the familiar, originality may increase (Schweitzer et al., 2016). Similarly, familiarity may promote inattention or mind wandering. Drivers on a familiar rural road may unintentionally “zone out” when driving (Burdett et al., 2016). Familiarity with what is well known means we may no longer pay close attention to our actions and environments. This lack of attention may result in ignoring the finer details and simply going with what is familiar (Felder, 2021). For example, they may not notice a leaning mailbox until it falls over. Familiarity positively and negatively affects how we judge people and situations. Information familiarity may result in quickly assessing the accuracy of information and faster decision making (Mapson & Major, 2021). Risk taking behavior may increase in a familiar environment (Karabon & Steiner, 2020). For example, the rural farmer who disconnects his seatbelt when turning off the highway onto a familiar gravel road adjacent to the family farm. Model Case Susan is visiting her rural high school for her 10th class reunion. The mascot statue by the office door and classroom buildings are all familiar to her. Without directions, she walks to the gymnasium where the party is being held. Immediately, the gym environment again brings forth memories of playing basketball all four years. Susan even remembers the smells. Looking around she sees people from her class. She is still familiar and talks regularly with her closest friends; other faces seem familiar, but she cannot freely recall who they are or how she knows them. At the registration desk, she sees a copy of the school newspaper, which she edited during her senior year, and pictures of football games and senior prom night, all bringing back memories of her Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 18 senior year. She reminisces about the connections she had with some teachers, particularly Mr. Gallagher who mentored her in math. Borderline Case Benjamin has just arrived at Stuttgart, Germany airport, where he is to meet with professional colleagues for an international conference. Although his heritage is German, this is his first time to Germany and his first international trip. Luckily, Stuttgart airport seems familiar because the environment includes restrooms, waiting areas, eating establishments, and so forth; similar to airports he has visited in the past. Despite a familiar feeling environment, he feels like a “fish out of water.” He does not speak German and is dependent on strangers to translate signs and information for him. As he sat in a waiting area where he is meeting his colleagues, a stranger approaches him and asks for directions in German. He tries to explain, in English, that he is an American and does not speak German. Being a stranger to the area, he thinks this encounter is unusual; however, he is approached by two more German strangers over the next 90 minutes. With three similar experiences, Benjamin believes that he may appear as more of a familiar “German” than he thought in the past. Related Case Mildred and Bob are having plumbing problems in their rural country home. Their long- time plumber just retired, and they called the “new” plumber in town. They met the new plumber at church a few times and heard from a friend that he did good work on their plumbing issues. The new plumber and his assistant are scheduled to do the plumbing work on a day that Mildred has a medical test at the city hospital a couple of hours away. Similar to their past practice with their long-time plumber, they decide to leave the house unlocked and call the new plumber to let him know they will be gone, but the house is open. Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 19 Contrary Case Marge is visiting her elderly aunt who lives a couple of hours from her home. Due to her work schedule, Marge visits infrequently but tries to help her aunt with errands when able. During this visit, Marge’s aunt needs more female incontinence pads that can be purchased at the local pharmacy. Marge has never purchased female incontinence pads before. When entering the pharmacy, Marge is too embarrassed to ask for guidance on where the pads are located. After some searching, she locates the product and gets in the checkout lane. While waiting for the person ahead of her to check out, she thinks the cashier is someone from her aunt’s church and that they may have met before. When it’s Marge’s turn to checkout, she feels embarrassed about the purchase and lets the cashier know that the pads are for her aunt. The cashier looks at her funny and says “okay.” As Marge leaves the pharmacy and walks to her car, she realizes that she had never met the cashier before. Illegitimate Case Since retiring ten years ago, Hank developed a passion for watching morning television. These shows became a part of his daily activities, such that he schedules all appointments, exercise, and visits around the show times. He is particularly fond of the sportscasting host, a retired professional athlete. Hank surfs channels and the Internet, following the sportscaster’s specials and personal life. When visiting his friends, Hank shares stories and tidbits such as the sportscaster’s birthday, upcoming appearances, even personal tragedies Hank learned about. Hank views the sportscaster as a personal friend, he feels a connection to the sportscaster and he knows him intimately; however, Hank has never met the sportscaster. Likewise, the sportscaster has no connection to Hank. Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 20 Implications for Rural Nursing This analysis is believed to be the first in-depth examination of the concept familiarity. The findings from this analysis supports familiarity as a concept in rural life and expand the early work of McNeely and Shreffler (1998). The identification of defining attributes, antecedents, consequences, and multiple cases provides detail on familiarity that was not previously known. The identification of empirical referents, or how familiarity is revealed in everyday life, is a major contribution to the understanding of rural life (Walker & Avant, 2019). Familiarity is often discussed in rural literature and theory without clear definition. Our intention is not to provide one definition but describe this broad concept. As researchers operationalize a definition, the components of familiarity described in this paper should be incorporated. Thus, this analysis serves as a foundation for future researchers when defining familiarity in rural life, which requires additional research and exploration. Familiarity was found to be a consequence of lack of anonymity (Swan & Hobbs, 2017). The result of this analysis clarifies the distinction between the closely related concepts (Swan & Hobbs, 2022). In the presence of familiarity, it is difficult to be completely anonymous (Richaud, 2018). As an individual becomes known, their lack of anonymity and familiarity increases (Swan & Hobbs, 2017). This is a normal relationship between the two concepts. However, over- familiarity may disrupt this relationship and become a liability to personal and professional life. Nurses need to recognize that judgments made in situations where over-familiarity exists may affect professional decision making. Further research is needed to understand the connections between the concepts. The complexity of familiarity begins with its uniqueness to everyone. Rural nurses experience familiarity in their personal and professional lives, often practicing in communities Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 21 where they have a deep understanding of the people, environment, history, and culture of the community (Richaud, 2018). The same is true for patients and families that interact with rural nurses. As such, familiarity, welcomed and unwelcome, may influence rural nurses, patients, and families. Rural nurses may want to be mindful that their perceptions of a familiar relationship or connection may not be shared by those assigned to their care. The breadth of literature included in this analysis provides a broad exploration of familiarity as a concept and as a given in the culture of rural communities. It is imperative that rural nurses gain skills in recognizing and understanding the importance of familiarity and consider the associated risks of over-familiarity in rural life. The findings from this concept analysis should serve as a guide for rural researchers as familiarity is further developed. Limitations Several limitations are identified in completing this concept analysis on familiarity. First, the word familiarity has 50 or more synonyms depending on the source referenced while familiar, has upwards of 100+ (Merriam-Webster Unabridged Dictionary, n.d.). As such, familiarities' use is pervasive in the literature and its meaning varies among authors, disciplines, and studies. This being so, we were continually clarifying and revising our preliminary understanding on familiarity which led to this concept analysis. To identify all uses of familiarity, our scoping review was intentionally broad to ensure a deep dive into the literature. Therefore, mixing editorials with various mixed research design studies could be considered a limitation. Second, multiple search terms related to familiarity were input into eight databases; however, it is possible other relevant literature might be available in other databases. A third limitation may be that since the scoping review of familiarity was limited to papers written in English, papers written in other language were not considered. Fourth, is the vast amounts of international and multidiscipline literature Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 22 screened, reviewed, and excluded before analyzing the remaining 186 articles. It is feasible that some applicable literature may have been missed. Furthermore, it is possible that earlier pertinent literature may have been overlooked. And finally, we found it difficult to complete the comprehensive analysis and synthesize the data due to the large number of articles reviewed, variety of disciplines involved, and inconsistency in how familiarity was described or used with studies and papers. Therefore, we may have misinterpreted data through our analysis. Conclusion Familiarity is a term frequently associated with people, places, and items known, but our understanding of its meaning varies by how the word is used and the context. Familiarity is linked to rural nursing research and theory, but inconsistencies in the term’s meaning and use have been noted, resulting in this concept analysis. To identify all uses for the concept, a scoping review of international and multidisciplinary literature was completed. The analysis, leading to identifying all uses of the concept, especially those relating to rural life is described. Additionally, three attributes, repeated exposure, knowledge, and deep understanding were identified and defined. Furthermore, antecedents, preceding familiarity, and consequences, resulting from familiarity were described. To understand how to apply the concept, a model case example was presented along with borderline, related, contrary, invented, and illegitimate case examples. Lastly, six empirical referents were listed. The findings also provide the components needed when defining familiarity in rural research. Understanding familiarity is necessary for recognizing how rural nurses experience familiarity and its influence in their personal and professional lives. Online Journal of Rural Nursing and Health Care, 23(1) https://doi.org/10.14574/ojrnhc.v23i1.729 23 References Arksey, H., & O’Malley (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19-32. https://doi.org/ 10.1080/1364557032000119616 Aromataris E., & Munn, Z. (Eds). (2020). JBI Manual for Evidence Synthesis. JBI. https://synthesi smanual.jbi.global. Baloglu, S. (2001). Image variations of Turkey by familiarity index: Informational and experiential dimensions. Tourism Management, 22(2), 127-133. https://doi.org/10.1016/S0261- 5177(00)00049-2 Borgonovi, F., & Pokropek, A. (2019). 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